Complex Trauma and Children Exposed To Domestic Violence

1. Complex Trauma and Children Exposed To Domestic Violence How innocent lives are shaped by disrupted beginnings Phil Wells

2. My Hopes and Dreams (What I think you can get out of this workshop). An informed discussion of trauma, complex trauma and traumatic stress as well as the effects on children exposed to Domestic Violence. Understanding and accepting the responsibility of our role as interventionist, clinician, healer and human being. Validation of all our efforts to help kids and families lead less hectic lives.

3. WARNING

4. Trauma Informed Services Trauma-informed services are not designed to treat symptoms or syndromes related to abuse or trauma. Instead, the primary purpose is to deliver mental health, and other services, etc., in a manner that acknowledges the role that violence and victimization play in the lives of most consumers of mental health and substance abuse services.

5. Fear not for the future, weep not for the past. Percy B. Shelley

6. What trauma survivors need to KnowJane Middelton-Moz • What happened to you is not normal, but you are normal • Healing takes time, be good to yourself • You survived the experience and you have many strengths • Continually validate yourself • You need people to help you heal. There are steps to healing, don’t rush it.

7. With the gift of listening comes the gift of healing, because listening to your brothers or sisters until they have said the last words in their hearts is healing and consoling. Someone has said that it is possible “to listen a person’s soul into existence.” Catherine de Hueck Doherty

8. Triggers and Flashbacks An event, symbol, reminder of something unfavorable that causes you to feel, act or respond in a certain way. It can set off a memory transporting a person back to the event of the original trauma. A flashback can take the form of pictures, sounds, smells, body sensations, feelings, or numbness. An event or circumstance that happens before something else.

9.    Definition of a traumatic event A traumatic event is any event or events, which overwhelms our core capacity to cope. It results in an experience of personal threat to our safety and/or the integrity of our identity. Exercise:(traumatic event)

11. Complex Trauma • Complex trauma describes both exposure to chronic trauma—usually caused by adults entrusted with the child’s care—and the impact of such exposure on the child. • Children who experienced complex trauma have endured multiple interpersonal traumatic events from a very young age. • Complex trauma has profound effects on nearly every aspect of a child’s development and functioning. Source: Cook et al. (2005). Psychiatry Ann,35(5):390-398

12. What Is Child Traumatic Stress? • Child traumatic stress refers to the physical and emotional responses of a child to events that threaten the life or physical integrity of the child or of someone critically important to the child (such as a parent or sibling). • Traumatic events overwhelm a child’s capacity to cope and elicit feelings of terror, powerlessness, and out-of-control physiological arousal.

13. Types of Traumatic Stress • Acute trauma is a single traumatic event that is limited in time. Examples include: • Serious accidents • Community violence • Natural disasters (earthquakes, wildfires, floods) • Sudden or violent loss of a loved one • Physical or sexual assault (e.g., being shot or raped) • During an acute event, children go through a variety of feelings, thoughts, and physical reactions that are frightening in and of themselves and contribute to a sense of being overwhelmed.

14. Types of Traumatic Stress • Chronic trauma refers to the experience of multiple traumatic events. • These may be multiple and varied events—such as a child who is exposed to domestic violence, is involved in a serious car accident, and then becomes a victim of community violence—or longstanding trauma such as physical abuse, neglect, or war. • The effects of chronic trauma are often cumulative, as each event serves to remind the child of prior trauma and reinforce its negative impact.

16. Domestic violence Domestic violence (also known as domestic abuse,spousal abuse, or intimate partner violence) occurs when a family member, partner or ex-partner attempts to physically or psychologically dominate another. Domestic violence often refers to violence between spouses, or spousal abuse but can also include cohabitants and non-married intimate partners.

17. Domestic violence in Vermont • In 2008, it was estimated that 7,835 children/youth (a conservative estimate) were identified through the Network’s 15 domestic violence programs as experiencing or having experienced domestic violence between July 1, 2007 and June 30, 2008. In 2008, The Department for Children and Families, Family Services, Domestic Violence Unit consulted on 1,892 child abuse reports that had co-occurring domestic violence.

18. Where one form of family violence exists, there is a likelihood the other A survey of more than 6,000 American families found that 50% of men who frequently assaulted their wives also frequently abused their children. Slightly more than half of female victims of domestic violence live in households with children under age 12 Studies suggest that as many as 10 million children witness domestic violence each year.

19. How does domestic violence affect children? No standard response to living with domestic violence and all children may react differently. Many children are very resilient and do overcome significant problems However children may experience a wide range of physical, emotional, behavioural and social problems as a result

20. Youth who witness domestic violence are more likely to: • Exhibit behavioral and physical health problems • including depression, anxiety, and violence • towards peers • Attempt suicide • Abuse drugs and alcohol • Run away from home • Engage in teenage prostitution • Commit sexual assault crimes

21. Risks Posed To Children By Exposure To Batterers Risk of exposure to threats or acts of violence towards their mother. Risk of undermining mother-child relationships. Risk of physical abuse of the child by the batterer. Risk of sexual abuse of the child by the batterer

22. Risks Posed To Children By Exposure To Batterers Risk to children of the batterer as a role model. Risk of rigid, authoritarian parenting. Risk of neglectful or irresponsible parenting. Risk of psychological abuse and manipulation. Risk of abduction. Risk of exposure to violence in the batterer’s new intimate relationships.

23. What do children say? Children describe being abused or neglected and being afraid They may take on more physical or emotional responsibility for family members / household tasks DV affects children’s schooling, educational and play opportunities and friendships Emotional and physical symptoms (e.g. nightmares) may not go away after they are away from the violence

24. How do children say domestic violence makes them feel? • Terrified and afraid - “walking on eggshells” • Love and loyalty Loss • Sadness, isolation and depression • Anger and aggression - “I’d like to kill him” • Guilt and shame - “I’m really sorry I didn’t stand up for you when daddy used to hit you but I was only little and I was afraid.” (McGee, 2000) • Stigma

25. Jane Middelton-Moz Children of Trauma Copyright: 1986 Jane Middelton-Moz From Legacy to Choice

26. Shame exercise Jane Middelton-Moz

27. Guilt and Shame Guilt Feeling responsible for an event, outcome, situation that maybe real or imagined Shame A feeling of disappointment about something inside of us. “ We feel guilt about what we do or don’t do, and we feel shame for what we are”.

28. SHAMECompulsion to repeat: • The one who is humiliated becomes the one who humiliates. • The one who is humiliated hurts and humiliates themselves • The one who is humiliated seeks out relationships where humiliation continues • Talking it out and feeling it out ends acting it out Jane Middelton-Moz Shame and Guilt the Master of Disguise

29. Prevalence of Child Abuse United States

30. 3 Million Reports of Child Abuse Annually • 1 Million Reports are Substantiated • Child Abuse World-Wide • 73 million boys • 150 million girls • Sexually abused annually • 53,000 children are murdered each year • World Health Organization

31. Prevalence of Trauma—United States • Each year in the United States, more than 1,400 children—nearly 2 children per 100,000—die of abuse or neglect. • In 2005, 899,000 children were victims of child maltreatment. Of these: • 62.8% experienced neglect • 16.6% were physically abused • 9.3% were sexually abused • 7.1% endured emotional or psychological abuse • 14.3% experienced other forms of maltreatment (e.g., abandonment, threats of harm, congenital drug addiction) Source: USDHHS. (2007) Child Maltreatment 2005; Washington, DC: US Gov’t Printing Office.

32. U.S. Prevalence • One in four children/adolescents experience at least one potentially traumatic event before the age of 16.1 • In a 1995 study, 41% of middle school students in urban school systems reported witnessing a stabbing or shooting in the previous year.2 • Four out of 10 U.S. children report witnessing violence;8% report a lifetime prevalence of sexual assault, and 17% report having been physically assaulted.3 • 1. Costello et al. (2002). J Traum Stress;5(2):99-112. • 2. Schwab-Stone et al. (1995). J Am Acad Child Adolesc Psychiatry;34(10):1343-1352. • 3. Kilpatrick et al. (2003). US Dept. Of Justice. http://www.ncjrs.gov/pdffiles1/nij/194972.pdf.

33. Vermont Children Affected by Trauma • Number of children in DCF protective custody (FY’04) • 2,148 • DCF intakes w/ domestic violence identified • 1,533 ( of 12,397) • Children exposed to domestic violence • 9119 • Emergency Room Injury Child Victims • 15,012 (10% referred to CMH) • Percentage in DCF custody served by CMH • 24% Personal communication, Ellie Breitmaier, MSW, Coordinator, DCF Domestic Violence Unit., J. & Ghosh, K. (February 6, 2004).Vermont Mental Health Performance Indicator Project. Young Trauma Victims served in Mental Health Programs. Network Against Domestic Violence

34. Prevalence of Trauma in Vermont • In 2005, 1,436 children in Vermont lived apart from their families in out-of-home care, compared with 1,432 children in 2004. In 2005, 18.3% of the children living apart from their families were age 5 or younger, and 30.2% were 16 or older. 1. • Of the children in out-of-home care in 2005, 95% were white, 2.7% black, 1% Hispanic, 0.2% American Indian/Alaskan Native, and 1.1% children of other races and ethnicities. 2. 1.Child Welfare League of America. (2007). Special tabulation of the Adoption and Foster Care Analysis Reporting System. Washington, DC: Author.  2."Other races and ethnicities" includes Asian, Pacific Islander, Illinoisan Native, unknown or unable to determine, missing data and two or more races. CWLA (2007) Special AFCARS tabulation. 

35. Prevalence of Traumain the Child Welfare Population • A national study of adult “foster care alumni” found higher rates of PTSD (21%) compared with the general population (4.5%). This was higher than rates of PTSD in American war veterans.1 • Nearly 80% of abused children face at least one mental health challenge by age 21.2 • 1. Pecora, et al. (December 10, 2003). Early Results from the Casey National Alumni Study. Available at: http://www.casey.org/NR/rdonlyres/CEFBB1B6-7ED1-440D-925A-E5BAF602294D/302/casey_alumni_studies_report.pdf. • 2. ASTHO. (April 2005). Child Maltreatment, Abuse, and Neglect. Available at: http://www.astho.org/pubs/Childmaltreatmentfactsheet4-05.pdf.

36. Prevalence in Child Welfare Population • A study of children in foster care revealed that PTSD was diagnosed in 60% of sexually abused children and in 42% of the physically abused children.1 • The study also found that 18% of foster children who had not experienced either type of abuse had PTSD,1 possibly as a result of exposure to domestic or community violence.2 1. Dubner et al. (1999). JCCPsych;67(3): 367-373. 2. Marsenich (March 2002). Evidence-Based Practices in Mental Health Services for Foster Youth. Available at: http://www.cimh.org/downloads/Fostercaremanual.pdf.

37. Impact of Child Abuse Children who have experienced a traumatic event show an increased incidence of: Ischemic heart disease Cancer Chronic Lung disease Skeletal fractures Liver disease

38. Temporal Lobe Epilepsy • Developmental Disabilities; 10-25% • 3-6% of abused children will have a permanent disability as a result of the abuse • Between 20-50% of abused children suffer mild to severe brain damage. • The vast majority of all child abuse occurs within the family system. • (Office of Trauma Services, Department of Mental Health, Mental Retardation and Substance Abuse Services, Augusta, Maine)

39. Impact of Child Abuse • Early abuse and neglect negatively effect the maturation of the developing brain. • 80% of traumatized children have disorganized attachment patterns • During adolescence traumatized children have a 300% greater chance to engage in substance abuse, self-mutilation and aggressive behavior • The Neurobiology of Childhood Trauma and Abuse, Bessel van der Kolk, M.D.

40. Impact of Child Abuse • Childhood trauma is associated with increased rates of: • Imprisonment • Substance abuse • HIV status • Unemployment status • Use of psychiatric services • Impaired Health Status • (Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards, Koss & Marks, 1998).

41. Impact of Traumatic Stress • A child’s response to a traumatic event may have a profound effect on his or her perception of self, the world, and the future. • Traumatic events may affect a child’s: • Ability to trust others • Sense of personal safety • Effectiveness in navigating life changes

42. “It was the worst part of my life – constantly being shouted at, frightened, living in fear. You will never know what it’s like, thinking that every day could be your last.”16 year old South Asian girl quoted in Mullender et al., 2002

43. The pain we carry around everyday Always going last/ being put aside Being violent Being beaten up while parents are drunk Family violence Child abuse No encouragement Always talking about mistakes Anger Blame Being judged Under estimated Adults aren’t paying attention Being lied to Sexual abuse/assault Not feeling respected Self destructive Shame Guilt Self hatred and hatred to others Mistissini,2009 Afraid of our own anger and violence

44. Effects of Trauma Exposure Dissociation. Some traumatized children experience a feeling of detachment or depersonalization, as if they are “observing” something happening to them that is unreal. Behavioral control. Traumatized children can show poor impulse control, self-destructive behavior, and aggression towards others. Cognition.Traumatized children can have problems focusing on and completing tasks, or planning for and anticipating future events. Some exhibit learning difficulties and problems with language development. Self-concept. Traumatized children frequently suffer from disturbed body image, low self-esteem, shame, and guilt.

45. Effects of Trauma Exposure Attachment. Traumatized children feel that the world is uncertain and unpredictable. They can become socially isolated and can have difficulty relating to and empathizing with others. Biology. Traumatized children may experience problems with movement and sensation, including hypersensitivity to physical contact and insensitivity to pain. They may exhibit unexplained physical symptoms and increased medical problems. Mood regulation. Children exposed to trauma can have difficulty regulating their emotions as well as difficulty knowing and describing their feelings and internal states.

47. Traumatic Reaction Exposure to Trauma Post-Traumatic Stress Disorder Avoidance/Numbing Hyperarousal Re-Experiencing Traumatic event

48. Post Traumatic Stress Syndrome • Persistent re-experiencing of the event (i.e., distressing dreams, distressing recollections, flashbacks, or emotional and/or physiological reactions when exposed to something that resembles the traumatic event). • Persistent avoidance of things associated with the traumatic event or reduced ability to be close to other people and have loving feelings.

49. Persistent symptoms of increased arousal (i.e., sleep difficulties, outbursts of anger, difficulty concentrating, constantly being on guard, extreme startle response). Duration of at least one month of symptoms. Disturbance produces clinically significant distress or impairment in social, occupational or other important areas of functioning PTSD

50. Childhood Trauma and Other Diagnoses • Other common diagnoses for children in the children’s Mental health system include: • Reactive Attachment Disorder • Attention Deficit Hyperactivity Disorder • Oppositional Defiant Disorder • Bipolar Disorder • Conduct Disorder • These diagnoses generally do not capture the full extent of the developmental impact of trauma. • Many children with these diagnoses have a complex trauma history.