Report: CT has made progress on child trauma, but gaps persist

Connecticut has made significant advances in providing help for children exposed to trauma — in some cases emerging as a national leader in addressing a problem research has linked to a greater likelihood of medical and mental health problems later in life, problems in school and a greater risk of involvement in the juvenile justice system, according to a report released Tuesday by the Child Health and Development Institute of Connecticut.

But, the authors added, more work is needed to prevent, identify and address trauma in children.

Jason Lang, one of the report’s authors, said a key challenge is to move beyond basic training and education on the effects of trauma to changing practices and systems.

“Everybody hears, ‘children exposed to trauma,’ and there’s not a lot of disagreement that that’s a bad thing or that that’s a problem that needs to be addressed,” said Lang, a clinical psychologist with expertise in trauma at the Child Health and Development Institute. “I think what becomes more complicated, though, is how you address it.”

The Child Health and Development Institute, a nonprofit based in Farmington, has been involved in a number of initiatives to expand the use of trauma-informed practices in Connecticut.

Alice Forrester, executive director of the Clifford Beers Clinic in New Haven, which is involved in several trauma-related initiatives cited in the report, said that while trauma is now being addressed in many different systems, there’s still a need for broader buy-in.

“We’re doing it in health care, we’re doing it in the schools, we’re doing it in clinical services, but we’re still in this position of doing trauma 101, introducing people to the concepts,” she said. “It’s still not a pervasive, accepted understanding [in the state about] the long-term health and learning consequences of chronic stress.”

Trauma is common, but sometimes overlooked
This is a photo of Alice Forrester

Arielle Levin Becker / CTMirror.org

Alice Forrester

Studies indicate that exposure to potentially traumatizing events including physical or sexual abuse, violence or serious accidents is common among children. One national study that used a relatively wide range of experiences, for example, found that 60 percent of children under 17 had been victimized or witnessed violence in the previous year.

Many children recover from those experiences, but some, especially those exposed to severe or chronic trauma, or who have little support to help them cope, can face significant and lasting problems. And because one hallmark of exposure to trauma is wanting to avoid thinking about it, children often don’t tell people unless they’re asked directly. In some cases, experts say, children whose trauma history wasn’t known have been misdiagnosed as having other problems and received ineffective treatment, or had symptoms of trauma treated as problem behaviors.

Lang gave an example of a child who was disruptive in one class at school. The school treated it as a behavioral issue. But when the child was eventually screened for trauma, he revealed that he had been sexually abused. The perpetrator resembled the teacher, and being in the teacher’s class brought back memories of the experience. Knowing that helped the school better address the child’s behavior, Lang said.

The point isn’t that trauma explains all problematic behaviors in children, Lang said. But, he added, “It is common enough and significant enough that it should be one of the main factors that are screened for or considered at least,” he said.

But, the report notes, the vast majority of Connecticut’s 784,000 children are not screened for trauma, especially preventively, before they exhibit problematic behaviors or require help.

Expanded training, screening, treatment
This is a picture of Dr. Kenneth Spiegelman, a pediatrician who trains other health care providers about training, during a presentation to school nurses.

Arielle Levin Becker / CTMirror.org

Dr. Kenneth Spiegelman, a pediatrician who trains other health care providers about training, during a presentation to school nurses.

The report also noted progress, including the fact that, since 2007, more than 50,000 children have been screened for exposure to trauma.

More than 8,600 mental health professionals, pediatricians and medical office staff, and juvenile justice and child welfare workers have been trained in understanding childhood trauma since 2007.

And in that time, more than 8,700 children have been treated using models shown through research to be effective, the result, in part, of a federal grant the state Department of Children and Families received to expand the use of proven treatments and develop a trauma-informed child welfare system. Most of the treatment models emphasize teaching children or adults what trauma is and how it affects them – often, people dealing with trauma don’t understand why they’re feeling the way they do, Lang said – and how to understand and regulate their emotions.

Connecticut was one of the first states to screen children involved in the child welfare system for trauma, and DCF now requires comprehensive trauma training for child welfare workers.

The report said the state Judicial Branch’s Court Support Services Division, which oversees most of the Connecticut’s juvenile justice system, has been a national leader in screening youth for trauma histories, starting in 2005. The agency recently began testing the use of trauma screening by juvenile probation officers, which the report said could make them more likely to pursue counseling and support rather than relying on disciplinary strategies that don’t necessary address the underlying trauma.

About 90 percent of youths involved in the juvenile justice system have histories of trauma, according to the report.

Thousands of police officers – who are often the first professionals to intervene during or immediately after a traumatic event – have received training on how to respond to behavioral health crises, and some police departments, including Manchester’s and Waterbury’s, have trained officers on minimizing trauma in children when their parents are arrested.

There are also several local initiatives that take a more comprehensive approach. The New Haven Trauma Coalition, for example, involves multiple agencies and focuses on school-aged children and includes providing trauma screenings in schools, training teachers about trauma and providing trauma treatment and care coordination in schools.

Gaps, challenges
This is a picture of Jason Lang

Child Health and Development Institute

Jason Lang

But the report noted that challenges and gaps remain.

Although many agencies now provide trauma treatments that have been shown to work, doing so can come at the expense of an agency’s bottom line, since it requires more time for staff training and, often, staff see fewer clients.

The report notes that pediatric primary care offices can be good settings for trauma screening, since they reach nearly all children. The Child Health and Development Institute has been pushing for pediatricians to screen children for trauma during well-child visits, and has been training pediatricians on trauma, but the report’s authors said that out of all behavioral health concerns, medical providers are least comfortable addressing childhood trauma.

And according to the report, there are some systems – including schools, early childhood education and child care, and pediatric primary care – that are just beginning to work on developing trauma-informed care. The report also suggests the need for proven programs that prevent child maltreatment and other trauma exposure and build resiliency.

The Connecticut Juvenile Training School in Middletown, a locked jail for young males that break the law.

CTMirror.org

The Connecticut Juvenile Training School in Middletown, a locked jail for young males that break the law.

DCF has recently come under fire for conditions inside the two juvenile jails it runs, where reports indicate that the vast majority of the youth have histories of trauma. Some trauma experts raised concerns about the use of restraint and seclusion inside the facilities and the overall environment, warning that they are particularly problematic for children dealing with the effects of trauma.

In a recent report, the Office of the Child Advocate said DCF “must dramatically expand and strengthen its training and supervision supports to ensure robust attention to trauma-informed principles.”

DCF officials have said restraint and seclusion should be avoided, and now require a clinician to play a larger role in incidents which involve placing children in isolation. Doing so, they hope, will help ensure that practices are more trauma-informed.

The view from one agency

Karen Ethier-Waring, director of clinical services at Child & Family Agency of Southeastern Connecticut, has seen the growth in trauma-informed care in Connecticut, and knows the remaining gaps.

About six years ago, all therapists at her agency were trained in one model — trauma-focused cognitive behavioral therapy — as part of a learning collaborative used to spread the practice widely in Connecticut.

In the past, there were just a few people at the agency who specialized in trauma and were willing to take on the “really overwhelming” cases. “And now all of our clinicians have a sense of competency,” Ethier-Waring said. “They have a sense of competency, ‘I know what I’m doing.’”

While the model works well for people who have had specific traumas, it doesn’t fit all clients, she said, and in some cases, hasn’t been as effective in clients who have had chronic trauma exposure. The model requires a lot of involvement by a child’s caregiver, but Ethier-Waring said some children her agency works with are in state custody and moving from foster home to foster home, without having a consistent adult in their lives.

“There’s still a long way to go,” she said.

But Ethier-Waring said she’s hopeful. Her agency is providing training on trauma to teachers in the New London Public Schools. “It’s just amazing how they go, ‘Oh, this makes sense,’” she said.

“I think school systems and towns are becoming more aware that we need to be more trauma-informed,” she said.

Recommendations

Among the report’s recommendations:

  • Create a high-level position or job function to focus on trauma-informed care at each state agency and community system that serves children, including school systems.
  • Require at least introductory trauma training for all staff in agencies or programs that serve children, including judges, court-appointed guardians that represent children and staff in educational and medical settings.
  • Routinely screen children for trauma when they enter any service system, and periodically while they receive services, using standardized measures.
  • Require or incentivize trauma screening in pediatric primary care, child care and early-childhood education, and schools – the settings where children are most likely to have contact with trained professionals.
  • Complete cost-benefit analyses of trauma-informed care in Connecticut to identify and expand the approaches deemed most cost-effective.
  • Provide higher reimbursement rates to clinical providers that show high-quality use of proven, cost-effective trauma-focused treatments.
  • Provide funding for trauma screening done by pediatricians and behavioral health providers.

Information about child trauma and treatment is available at www.kidsmentalhealthinfo.com.

Jacqueline Rabe Thomas contributed to this story.

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