Trauma Screenings - PowerPoint Presentation

Slide1

Trauma Screenings

Marisol Acosta,

MEd, LPC-Supervisor , Project Director Texas Children Recovering From Trauma Initiative Department of State Health Services, Mental Health and Substance Abuse Division

April 17, 2015Slide2

Objectives

Increase the understanding and importance of trauma screenings: “why” screen, “what” to screen, and “how” to screen

Differentiate Trauma Screenings vs Trauma AssessmentOverview of different types of trauma screening toolsSlide3

The “WHY”Slide4

Facts

Trauma is widespread and pervasive

Trauma does not occur on a vacuum, but within the context of a communitySAMHSA, 2014Slide5

Facts

Physical traumas are the leading cause of death for individuals ages 1-44

(University Health System of Bexar County, 2014)70% of adults have experienced some type of traumatic event at least once in their lives. (National Council on Behavioral Health, 2014)In the U.S. a woman is beaten every 15 seconds; and a forcible rape occurs every 6 minutes. (National Council on Behavioral Health, 2014) 5Slide6

Facts about children

25% of all children have experienced at least one traumatic event (NCTSN, 2007)

Before age of four, 26% of all children have witnessed or experienced a traumatic event (SAMHSA, 2011)Children with disabilities are at least 2 times more likely to be abused or neglected. (NCTSN, 2004)83-93% of children living in neighborhoods with high rates of violent crimes would have experienced trauma (National Center for Children in Poverty, 2007)Slide7

Children in Texas

66,897 children/youth were confirmed victims of abuse and neglect

(DFPS, 2010)63% of them were between the ages of 0-13 (DFPS, 2010)The incidence of PTSD was between 15-90% depending on the type of abuse (TexProtects, 2010)In 2009, 193,505 incidents of family violence were reported (Texas Council on Family Violence)In 2007, 369 children were identified as victims of human trafficking in Texas

(THTTF, 2011)In 2011, Texas became the leading state of residence of refugees in the U.S. and 34% were younger than 18 (Martin & Yankay

, 2011)Slide8

WHY Screen for Trauma?

To Understand and SupportDevelop a collaborative relationshipPrevent Adverse Effects

To Provide Appropriate Care and ServicesTreat Adverse EffectAddress the impact of trauma and increase functioning and coping mechanismsFoster Resilience & RecoverySlide9

Why screen for trauma?

To Become A Trauma Informed OrganizationA system or program “informed”, knowledgeable and sensitive to the impact of trauma in the individual/families’ lives and/or the vulnerabilities of survivors of traumatic events

Services are delivered in a way to avoid re-traumatizationFosters consumer/individual participationAddresses the vicarious impact on the workforce With Individuals That Receive Services:Acknowledge history of trauma in service planning: prioritize safety, focus on recovery & wellness, incorporate’s client’s voice and choiceTrauma ScreeningsUnderstand client’s behavior or interactions may be a reflection of they trauma reactions and effects (not “laziness”, not “lack of compliance” or “attitude”)Slide10

It’s

a Best Care Practice National Association of State Mental Health Program Directors (NASMHPD)

Substance Abuse and Mental Health AdministrationNational Center on Trauma Informed CareNational Child Traumatic Stress NetworkNational Council on Behavioral HealthProfessional AssociationsSlide11

To Address/Prevent the “

Effects’’of Trauma

Duration:Short-TermLong-TermInability to cope with normal stressors and daily livingImpacts neurobiological functions11

Adverse Childhood Events (ACE) Study

CDC and Kaiser Permanente in CA from 1995 to 1997, and more than 17,000 participantsSlide12

The impact of lack of screenings

Trauma history is overlooked by professionals in mental health settings.

Even when 1 event is has been reported, clinicians overlook other forms of abuse or maltreatment (Briere, 2004)Studies have found that child abuse disclosure of psychotic patients are often dismissed, ignored, or marginalized under the belief that discussing the issues will make them worse. (Hammersley, 2004)Slide13

Trauma is rarely reflected in primary or secondary

diagnosisStudy Findings

46% of women in psychiatric hospitals with a psychotic disorder have history of incest (van der Kolk, 1987)98 % of patients with serious mental illness (schizophrenia and bipolar disorder) reported at least 1 traumatic event, only 2% had a diagnosis of PTSD in their chart. (Mueser et al, 1998)Slide14

Trauma responses are often misdiagnosed under symptoms of:

ADHDBipolar DisorderMood Disorder NOS

Psychosis NOSBorderline Personality - Tucker, 2002Slide15

Risks of Failing to Screen

Misdiagnosis Inappropriate treatment plan

Increase vulnerability to substance useIncreases the probability of developing other serious mental illness, physical illness and risk of early deathIncrease chances of re-traumatizationIncrease social isolation Increase risk of suicide (in some traumatic events)Creating cascading effect on the individuals life and inappropriate care.Slide16

Elements that Contribute to the Failure to Screen

Underreporting of Trauma Survivors

Lack of TrustShame and GuiltMemory problemsAvoidance of Reminders of TraumaCultural beliefs about traumaMinimizing trauma eventsFear of retaliation by abuser (told to keep it a “secret”)Fear of lossInability to verbalize (children)Slide17

Elements that Contribute to Failure to Screen

Underreporting by ProviderLack

of training“It’s not required” /”No time”Personal beliefs that the client will get worse Lack of understanding and competency in how to address, respond or treat traumaProviders personal discomfort in talking about abuse or trauma (e.g. sexual abuse)Cultural/personal beliefsProvider only asks about physical and sexual abuseSlide18

“Universal trauma screenings and specific trauma assessment methods are necessary to developing relationships with trauma survivors and offering appropriate services”

Harris &

Fallot 2001Slide19

The “WHAT”

What are we screening?Slide20

TRAUMA

Shell ShockAftermathTrauma

Traumatic EventChildhood Traumatic StressAdverse Childhood EventsToxic StressStressorsWhy so many words?Slide21

What is considered a traumatic “Event”?

Event or circumstances that created the experience that caused an actual or extreme threat of physical or emotional harm

(SAMHSA, 2014)A common definition in the trauma field:

A traumatic event is

an experience

that

causes physical

,

emotional

,

psychological distress

, or

harm. It is an event that is perceived and experienced as a threat to one's safety or to the stability of one's world.Slide22

An “Event” as a “Stressor”

The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows:

(1 required) Direct exposure. Witnessing, in person , orIndirectlyRepeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties Diagnostic Statistical Manual -5 of Mental Health Disorders(APA, 2013)

22Slide23

The “Experience” of the event

…helps determine whether the event or circumstances is a traumatic event

The experience and perception of a particular event may be considered traumatic by one in individual and not for anotherHow individuals labels, assigns meaning, and is disrupted physically and psychologically by an event will contribute to whether or not it is experienced as traumatic (SAMHSA, 2014)23Slide24

VIOLENCE

Definitions of violence change through time and vary according to culture of a particular country or region

(Online Encyclopedia of Mass Violence, 2012)Buddhist SwastikaNazi SwastikaSlide25

Violence:

according to the World Health Organization (WHO)

"the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.“(World Report on Violence and Health: WHO, )Slide26

Three subtypes of violence according to the

victim-perpetrator relationship

Self- directed violenceSelf abuse / “Self-harm” (self-mutilation, cutting, etc)SuicideInterpersonal violence (refers to violence between individuals)Family/Partner (domestic: child, partner, elder)Community violence: acquaintance, strangersCollective violence

Refers to violence committed by larger groupsSocialPoliticalEconomic

(World Health Organization)Slide27

Johan Galtung’s

Three Forms of Violence

VIOLENCEDirect Violence (hurting others physically)Cultural Violence(beliefs /cultural stories that glorify and normalize violence)

Structural Violence

(embedded into systems restricting rights and access to resources)

Visible

InvisibleSlide28

Pandora’s Box of Invisible Violence

Structural Violence

Unequal access to: water, food, housing, services, health care, terms of market tradeDiscrimination Laws / Gender Inequality/Institutionalized RacismSymbolic ViolenceSocial beliefs against indigenous population, against migrants, beliefs of certain punishmentsNormalized Violence“Normalizing the unthinkable”Human rights violationsJustification for child abuse, rape or domestic violence (as a norm)Separation of classes or groupsSlide29

Childhood Traumatic Stress

Child traumatic stress occurs when children and adolescents

are exposed to traumatic events or traumatic situations that overwhelm their ability to cope.These reactions interfere with his or her daily life and ability to function and interact with others.  -National Child Traumatic Stress Network 29Slide30

Events that can be considered traumatic

NeglectAccidents, Medical ProceduresNatural /Man-Made Disasters

Abuse: emotional, physical, sexualBullyingExploitation/Human TraffickingDomestic Violence/Community ViolenceWar/TortureHistorical TraumaMilitary Life Transitions/ExperiencesWitnessing an “event”30Slide31

In Young Children

Separation from parent or caregiver/attachment disruptionAbuseNeglect

HungerAccidents/Physical TraumaWitnessing Violence (Family Violence)Impaired CaregiverRapid developing brains increase vulnerability.Infants and Toddlers are impacted by problems affecting their parents. (e.g. Post-Partum Depression, substance abuse, disruptive bond or lack of understanding)31Slide32

Physical Responses

Mental Responses

Behavioral Responses

Social Responses

Common Responses to

Traumatic

StressSlide33

Common Responses to Trauma

Re-experiencing the event in diverse manners (Intrusions)

AvoidanceNegative alterations of cognitions (thoughts) and mood (feelings) that began or worsened after the eventAlterations in arousal and reactivitySlide34

Exposure to Trauma

Exposure to traumatic events is related to the onset of behavior changes

in children/youth. In some, it also increases the risk of onset of mental disorders:Depression*AnxietyTrauma-and-Stressor Related DisordersOther Slide35

Trauma-and-Stressor Related Disorders in Children

Reactive Attachment DisorderDisinhibited Social Engagement Disorder

Post Traumatic Stress Disorder (PTSD)PTSD for Children 6 Years and YoungerAcute Stress DisorderAdjustment DisorderOther Specified Trauma-and-Stressor Related DisorderDSM-5Slide36

The “HOW”

How do you screen?Slide37

Definitions: Trauma Screening vs Assessment

Trauma Screening

Brief and focused inquiry to determine whether an individual has experienced a specific type of traumaTrauma AssessmentAn in depth exploration and evaluation of the nature, severity and impact of traumatic events and its sequelae in the individuals functioningSlide38

Types of Trauma Screenings

History of traumatic event exposure (types of trauma exposure)

Presence of Symptoms/responses to Trauma or Post Traumatic Stress DisorderCombines both history of exposure and presence of symptomsMultiple Symptoms of Trauma and Other related diagnosis or life domains (e.g. depression, anxiety, anger, trauma, PTSD, sexual concerns) (Strand, Sarmiento, and Pasquale, 2005)Slide39

Prioritize and give clients choice and control

Explain clearly the reasons for screening

Provide the choice that they can refuse to answer any questions, not answer a questionProvide the opportunity for them to stop the screening and reschedule appointmentProvide the options for them to self-regulate and sooth themselves if needed (e.g. allow to grab a pillow, toy, blanket)Explain that they can ask to take a breakIf available, encourage the completion of a self-report trauma screening toolSlide40

How to Ask:

Best Practice:Ask for exposure of all types of trauma

(like a checklist)Other practice (not as effective)Ask general question: “Have you ever or has your child ever experience or have been exposed to an event or incident that was actual or threatening serious injury, violence or danger to you (child) or someone else? Or an event that someone can consider traumatic?”How NOT to ask: “Have you ever experienced a traumatic event or witnessed trauma?Slide41

General Guidelines

Universal Screenings (screen everyone/ all age groups for all services)Create a safe environment

Do the screening as early as possible in the Intake Process or at least in the 1st Psychosocial Assessment visit.Use unambiguous and straightforward language (no jargon, no abbreviations, call things by their name: “rape”, “torture”, “penis”, “Vagina”. “abuse”Briefly discuss self-regulation and coping skills and provide a brief written handout in case person feels distress by trauma reminders after the appointment.Slide42

Assessment of Complex Trauma: developing a common framework across systems

Create a Safe Environment

Provide adequate privacy (in particular for the child), Encourage to ask questions & provide assessment toolsReview limits of confidentialityGather information using a variety of techniques and approaches (clinical interview, standardized measures, and behavioral observations.)Assess for wide range of traumatic events. Determine when they occurred so that they can be linked to developmental stages and onset of behavior problems.Assess for a wide range of symptoms risk behaviors, functional impairments, and developmental derailments.Slide43

4. Gather information from

Multiple perspectives (child, caregivers, teachers, other providers,

etc). Talk to the child – start treatment with event child find more stressful or threatening5. Work with Family to Make Sense of Results and Develop a Treatment/Service Plan Try to make sense how each traumatic event might have impacted developmental tasks and derailed future development. Try to link traumatic events to trauma reminders that may trigger symptoms or avoidant behavior. 6. Assess Trauma Over Time (ongoing assessment)   (NCTSN, 2015)Slide44

Special Assessments of Trauma

Forensic Assessments for Victims of Crimes (e.g. abuse)

Asylum Seekers Evaluation or Psychological Evaluation for Special Visas(e.g. human trafficking, domestic violence, victims of crime, unaccompanied minors, etc.)Slide45

List of Trauma Screenings

Trauma Screenings (Events Only)

Brief Trauma Questionnaire (A)Upsetting Events Survey (A)Life Event Checklist (A)Trauma Events Screening Inventory (C)Trauma Screenings (Symptoms Only)PTSD Checklist PCL (A)Abbreviated PCL-Civilian Version (A)Child Post-traumatic Symptoms Scale (CPSS)Trauma Screening Questionnaire (A)Youth Outcome Questionnaire (Y)Children’s Alexithymia MeasureAttachment Questionnaire for ChildrenSlide46

Both History & Symptoms

Harvard Trauma Questionnaire (A) (Y)

UCLA PTSD Reaction Index (C)(Y)Recognize Trauma – trauma screening tool (C, Y) Multiple symptomsBeck Depression Inventory IIJohn Hopkins Depression & AnxietyCRAFFT (C)Child Behavior Checklist for Young Children (C) (Y)Child & Adolescent Needs & Strengths (CANS Trauma), (Texas CANS)Structured Interview for Disorders of Extreme Stress (C, Y)Trauma Symptoms Checklist for Children (multiple versions)Slide47

Where to find Trauma Screening Tools?

National Child Traumatic Stress Network

http://www.nctsn.org/content/standardized-measures-assess-complex-traumaSAMHSAhttp://www.integration.samhsa.gov/clinical-practice/screening-toolsNational Center for PTSDhttp://www.ptsd.va.gov/professional/assessment/overview/index.aspThe Anna InstituteSlide48

Children's Mental Health Awareness Walk

Saturday, May 2nd 2015Texas State CapitolSlide49

Texas Children Recovering From Trauma

Aim:

Transform children’s mental health services in Texas into a trauma-informed care system that fosters resilience and recovery.How? Creating a Category III Community Treatment Services Centers

members of the National Child Traumatic Stress Network

(NCTSN) and their learning

community:

Heart of Texas Region MHMR

CenterServes

the following counties: Bosque

, Hill, McLennan, Falls, Limestone and Freestone.

Target Population:

Children ages 3 to 17 impacted by trauma or children of military families.

Funded by: SAMHSA’s National Child Traumatic Stress Initiative

Grant No: 1U79SM061177-01

Funding Period Oct 2012-Sept 2016Slide50

How?

Through Training:

Creating Community Partners Creating of a Statewide Transformation Strategic PlanStatewide Summit on Transformation to Trauma-Informed CareANNOUNCEMENTS:TRAUMA INFORMED NETWORK OF TEXAS (Join Us!)

TRAUMA INFORMED CARE SUMMIT (August 2016)Slide51

Contact Information:

51

Marisol Acosta, MEd, LPC-SupervisorProject Director , Texas Children Recovering From Trauma, Child & Adolescent Services, MHSA Division Department of State Health ServicesEmail: Marisol.Acosta@dshs.texas.govPhone: 512-206-4830DSHS-MHSA DivisionP.O. Box 149347, MC 2091

Austin, TX 78714-9347

Funded by SAMHSA NCTSI Initiative Grant #5U79SM061177-03