Trauma Informed Health Care

Information about Trauma Informed Health Care

Published on August 5, 2014

Author: CPEIP

Source: authorstream.com

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PowerPoint Presentation: Trauma Informed Health Care Trauma in Young Children: Trauma in Young Children Trauma is an event that is unpredictable, produces a feeling of helplessness, and overwhelms one’s capacity to cope. Toxic Stress & Trauma: Toxic Stress & Trauma Frequent or continual stress on young children who lack adequate protection and support from adults is strongly associated with increases in the risks of lifelong health and social problems . PowerPoint Presentation: Health Care: The Need Early Adverse Experiences: Physical Health Problems Mental Health Problems Crime & Delinquency Addictions Poor Parenting Capacity Academic & School Problems …lead to a multitude of societal p roblems: Early Adverse Experiences Most Maltreated Children Have Developmental Problems: Most Maltreated Children Have Developmental Problems First Five Years Hold Most Opportunity & Vulnerability : First Five Years Hold Most Opportunity & Vulnerability 7 Left Behind By Kindergarten ACE Study: ACE Study Physical abuse Emotional abuse Sexual abuse An alcohol and/or drug abuser in the household Someone who is chronically depressed, mentally, ill, institutionalized, or suicidal One or no parents Emotional or physical neglect ACEs Questionnaire The Relationship of Adverse Childhood Experiences & Adult Health Source: CDC. (2014). Injury prevention and control: Adverse Childhood Experiences study . http://www.cdc.gov/violenceprevention/acestudy/ Adverse Childhood Experiences : Adverse Childhood Experiences Physical, emotional or sexual abuse ( 25% beaten as a child ) Emotional or physical neglect Growing up with family members who had mental illness, alcoholism or drug problems ( 25 %) Family violence Incarcerated family member One or no parents Parental divorce Adverse Childhood Experiences (ACE) Study. Information available at http://www.cdc.gov/ace/index.htm Of 17,000 respondents, two-thirds had at least 1 adverse childhood event. Widespread Prevalence of Adverse Childhood Experiences : Source: V. Felitti , 2005 Widespread Prevalence of Adverse Childhood Experiences Substance abuse 27% Parental separation/divorce 23% Mental illness 17% Battered mother 13% Incarcerated family member 6% Household dysfunction Psychological 11% Physical 28% Sexual 21% Emotional 15% Physical 10% Abuse Neglect Of 17,000 respondents , 2/3s had at least 1 ACE . Adverse Childhood Experiences (ACE) Study. Information available at http://www.cdc.gov/ace/index.htm ACE Scores Linked to Physical & Mental Health Problems: ACE Scores Linked to Physical & Mental Health Problems One in six people had 4 or more ACEs. People with 4 or more ACEs were: Twice as likely to be smokers . Seven times as likely to be alcoholics . Men with 6 or more ACEs were 46 times as likely to inject drugs. Adverse Childhood Experiences (ACE) Study. Information available at http://www.cdc.gov/ace/index.htm ACE Scores Linked to Physical & Mental Health Problems: ACE Scores Linked to Physical & Mental Health Problems People with 4+ ACEs were likely to: Be sexually active before age 15: 6x Have cancer or heart disease: 2x Attempt suicide: 12x People with 7+ ACEs had: A 360% higher risk for heart disease, even if they did not smoke, drink, or carry extra weight Adverse Childhood Experiences (ACE) Study. Information available at http://www.cdc.gov/ace/index.htm Trauma Informed Schools: Trauma Informed Schools 13 * Source: National Child Traumatic Stress Network 1 of 4 School children exposed to a traumatic event. ACE Study: Early Adverse Experiences Lead to Multiple Problems in Society: ACE Study: Early Adverse Experiences Lead to Multiple Problems in Society Academic / School Mental Health Crime/Delinquency Physical Health Domestic Violence Addictions Impact of Toxic Stress Over Lifetime: Impact of Toxic Stress Over Lifetime ACE Study Shows an indisputable relationship b etween Adverse Childhood Experiences & Adult Health Source: CDC. (2014). Injury prevention and control: Adverse Childhood Experiences study . http://www.cdc.gov/violenceprevention/acestudy/ The Effects of Poverty on Development: The Effects of Poverty on Development Impact of Poverty on the Brain: Impact of Poverty on the Brain Inadequate Nutrition Substance Abuse Maternal Depression Exposure to Environmental Toxins Trauma/Abuse Quality of Daily Care To Early Brain Development Impact of Poverty Critical & Sensitive Periods for Development: Critical & Sensitive Periods for Development 18 PowerPoint Presentation: 19 Shawn insert the NSCDC slide on Persistent Stress Changes Brain Architecture 19 PowerPoint Presentation: Health Care: The Vision Trauma Informed Health Care: Trauma Informed Health Care Have I Considered Whether Trauma Has Played A Role in….? Smoking Drinking Maternal Depression Obesity “Trauma can be a single event, connected series of traumatic events, or chronic lasting stress.” Diagnostic Classification: 0-3R : “ Trauma can be a single event, connected series of traumatic events, or chronic lasting stress.” Diagnostic Classification : 0- 3R Illness or medical procedure Serious accident or hospitalization Traumatic grief or separation Fire , hurricane, flood, earthquake, or other disaster War, terrorism, political violence Physical, sexual, emotional or psychological maltreatment Witness to violence at home, school, or neighborhood Neglect Family disruption (moves, loss of job, illness, death , divorce, incarceration ) Myths About Early Childhood Trauma: 23 Myths About Early Childhood Trauma Baby’s Brain: Baby’s Brain 24 Exquisitely dependent on relationships & experiences to thrive. Critical Periods for Brain Development : Critical Periods for Brain Development 25 Time: 5:18 Brain Plasticity: The Capacity to Grow or Diminish: Brain Plasticity: The Capacity to Grow or Diminish Raising children in enriched or impoverished environments impacts the development of neural circuits. ZERO TO THREE BrainWonders 26 Cognitive Development Neglect Impacts Prefrontal Lobe Reducing Executive Functions: Cognitive Development Neglect Impacts Prefrontal Lobe Reducing Executive Functions Healthy Child Neglected Child Courtesy of Dr. H.T. Chugani from the Children’s Hospital of Michigan, Wayne State University Executive Functioning: Higher order mental abilities are needed to deal with confusing and unpredictable situations or information . Executive Functioning Stress Compromises Learning & Executive Functioning : Stress Compromises Learning & Executive Functioning The prefrontal cortex, an essential part of the brain for self regulation, is most affected by early stress. As a result, children in stressful environments find it harder to concentrate , sit still, follow directions, or rebound from disappointment. Uncontrollable impulses and negative feelings make it hard to learn. 29 Symptoms of Trauma in Young Children: Symptoms of Trauma in Young Children Sleep troubles, nightmares, fear of falling asleep Loss of appetite, refusal to eat Headaches, stomach aches, aches and pains Increased aggressive behavior and angry feelings Hyperactivity (very high activity level) Hyper vigilance (constant worry about possible danger) Repetitive play about a violent event Loss of skills learned earlier (toilet training, language skills) Different Aged Children React Differently to Trauma: Different Aged Children React Differently to Trauma Babies Toddlers From clingy to flat affect with no joy Prolonged u ncontrollable crying Doesn’t explore No preferred caregiver Failure to thrive Biting, kicking, tantrums, unprovoked aggression Disinterested in toys Indiscriminate preferences of caregivers. No appetite Preschool School Age Repetitive play about violent event Sleep troubles or nightmares Hyper vigilance Skill r egression Grades drop Preoccupied with the trauma Poor self-esteem Bedwetting or thumb sucking may reappear 31 Infant/Toddler Reactions to Stress: Infant/Toddler Reactions to Stress Aggression Clinging Crying Defiance Eating problems Fearfulness Inattention Irritability Nightmares Over-activity Physical complaints Rebellion Regression Sadness Sleep disturbance Temper tantrums Under-activity Vomiting Infant Toddler Feelings Associated with Separation: Infant Toddler Feelings Associated with Separation Abandonment Ambivalence Anger Anxiety Confusion Depression Fearfulness Frustration Grief Guilt Loss of control Loss of power Rejection Relief Sadness Harvard University’s Center on the Developing Child: Harvard University’s Center on the Developing Child Untreated Adverse Early Childhood Events Only Exacerbate Over Time : Untreated Adverse Early Childhood Events Only Exacerbate Over Time Adverse Childhood Experiences (ACE) Study. Information available at http://www.cdc.gov/ace/index.htm Transgenerational Transmission: Transgenerational Transmission Mothers who report experiencing stress during pregnancy are more likely to have babies who are hyperactive and developmentally delayed. Newborns of depressed mothers are more irritable and hard to soothe, have more problems sleeping, and have higher levels of the stress hormone cortisol in their blood. “ …the handing down of a susceptibility from parent to child. ” 36 Health Care: In Practice: Health Care: In Practice Trauma Informed Care : Trauma Informed Care 38 Have I considered whether trauma has played a role? Ask trauma informed questions Use a trauma lens to understand behavior Screen as part of services Ensure emotional safety Avoid re - traumatization Consider trauma in all decisions (childcare placement, referrals, etc). Dr. Jeffrey Brosco, M.D. Webinar: Social Determinants of Trauma: Dr. Jeffrey Brosco , M.D. Webinar: Social Determinants of Trauma Click here to listen to the webinar. (51 minutes) AAP Policy Statement 2012: AAP Policy Statement 2012 “AAP is committed to leveraging science to inform the development of innovative strategies to reduce the precipitants of toxic stress in young children and to mitigate their negative effects on the course of development and health across the life span.” - American Academy of Pediatrics, Policy Statement: Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician Caring for Foster Care Kids: Caring for Foster Care Kids American Academy of Pediatrics. Primary care tools . Available at http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Pages/Primary-Care-Tools.aspx Trauma-Informed Assessment: Trauma-Informed Assessment Sets the tone for early stages of engagement and is built on the development of safety and trust Clinicians must be aware of Understandable fears many survivors bring to situations that call for self-disclosure The boundary difficulties some survivors have that impair self-preservation and protection and the intensity of their trauma experiences Source: Harris & Fallot 2001 PowerPoint Presentation: Because trauma comes in many different forms for children of varying ages, gender, and cultures, there is no simple, universal, highly accurate screening measure. Screening approaches should identify risk factors such as poverty, homelessness, multiple births during adolescence, and other environmental vulnerabilities of trauma-related symptoms and behavior problems associated with trauma histories PTSD symptoms (which vary with age) Behavioral symptoms associated with trauma Screening and Assessment for Children and Adolescents Source: Hodas 2004 Guidelines for Trauma-Informed Assessment: Guidelines for Trauma-Informed Assessment Clinicians must follow the patient’s lead and contribute to his/her sense of control during this process by: Being clear about the steps and process of assessment Being clear about the reason for the questions (e.g. We have found that many people who come here for services have been physically or sexually abused at some time in their lives. Because this can have such important effects on people’s lives, we ask everyone about whether they have ever been a victim of violence or abuse.) Being clear about the patient’s right not to answer questions Source: Harris & Fallot 2001 Screening and Assessment for Children and Adolescents: Screening and Assessment for Children and Adolescents Questions about trauma should be part of the routine mental health intake of children, with parallel questions posed to the child’s parent or legal guardian. Screening and assessment for trauma should occur also in juvenile justice and out-of-home child protection settings. Assessment for trauma exposure and impact should be a routine part of psychiatric and psychological evaluations, and of all assessments that are face to face. Source: Hodas 2004 PowerPoint Presentation: 3 Basic approaches to assessment of trauma in children and adolescents: Instruments that directly measure traumatic experiences or reactions Broadly based diagnostic instruments that include PTSD subscales Instruments that assess symptoms not trauma specific but commonly associated symptoms of trauma Screening and Assessment for Children and Adolescents Source: Wolpaw & Ford 2004 Screening and Assessment for Children and Adolescents: Screening and Assessment for Children and Adolescents Parents, guardians or other involved adults would have to participate in screenings of younger children. Older children and adolescents could complete a self-report measure. Positive screens will require a more comprehensive follow-up evaluation conducted by a licensed clinical social worker, infant mental health therapist, or another licensed mental health clinician. Source: Hodas 2004 Sample Trauma Screening and Assessment Measures for Children and Parents: Sample Trauma Screening and Assessment Measures for Children and Parents For Trauma Exposure/History: Self-Report and Structured Interview: Childhood Trauma Questionnaire (Bernstein et al, 1994) For PTSD Symptoms: Self-Report and Structured Interview Clinician Administered PTSD Scale for Children and Adolescents ( CAPS-CA) (Newman , 2002) UCLA PTSD Reaction Index for Children ( Steinberg et al, 2004) Trauma Symptom Checklist for Children (TSC-C): Anxiety, Depression, Anger, Posttraumatic Stress, Dissociation and Sexual Concerns ( Wolpaw et al, 2005) Child Behavioral Checklist (CBCL) (Achenbach, 2007) Sample Trauma Screening and Assessment Measures for Children and Parents: Sample Trauma Screening and Assessment Measures for Children and Parents For Psychosocial and Psychiatric Symptoms: Self-Report and Structured Interview: Diagnostic Interview Schedule for Children (DISC ) (Shaffer et al 1992) Diagnostic Interview for Children and Adolescents-Revised (DICA-R) (Reich et al, 1991) For Self-Regulation: Self Report Parenting Stress Index Short Form ( PSI) ( Abidin , 1995) Screening Codes: Screening Codes Code: 96110 Developmental/Behavior Screening (included parent/patient completed scales) Must document instrument administration/scoring/interpretation in chart. When using office visit code and screening code in the same encounter, add modifier 25 to visit/consult code and some insurances require modifier 59 to screening code. Can report multiple units if more than one code is used ( ie : use 96110 twice for a parent and physician form). May need modifier 76 if doing 2 different screenings at same visit (depends on insurance), but modifier 69 is most appropriate. American Academy of Pediatrics. (2013). Helping foster and adoptive families cope with trauma . Available at http://www.aap.org/en-us/professional-resources/practice-support/Coding-at-the-AAP/Documents/CodingTips.pdf PowerPoint Presentation: Health Care: Recommendations Systems Changes to Mitigate Trauma & Toxic Stress: Systems Changes to Mitigate Trauma & Toxic Stress Education on the impact of trauma across systems Increased trauma screenings Expanded evidence based treatments Trauma lens across systems 1. Widespread Education on the Impact of Trauma: 1. Widespread Education on the Impact of Trauma National Child Traumatic Stress Network Trauma Informed Tool Kit : National Child Traumatic Stress Network Trauma Informed Tool Kit National Child Traumatic Stress Network at www.nctsn.org/ Training & Webinars for Physicians on Trauma: Training & Webinars for Physicians on Trauma 55 Have you considered whether trauma has played a role in…? https://www.youtube.com/watch?v=r1-JLA8JCAw: https://www.youtube.com/watch?v=r1-JLA8JCAw 2. Increase Trauma Screening: 2 . Increase Trauma Screening 3. Expand Evidence-Based Treatments : 3. Expand Evidence-Based Treatments Time: 1:35 Where do I refer for services?: Where do I refer for services? Please feel free to contact your local chapter of the Florida Association for Infant Mental Health (FAIMH) for a professional closest to you that can meet the needs of your patient. FAIMH Local Chapters : http://faimh.org/localChapters.cfm We also welcome you to become a member of the FAIMH for only $25 at www.faimh.org! 4. Trauma Lens Across Systems: 4. Trauma Lens Across Systems Mental Health Education Health Domestic Violence Delinquency Early Childhood Substance Abuse Child Welfare Judicial Collective Impact…: Collective Impact… 62 PowerPoint Presentation: 63 Trauma Informed Health Care Untreated trauma is the root of the intergenerational transmission of trauma “It’s the most important opportunity for the prevention of health and social problems and disease and disability that has ever been seen.” Dr. Vincent Fellitti, Author, ACE Study: “ It’s the most important opportunity for the prevention of health and social problems and disease and disability that has ever been seen. ” Dr. Vincent Fellitti , Author, ACE Study Time: 0:52

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