2011 Children’s Roundtable Summit
Seven Springs, PA
Marty Beyer, Ph.D.

Trauma can interfere with all aspects of a child's functioning, especially when he/she experiences repeated or multiple losses, maltreatment, exposure to frightening situations or other trauma.
While other children are growing emotionally, a child coping with trauma is distracted from normal developmental tasks.

Children who experience loss, maltreatment, or other trauma may:
• be delayed
• be depressed
• have problems with regulating emotions
• be fearful
• have trouble concentrating in school
• be sensitive to unfairness
• be tentative in trusting others
• show aggression
• blame themselves for their difficulties.

Especially during their first three years, children who receive consistent, responsive caregiving develop trust which research has shown is linked to brain development and the ability have secure attachments and manage their emotions in the future.
Loss of or rejection by a caregiver, or multiple caregivers, can damage a child and lead to insecure attachments These children become easily distressed, are difficult to soothe, and both want comfort and are angry with their caregiver.

"The experience of trauma represents for children a loss of the developmentally appropriate expectation that their parents will protect them from harm. Young children rely on their parents for the consolidation of their sense of self, which is established through modulation of emotion...[and] interpersonal relationships...[which are] disrupted when a child lives in chronic circumstances of traumatic stress."
(Osofsky, Young Children and Trauma, 2004)

Legacies of Biological Disruption from Adversity
Shonkoff www.developingchild.harvard.edu
• Cognitive, emotional and social capacities are intertwined in the architecture of the developing brain
• Toxic stress disrupts brain circuits and overloads the child’s stress response system
(including immune system, heart rate and stress hormones)
• Children who have experienced significant adversity require early specialized intervention:
> stable and supportive relationships
> language-rich environment
> mutually responsive “SERVE & RETURN”

There ’s Good News from Brain Science for Children in Foster Care
• Using brain science, the needs of children in foster care can be understood in ways never before possible
• Identifying which children in foster care are at greatest risk and how to help them can be done with increasing precision
• Preventing toxic stress and mitigating its effects in young children in foster care is possible

EVIDENCE-BASED INTERVENTIONS
Preventive intervention for maltreated pre-school children
Fisher www.oslc.org
Neglected children, perhaps due to fewer “serve and return” experiences, may have blunted stress hormone levels and diminished brain activity in response to corrective feedback.
With 4-6 months of intervention, they return to normal cortisol and brain activity, and greatly reduced behavior problems
Attachment Biobehavioral Catchup
Dozier www.abcintervention.com
Teaching parents and foster parents “relentless parenting,” caring in a highly responsive “serve and return” way to children who push caregivers away and/or have behavior problems that do not invite nurturing
Family Check Up
Dishion www.cfc.uoregon.edu/intervention
Early support for positive parenting practices that prevent the development of children’s problem behaviors, particularly reducing coercive interactions

Safe Care
Lutzker www.publichealth.gsu.edu/safecare
Parent training in parent-child interaction and problem-solving
Parent Child Therapy
Zeanah www.infantinstitute.com
Interactive therapy between parents and young children experiencing interpersonal violence and traumatic loss, including children in foster care
Incredible Years
Webster-Stratton www.incredibleyears.com
Parent training focused on enhancing parenting skills, knowledge of child development and positive child behavior. Caregivers reported lower levels of parenting stress and increased empathy toward their children.

Hector's foster parents are having trouble with his temper tantrums which happen a lot, disturbing meals, bedtime, and the other children in their home. Their assumptions about his temper tantrums are:
• His mother was not attuned to his distress
• He has an insecure attachment to his mother
• His mother modeled poor emotion regulation
• His mother did not have a consistent bedtime routine

If we look behind Hector’s temper tantrums we see overwhelming feelings that he cannot express.
His feelings of loss are too much for him to soothe himself. He is protesting that everything is out of control.

A child's unique temperament frames his/her response to trauma:
"...reserved children may tend to respond to the trauma with internalizing behaviors such as affective numbing, social withdrawal, constricted exploration, separation anxiety and new fears. In contrast, active and outgoing children may be more prone to respond with externalizing behaviors such as recklessness, temper tantrums, defiance and aggression."
(Osofsky, Young Children and Trauma, 2004)

The younger the child, the less they are able to communicate about their distress. Many children who enter care are under 3 years old, and their parents, relatives, foster parents and others have trouble deciphering what they need.

Depression is common but often not diagnosed in traumatized children.
Their behavioral problems become the focus rather than their underlying sadness, isolation, selfdislike and feeling rejected.

Children with untreated trauma adjust poorly in middle school because their delayed development, problems with regulating emotions and relationship difficulties are so noticeable.

Trauma exposure plays a key role in the development of behavior problems in adolescents-the effects of trauma contribute to the impulsivity and anger associated with school difficulties, substance abuse and gang involvement. "We are beginning to move from the mere recognition that juvenile delinquents have often faced extreme adversity in their childhood, to the understanding that such adversity has had specific effects which contribute to delinquency."
(Greenwald, Trauma and Juvenile Delinquency, 2002)

"At times she is so overwhelmed and exhausted by worries and troubles that she feels hopeless and depleted. She cares for her family but is acutely aware of the pervasiveness of their problems which weigh heavily on her. Caring for others in the family sometimes keeps her from caring for herself. Tiffany sees the world as a hazardous place, where she must confront dangers without help from others."

• Girls experience more negative life events than boys
• Girls are more upset by stress, are prone to see themselves as helpless, fear abandonment by others, and express a greater need for closeness and nurturing than boys do
• Girls report significantly lower levels of self-worth and satisfaction with their social and academic achievement than boys.
• Many girls who previously seem resilient appear to lose self-confidence around age 11 or 12.
• Connection with others is the central organizing feature of development in girls, and their focus on relationships creates a concern over loss of closeness that can dominate girls' thinking from elementary through high school.

Traumatized youth tend to misinterpret and be offended by relatively benign things that others say and do. They have often had difficulty since childhood modulating their reactions and putting their feelings into words instead of aggression.
Traumatized youth can be surprised by and unable to control their angry outbursts when they feel threatened if memories of their past victimization are triggered.

This reflexive reaction to provocation may not be understood as an effect of trauma. Foster parents, group home staff and school staff may not have training in managing a traumatized child, which would emphasize that:
• these children overreact to threat, reflexively, without thinking
• praise is much more effective than punishment in changing their behavior
• adult actions can prevent most of their behavior problems
• crucial skills for caring for a traumatized child are:
– avoiding power struggles
– de-escalation before they get out of control
– teaching children not to be so rejection-sensitive
– and what to do with their angry feelings

RESPONDING EFFECTIVELY TO
TRAUMATIZED CHILDREN
IN FOSTER CARE
Removal and placement are always traumatic for children, no matter what the circumstances.
Even in abusive situations, there is a loss of everything familiar to the child and the attachment between the child and parent is affected

The child's first placement in foster care should be the child's only placement. Children need consistent caregivers and multiple moves disrupt their attachments and can damage a child's trust and ability to build relationships.

Training for foster parents should include information about attachment, including: how foster parents can support the child's attachment to his/ her parent and help the child have multiple attachments. Foster parents also need information about children's possible visit reactions, especially to separating again from family.

Parents and foster parents should have support for finding common ground in meeting the child's needs.
When foster parents and parents have a positive relationship children feel reassured, safer, and happier; they are not torn between the caregivers in their lives and their multiple attachments are supported.
Parent-foster parent communication promotes reunification or another permanency plan, and makes it more likely that attachments can continue no matter what the permanency outcome.

Visits are the primary way that the attachment between parents and their children is maintained and strengthened while they are separated.
Visits must be frequent and arranged in a way that supports the parent to parent their children during their family time.

TRADITIONAL VISITS
BRING OUT THE WORST IN EVERYONE
Throughout the time the case is open, parents' concepts of their children's needs may remain different from the worker, foster parent, parenting teacher, or therapist.
The parent's grief, anger, and preoccupation with complying with court-ordered services may obscure their child's needs.
Parents may act out their anger about the child's removal during visits.
Their child's reactions to separation and the conditions that brought them into care may be challenging for the parent to manage in visits.
Parents report that being watched by someone taking notes during visits makes them uncomfortable and less likely to do anything with their children for fear of making a mistake.
Children's behavior reflects their feelings about being separated from family members, about maltreatment that preceded placement, and their confusion about living with a new family.

PARENT REACTIONS TO TRAUMA
Many parents of children in foster care experienced trauma as they were growing up. Some were in foster care themselves.
The loss of their children and the resulting instability and sense of guilt take a toll on parents.
• They feel helpless and hopeless.
• They get frustrated that "the system" is so slow.
• They are emotionally fragile as they "start their lives over" in alcohol/drug treatment and domestic violence programs.
• They feel guilty for having been inattentive to their children’s needs in the past.
• Those who have not fully grieved the death of a loved one have even more trouble with the separation from their children.

When they visit their children, parents are overwhelmed by their mixed feelings of pleasure, sadness, awkwardness and defensiveness.
They envy the foster parent.
Separating from their child in visit after visit is so painful it is hard for them to return.
Even though they enjoy their children, visits make most parents feel inadequate and miserable.

VISIT COACHING SUPPORTS PARENT RESPONSIVENESS
TO THEIR TRAUMATIZED CHILDREN and
KEEPING THEIR OWN REACTIONS FROM GETTING IN THE WAY
Visit Coaching is fundamentally different from supervised visits.
Instead of watching the family, the Visit Coach is actively involved in supporting them to meet their children's needs.

Visit Coaching includes:
• Helping parents articulate their children's needs to be met in visits
• Preparing parents for their children's reactions
• Helping parents plan to give their children their full attention at each visit
• Appreciating the parent's strengths in responding to each child and coaching them to enhance their attentiveness
• Supportively reminding the parent immediately before and during the visit of how they planned to meet each child's needs
• Helping parents visit consistently and keep their anger and depression out of the visit