Trauma Workgroup Members

A trauma survey for professionals was developed and sent out to the lead dependencyjudge and child welfare administrator in each county. Leaders were asked to take thesurvey and to send it to their local Children’s Roundtable members with instructions totake the survey and pass it along to all of their employees and court-involved contractproviders. The survey can be found at: https://www.surveymonkey.com/s/BBDV7ZR.While the survey is still open, preliminary results show a strong understanding oftrauma, its pervasiveness and its relevance to both children and parents. Systempartners report having received training on trauma while simultaneously wanting more.Full results of the survey will be available in the 2016 SRT report.After asking professionals for their views and experience with trauma in the dependencysystem, a survey for parents and a survey for children and youth were created. Copiesof this survey can be found as attachments to this report. These surveys are intendedto collect information from individuals in the courthouse, either before or after theirhearing. Jurisdictions that are interested in understanding the parent and child point ofview can use these tools. The TWG is currently soliciting volunteer jurisdictions toadminister the parent and child surveys during a one week to one month time period(based on the number of hearings during those timeframes). Each site hosting thesurvey will need to identify a person or people who are available to provide assistanceto individuals and collect the forms once completed. Surveys will be tabulated andaggregate results made available in the 2016 SRT report. If a jurisdiction is interestedin receiving the results of their own surveys, they will be provided.In keeping with trauma-informed core values, Alternate Dispute Resolution (ADR),methods, used in many different sections of the court, was discussed as being apossible way to empower and provide parents and children choice. Information wasshared by Venango County, who uses a facilitation model to handle adjudicatoryhearings and by Judge Pratt in Fort Wayne, Indiana who provided the genesis of thatmodel. The TWG thought, in light of the ADR practice being used in other areas of thecourt and its potentially positive impact on a trauma-informed court, further explorationshould be done. As part of this exploration, the TWG is seeking the SRT’s approval topartner with volunteer jurisdictions to implement and collect data about the practice’susefulness.Lastly, many counties have expressed difficulty knowing what trauma specific servicesare available in their communities. The TWG reached out to a number of BehavioralHealth Managed Care Organizations asking if they had a system in place to designateor track these providers. Collecting responses is an ongoing task; however, the two thathave been received are included in this report’s attachments.CONCLUSION:The child welfare and dependency systems have an ever increasing awareness of thecomplex and intricate layers of trauma woven throughout. By becoming trauma4

informed in both culture and practice, these systems have an opportunity to help thosewhom they serve continue on their journey to health and wholeness. Wanting what isbest for children must include the willingness to look at one’s own practices through atrauma lens and see what those before you see. Change is hard but areas that causeunintended harm need to change. In the end, all will be better for it.RECOMMENDATIONS:The Trauma Workgroup respectfully submits to the Pennsylvania State Roundtable thefollowing recommendations:1. Develop an electronic resource to highlight innovative and best practices fromcounties who are becoming Trauma-Informed and Trauma-Responsive so thatcounties can network and provide peer support for implementation.2. Work jointly with volunteer counties to obtain parent and child/youth opinions oftheir court experiences via a survey.3. Explore the feasibility of the Alternate Dispute Resolution model Facilitation independency cases by asking volunteer counties to try the method on a smallnumber of cases and report back on criteria such as implementation, cost andimpact on length of hearings.5

ATTACHMENTS1. A series of articles from Children’s Mental Health Matters by Dr. Gordon Hodas,M.D., child psychiatrist consultant for the Pennsylvania Office of Mental Healthand Substance Abuse Services: A Primer on Childhood Trauma and Trauma-Informed Care, Part 1 Childhood Trauma and Trauma-Informed Care, Part 2: From “TraumaInfirmed” to “Trauma-Informed” System-Induced Trauma What It Is and How to Prevent It The Trauma-Informed Checklist2. Trauma Infographic3. Parent Survey4. Child/Youth Survey5. Pennsylvania Medicaid Managed Care Organization Directory (Nov 2014)6. Community Care Behavioral Health Organization Letter7. Tuscarora Managed Care Alliance Letter6

Attachment 1Children’s MentalHealth MattersNumber 4, October 2012A Primer on Childhood Trauma and Trauma-Informed Care, Part IBy Gordon R. Hodas, M.D.IntroductionOver the past decade, there has been increasingrecognition of the damaging effects of childhoodtrauma, in particular childhood maltreatment. Many inthe field of human services have also been learningabout trauma-informed care. At the same time, thepervasiveness and consequences of childhood traumaremain unclear to many, and efforts to promotetrauma-informed care can be misunderstood by someas “pampering” difficult youth who “need to be put intheir place.”For the above reasons, I offer a primer on trauma andtrauma-informed care. Part I highlights key pointsabout the pervasiveness and impact of childhoodmaltreatment. This impact is evident in childhood and,all too commonly, continues into adolescence andacross the lifespan. Part II will describe traumainformed care and consider how its consistentimplementation can promote resiliency and growth foryouth and others. I hope that those who are alreadyfamiliar with childhood trauma and trauma-informedcare will feel validated. For others less familiar, I hopethe discussion will promote a sense of curiosity andcommitment to learn more.Pervasiveness of Childhood Trauma andMaltreatmentWhile there are many types of trauma, maltreatment(neglect, physical abuse, psychological abuse, andsexual abuse) and being a witness of domestic violenceoften have the most severe consequences on childrenand adolescents. These forms of trauma tend to createthe greatest sense of personal shame and are ofteninflicted by people whom the child has trusted. Inaddition, due to personal stigma and at times directthreats by the perpetrator, the child frequentlymaintains secrecy about the events. The child maymistakenly believe that he or she is responsible for thetrauma or may fear being called a liar by their family orothers if they speak up.Unfortunately, childhood maltreatment is not typicallya single, isolated event, but instead is part of anongoing pattern of abuse. Sometimes the abuse isregular and predictable, while at other times the abusemay be intermittent and unpredictable. In eithercircumstance, the child is likely to experience fear andeven terror, and the impact on the child’s braindevelopment and emotional functioning can besignificant and long-standing.The percentage of youth in America who haveexperienced significant trauma is extremely high – upto 80 percent and higher for high-risk youth and thoseliving in urban settings and in poverty – and many ofthese youth have multiple exposures (Cooper, 2007;Fairbank 2008). Youth at high risk with high rates oftrauma exposure include those involved in publicsystems – child welfare, juvenile justice, drug andalcohol, mental health – and those who are homeless(Cooper 2007).Impact of Trauma on Children and AdolescentsIt is important to understand what happens to thebrain development of youth who have experiencedsevere trauma, particularly repeated maltreatment.The brains of these individuals are typically smallerthan the brains of youth who have not experiencedabuse. There is less development of the prefrontalcortex – the part of the brain responsible for problemsolving, decision-making, judgment, and self-control. Inaddition, the corpus callosum, which connects the twohemispheres and therefore facilitates integratedfunctioning, is also under-developed.In terms of neurobiology (the chemistry of the brain),youth who have been abused have an increasedamount of adrenaline, which along with other1

chemicals is responsible for arousal – the so-calledfight-or-flight response that occurs when one is in alife-threatening crisis. Hyperarousal occurs frequentlyin youth who have been abused, even in response tominimal or no discernable threat. The individual getsprovoked easily and loses emotional and behavioralcontrol, and then has great difficulty recovering. Thisloss of control and slow recovery are related to thehigh level of adrenaline and other chemicals in thebrain. Loss of control is also due to the youth’s limitedskills for dealing effectively with stress, anger,disappointment, and other challenging emotions.As the child gets older and enters adolescence, theabove problems often get worse rather than better.Loss of control occurs more quickly and may appear tobe unpredictable. Behavior is often quite impulsive, sothat the youth acts without thinking. Explosions ofanger upset classmates and frustrate adults. Gainingthe youth’s trust can also be very difficult – life hastaught the youth that he or she is less likely to be hurtby remaining guarded and withholding trust. As aresult, the youth may challenge even a caring adult,and “test” the adult to find out if the person perseveresin the relationship or gives up. Such behavior mayconfuse and alienate many well-meaning adults whocould become youth mentors.Youth who have experienced abuse and maltreatmentrarely discuss it, and often try to present themselves asbeing strong and “in control.” As a result, adults maymistakenly believe that inappropriate youth behaviorsas described above are intentional and willful, ratherthan a useful adaptation in response to to past trauma.More likely, instead of feeling in control, the youth isoverwhelmed and preoccupied with issues of safetyand survival.Youth who have been maltreated tend to devalue theirlife and the lives of others. As a result, they may appearto lack empathy. When they act violently, theyexperience the other person as a threat to their safetyrather than as a real person. They may also perceivethe person as a symbol of a world that has punishedand humiliated them rather than as a real person,further increasing the risk of a violent response.Impact of Trauma Over the LifespanChildhood trauma typically impacts the individual overthe entire lifespan, leading to greater vulnerability tonegative outcomes in both physical health andbehavioral health. Data leading to this soberingconclusion has come in particular from the AdverseChild Experiences (ACE) Study, a longitudinal studythat began at Kaiser Permanente in California in 1995.This study involved more than 17,000 middle classadults with private Kaiser Permanente healthinsurance, who were asked to complete a ten-itemquestionnaire involving the occurrence ofmaltreatment and other adversities during theirchildhood. These same individuals received acomprehensive physical examination, and were alsoasked extensive questions about their mental andphysical health. It was found that, the greater numberof adversities experienced by an individual duringchildhood, the greater the risk-taking that occurredduring adolescence and the greater the impairment ofmental and physical health status over time. The ACEstudy is ongoing, with the study group having beenfollowed for nearly 30 years.Consequences During Childhood and Risk-TakingDuring AdolescenceIn addition to developing symptoms related to trauma,children subjected to maltreatment typically developimpaired attachments to their parents or othercaregivers. This impairment can influence the entiredevelopmental process, impacting other relationshipsand the ability to learn and think critically, developempathy, and regulate emotions during times ofchallenge and stress.During adolescence, youth with a history ofmaltreatment and adversities are at significant risk ofearly initiation of smoking, illicit drug use, sexualactivity and adolescent pregnancies, and suicideattempts. In addition, such youth often placethemselves in dangerous situations and may challengeothers with little regard for the potentialconsequences. Their behaviors may result in violentbehavior toward others, as well as personalvictimization.Negative Outcomes in AdulthoodUnfortunately, high risk behaviors and negativepatterns persist over the lifespan (Centers for DiseaseControl and Prevention. 2005). Substance abuse andsmoking may be serious problems. Antisocial behaviormay result in arrests and incarceration. There may below levels of educational achievement, underemployment, or unemployment. Divorce is common,Children’s Mental Health Matters is a monthly column to support children, adolescents and their families from the Office of Mental HealthServices, Bureau of Children’s Behavioral Health Services. It is available online at www.parecovery.org and can be printed and distributed asdesired.2

and domestic violence may be perpetrated by males,while females may experience repeated domesticabuse. In addition, nutrition and self-care may be poor,and the need for regular medical and dental care maybe disregarded.recognized factor in the shorter life expectancy ofindividuals receiving services in the public behavioralhealth system.These negative patterns affect one’s emotional andphysical wellbeing, with a variety of negativebehavioral and physical health outcomes emergingover the lifespan. Behavioral health disorders are morefrequent among survivors of abuse than among thosenot subjected to abuse, and may take many forms. Withsevere, chronic trauma, post-traumatic stress disorder(PTSD) may emerge. PTSD, which involves thecombination of hyperarousal, re-experiencing andavoidance, greatly impairs one’s functioning andquality of life. Other potential behavioral healthproblems include substance abuse, panic attacks,depression and suicide attempts, psychosis, socialisolation, negative thinking, and continued risk-takingbehaviors.The public health impact of childhood maltreatmentand trauma on Americans has only recently beenrecognized in the media and by the public. The ACEstudy has shown that mind and body are truly linked,with life adversities significantly affecting not just onebut both of these domains, and with the consequencestypically life-long. Given the stigma associated withtrauma and maltreatment, under-reporting is common,and many trauma survivors have little idea how theirlives have been affected by their adverse lifeexperiences.Physical health disorders may also result fromsignificant trauma exposure, due in part to risk takingand personal disregard of one’s health. Adolescentsmoking is likely to continue into adulthood,predisposing individuals to many physical healthdisorders. There is also an increased likelihood ofmultiple sexual partners and sexually transmitteddiseases in adulthood. Physical inactivity and obesityare common. Specific physical health diseases mayinvolve heart disease, chronic lung disease, liverdisease, cancer, skeletal fractures, and autoimmunedisorders.Taken together, the net effect of these behavioral andphysical health impairments is poor quality of life,often followed by premature death. From a publichealth perspective, the impact of trauma is an under-Discussion and ConclusionWhile one might easily become discouraged by thedata on childhood trauma and its long-term impact, Isuggest withholding judgment, because this is only halfof the story. There are ways to respond to trauma andprevent re-traumatization, thereby helping othersovercome adverse experiences, become more resilient,and work towards recovery. While some individualsmay need specific, clinically-based trauma treatment,many others can benefit from a much less complexpublic health approach known as trauma-informedcare. Part II of this primer will consider what traumainformed care involves, and how each of us, onceinformed, has the capacity to make a positivedifference. Human relationships can cause harm, butthey can also promote healing and recovery. One mustnever underestimate the power of basic respect andkindness – critical components of trauma-informedcare – in helping others overcome the legacy of trauma.ReferencesAdverse Childhood Experiences Study. (2005). Centers for Disease Control and Prevention, Department of Healthand Human Services.Chapman, J. & Ford, J. (2005). Trauma exposure, post-traumatic stress, and suicide: Risk in juvenile detainees.www.NCTSNet.org.Cooper, J. (2007). Facts about trauma for policymakers: Children’s mental health. National Center for Children inPoverty.Children’s Mental Health Matters is a monthly column to support children, adolescents and their families from the Office of Mental HealthServices, Bureau of Children’s Behavioral Health Services. It is available online at www.parecovery.org and can be printed and distributed asdesired.3

Garbarino, J. (1999). Lost Boys: Why Our Sons Turn Violent and How Wed Can Save Them. New York: Free Press.Fairbank. J. (2008). The epidemiology of trauma and trauma related disorders in children and youth. PTSDResearch Quarterly, 19 (1), 1-3.Hodas, G. (2006). Responding to childhood trauma: The promise and practice of trauma informed care. NationalAssociation of State Mental Health Program Directors.Jennings, A (2004). The damaging consequences of violence and trauma: Facts, discussion points, andrecommendations for the behavioral health system. National Association of State Mental Health Program Directors.Karr-Morse, T. & Wiley, M. (2012). Scared Sick: The Role of Childhood Trauma in Adult Disease. New York: BasicBooks.National Association of State Mental Health Program Directors (NASMHPD) and National Technical AssistanceCenter for State Mental Health Planning (NTAC). (2004). The damaging consequences of violence and trauma:Facts, discussion points, and recommendations for the behavioral health system. Washington, D.C.: U.S.Department of Health and Human Services (HHS).Perry, B. (2004). Understanding traumatized and maltreated children: The core concepts – Living and workingwith traumatized children. The ChildTrauma Academy.Van der Kolk, B. (2003). The neurobiology of childhood trauma and abuse. Child and Adolescent Psychiatric Clinicsof North America: Posttraumatic Stress Disorder, 12 (2), 293-317.Gordon R. Hodas, M.D. is a child psychiatrist consultant for the Pennsylvania Office of Mental Health and SubstanceAbuse Services.Children’s Mental Health Matters is a monthly column to support children, adolescents and their families from the Office of Mental HealthServices, Bureau of Children’s Behavioral Health Services. It is available online at www.parecovery.org and can be printed and distributed asdesired.4

Attachment 1Children’s MentalHealth MattersNumber 5, November 2012Childhood Trauma and Trauma-Informed Care, Part IIFrom “Trauma-Infirmed” to “Trauma-Informed”By Gordon R. Hodas, M.D.IntroductionWe have seen that childhood trauma – childhoodmaltreatment in particular – is a life-alteringexperience and also a serious public health problem.Childhood trauma is pervasive, and has significantimpact on development and health during childhoodand adolescence and over the entire lifespan. Thepreviously discussed ACE study has demonstrated adirect correlation between the number of adversities(including maltreatment and loss) experienced by anindividual during childhood and the severity ofnegative mental and physical health over time.Ongoing medical research can now partly explain howtrauma impacts brain development and function,thereby connecting epidemiological outcomes withbiological pathways.In response to increased recognition of the impact oftrauma on society, various mental health and otherhuman service systems have been learning about“trauma-informed care.” However, due to differentterminology and different frames of reference, thediscussion can be confusing. In addition, amidst thevarious terms and formulations by experts, the coreconcept of “trauma-i

Clearfield County Honorable Oliver Lobaugh President Judge Court of Common Pleas Venango County Honorable Kelley Streib Judge Court of Common Pleas . Fayette County CYS Nastassja Reese Allegheny County Court of Common Pleas Youth Representative Trauma Workgroup Members Co-Chairpersons Honorable Kathryn Hens-Greco