Trauma-informed care in child/family welfare services

CFCA Paper No. 37 – February 2016

What is the evidence that a trauma-informed approach is needed?

Research suggests that exposure to adverse, potentially traumatic events in childhood is not uncommon (Anda et al., 2006). For example, the Adverse Childhood Experiences (ACE) study in the USA showed that of 17,337 respondents, 64% had experienced at least one adverse experience5 and approximately 12% had experienced four or more in the first 18 years of life (Anda et al., 2006). Further to this, a recent report suggested that childhood trauma affects an estimated five million Australian adults (Kezelman, Hossack, Stavropoulos, & Burley, 2015). There is also a great deal of evidence associating traumatic experiences with a broad range of deleterious outcomes in childhood, adolescence and adulthood (e.g. Anda et al., 2006; CFCA, 2014a, 2014b; Dube et al., 2001; Hahn Fox, Perez, Cass, Baglivio, & Epps, 2015; Johnson-Reid, Kohl, & Drake, 2012; Nurius, Green, Logan-Greene, & Borja, 2015).

Individual responses to traumatic experiences vary widely, with not all exposure leading to negative outcomes. It is the individual response to the experience that determines whether it is considered traumatic or not (SAMHSA, 2014). If effects occur they can be short- or long-term and may occur immediately following exposure to adversity or have a delayed onset (SAMHSA, 2014).

Multiple studies have reported negative effects associated with experiencing trauma across all facets of life. Mental ill-health, physical illness, social and relational difficulties, and poor academic and employment outcomes have all been linked to previous traumatic experiences. Anda and colleagues (2006) found a strong relationship between increased numbers of adverse childhood experiences and increased prevalence and risk of:

  • affective disturbances (e.g. panic attacks, anxiety, hallucinations);
  • somatic disturbances (e.g. sleep disturbance, severe obesity);
  • smoking, illicit drug use, injected drug use, alcoholism (for people with four or more adverse childhood experiences);
  • early intercourse, promiscuity and sexual dissatisfaction;
  • impaired memory of childhood; and
  • high perceived stress, difficulty controlling anger and risk of perpetrating intimate partner violence (for people with four or more adverse childhood experiences).

Further to this, the study found that as the number of adverse childhood experiences increased so too did the average number of co-occurring negative outcomes (Anda et al., 2006). There is strong evidence to indicate that certain types of trauma rarely occur in isolation. Research suggests, for example, that the different child maltreatment types are interrelated: sexual abuse, physical abuse, psychological maltreatment, neglect and exposure to domestic and family violence typically occur in combination with each other. A large proportion of children and young people who experience childhood abuse or neglect are exposed to more than one type of abuse (known as "multi-type maltreatment"; Price-Robertson, Higgins, & Vasallo, 2013). Further to this, other forms of victimisation such as bullying or assault by a peer have often been found to co-occur with child maltreatment (known as "poly-victimisation"; see Finkelhor, Ormrod, & Turner, 2007).

Multiple victimisation experiences across different domains are consistently associated with poorer outcomes than a single adverse or maltreatment experience. Those who experience multi-type maltreatment or poly-victimisation are more likely to experience high levels of trauma symptoms and worse outcomes than those who are exposed to no maltreatment or only one type (Finkelhor et al., 2007; Higgins & McCabe, 2001). Supporting these findings, a recent large scale US study of children in the Illinois child welfare system found that children who experienced both violent interpersonal and attachment-based ("non-violent") traumas within the caregiver system experienced greater difficulties across several areas of impairment (including attention/behavioural dysregulation and self/relational dysregulation) and were significantly more likely to exhibit PTSD-like symptoms compared to children who had experienced neither type of trauma, violent trauma only or non-violent trauma only (Kisiel et al., 2014).

Co-occurring mental health issues and disorders such as conduct disorder and oppositional defiant disorder (in children), PTSD, depression and other affective disorders, borderline personality disorder, somatoform disorders, psychotic and dissociative disorders have commonly been associated with traumatic experiences (Bateman, Henderson, & Kezelman, 2013; Breslaue, 2009; CFCA, 2014a, 2014b; Nurius et al., 2015; van der Kolk et al., 2005). Self-harm and suicide attempts have also been linked with previous traumatic experiences (Bateman et al., 2013; Cozolino, 2010; Dube et al., 2001; Herman, 1992; Johnson-Reid et al., 2012). In one study, Dube and colleagues (2001) reported that any adverse childhood experience increased the risk of attempted suicide by 2-5 fold with the relationship being partially mediated by illicit drug use, depressed affect and self-reported alcoholism.

Those who have had previous traumatic experiences also commonly report physical health issues. For example, in summarising research on the potential effects of trauma exposure, Bateman and colleagues (2013) found that "survivors of child maltreatment were at increased risk of hepatitis, diabetes, heart disease, cancer, a stroke, are more likely to have surgery and are at increased risk of having one or more chronic pain symptoms" (p. 19). The same authors also noted a range of conditions that child sexual abuse survivors were at increased risk of, including irritable bowel syndrome, asthma, arthritis and digestive problems.

In addition, childhood trauma exposure has been linked to involvement with the criminal justice system. A large study exploring adverse childhood experiences of serious, chronic and violent juvenile offenders and juveniles referred to the justice system for single non-violent offences found that every additional adverse childhood event experienced increased the risk of becoming a serious, chronic and violent juvenile offender by more than 35%, even when other known risk factors for violent behaviour were accounted for (Hahn Fox et al., 2015).

Lastly, difficulties in interpersonal relationships are often reported as a result of experiencing trauma (Bateman et al., 2013; Briere & Spinazzola, 2005; Evans & Coccoma, 2014; van der Kolk, 2005).

Although individual responses to traumatic experiences may vary widely, research has found a strong relationship between the degree of risk of experiencing multiple and complex negative outcomes following traumatic experiences and factors such as the age at which the experience/s occurred, the nature of the experience/s (with negative effects being particularly associated with trauma of an interpersonal nature such as child abuse and neglect), and the severity and chronicity of the experiences (Cozolino, 2010; Herman, 1992; Kisiel et al., 2014; National Scientific Council on the Developing Child, 2014 [NSCDC]; Resick et al., 2012; van der Kolk et al., 2005). As noted by Cozolino (2010):

The impact of trauma depends on a complex interaction of the physical and psychological stages of development during which it occurs, the length and degree of the trauma, and the presence of vulnerabilities or past traumas. The impact of chronic trauma becomes woven into the structure of personality and is hidden behind other symptoms, making it difficult to identify, diagnose and treat. (p. 266)

Traumatic events experienced early in life can be extremely damaging to the developing brain. Neural development relies on the interplay of genes and environmental inputs (particularly interaction with primary carers) and early adversity or disrupted attachment relationships that lead to chronic high levels of stress can interfere with key neurobiological development (NSCDC, 2014). Pamela Alexander (2013) suggested that "affective synchronization between mother and child" (p. 45) in carer-infant interactions is crucial for brain development, social development and stress regulation. Early onset, sustained trauma that interferes with this can lead to deficits in multiple domains: dysfunction in fear extinction; affect or emotional regulation; behaviour regulation; learning, cognition and attention; and self and relational dysregulation (Cook et al., 2005; Courtois & Ford, 2009; Evans & Coccoma, 2014; Kisiel et al., 2014; NSCDC, 2014; van der Kolk et al., 2005).

Research has also highlighted that experiencing traumatic events tends to increase the chances of experiencing further traumatic events across the life course. Cozolino (2010) argued that:

Enduring personality traits and coping strategies that emerge in these situations [experiencing early onset, sustained trauma] tend to decrease positive adaptation and increase an individual's vulnerability to future trauma. This can manifest through engagement in abusive relationships, poor judgement, or a lack of self-protection. (pp. 268-9)

Finally, in examining the need for a trauma-informed approach to care it is pertinent to note that in many cases, due to the co-occurrence of problems resulting from experiencing trauma, individuals may find themselves in multiple systems, cycling in and out of specific services over many years to access, for example, treatment for drug and alcohol addictions, support for employment opportunities and therapeutic services for mental illness.

Historically, the underlying factor often linking a constellation of needs together - the history of abuse and its impacts - has not been adequately acknowledged or integrated into these service systems' service responses to individuals (Harris & Fallot, 2001). Further, populations with complex needs are at high risk of falling through the gaps of service delivery systems due to a lack of service co-ordination and the related barriers to service integration (Whiteford & McKeon, 2012). This can mean that clients: are deemed ineligible for services (e.g. cannot engage in mental health treatment until they have "dealt with" their substance abuse issue or vice versa); are expected to separate out their trauma experiences from their service or treatment needs ("we don't deal with trauma in this parenting class"); and experience services systems' responses as re-traumatising.

The SAMHSA-funded Women With Co-Occurring Disorders and Violence Study was a comprehensive 5-year project (1998-2003) across multiple sites, which provided evidence that integrating different services, such as mental health and substance abuse services where there was client need for both, was effective. This study showed that trauma-informed approaches could enhance the effectiveness of mental health and substance abuse services for women with co-occurring mental health and substance abuse disorders (Huntington et al., 2005; Morrisey et al., 2005). A trauma committee for this study also developed an understanding of trauma-informed principles and ways in which mental health and substance abuse service providers could use the approach (Elliot et al., 2005). In the years since the study, further development, debate and discussion has resulted in an expanded evidence base about the effects of trauma and appropriate approaches for services.

5 The adverse childhood experiences measured were three types of childhood abuse: emotional abuse, physical abuse, and contact sexual abuse; and five measures of household dysfunction during childhood: exposure to alcohol or other substance abuse, mental illness, violent treatment of mother or step-mother, criminal behaviour in the household, and parental separation or divorce (Anda et al., 2006, p. 176).