By Ta Lynn Mitchell
Children who are physically or sexually abused, or who go through other trauma-inducing experiences, can develop mental health disorders and related problems. Indeed, trauma can fundamentally affect how a young person grows and develops. Trauma-informed care is a treatment approach that explicitly acknowledges the role trauma plays in people’s lives. That approach is increasingly being developed and refined as a method of treatment by professionals working in medicine, mental health, education, foster care, juvenile justice, and other areas.
Exposure to Trauma
Dr. Nadine Burke Harris, Founder and Chief Executive Officer at the Center for Youth Wellness run by the City of San Francisco, is regularly approached by parents of children with behavioral problems, and has found that trauma is almost always at the root those problems.
“When I did a thorough history and physical, it turns out these kids … were exposed to tremendous violence, parental mental illness, community violence [and] household dysfunction,”1 said Harris, former medical director of Bayview Child Health Center in San Francisco. The youths' behavioral issues could not be understood outside of this context of trauma, she said.
According to Ann Jennings, who directed the nation's first state-level trauma center Office of Trauma Services for Maine’s Department of Behavioral and Developmental Services, the traumatic experiences of adults and youth with the most serious mental health problems are “interpersonal in nature, intentional, prolonged and repeated ... They include sexual abuse or incest, physical abuse, severe neglect, and serious emotional and psychological abuse.” Witnessing acts of violence can also be trauma-inducing, she said.2
Traumatic experiences can have devastating and long-lasting effects. Mental health problems can be one consequence, as can "co-occurring disorders such as chronic health conditions, substance abuse, eating disorders, and HIV/AIDS."3 A person traumatized in childhood may resort to criminal behavior. According to one study of all juvenile detainees nationwide, 93.2 percent of males and 84 percent of females reported having had a traumatic experience4. It was also found that 18 percent of females and 11 percent of males met all of the criteria for Post Traumatic Stress Disorder, or PTSD.5
Awareness of the profound and lasting effects of childhood trauma grew out of a study conducted by Kaiser Permanente in the 1990s, according to Paul Tough in his article “The Poverty Clinic: Can a Stressful Childhood Make You a Sick Adult”6. In Kaiser's Adverse Childhood Experiences (ACE) study, patients were given a questionnaire asking them to describe "adverse childhood experiences" such as parental divorce, physical abuse, emotional neglect, sexual abuse, and growing up with family members who suffered from mental illness, alcoholism, or drug abuse. More than 17,000 patients participated in the study. Each one was assigned an ACE score based on one point given for each category of trauma the patient had experienced.
When “researchers looked at patients with ACE scores of 7 or higher who didn’t smoke, didn't drink to excess, and weren’t overweight, [they found that] their risk of ischemic heart disease (the most common cause of death in the United States) was 360 percent higher than it was for patients with a score of 0."7 What emerged was a growing recognition of the impact that trauma experienced during childhood has on health later in life.
Trauma-informed care has grown as a method and a movement. It was once viewed as a form of treatment only for “a select group of individuals, under extraordinary circumstances – for example, survivors of catastrophic events such as war, earthquakes, and abduction.”8 Today, trauma-informed care is recognized as appropriate for anyone who's been through some kind of traumatic event.
Since most such events occur in childhood, reaching out to and treating young people is critical. Tonier Neen, a trauma survivor who benefited from trauma-informed care and now travels around the country educating others, emphasizes the importance of asking the right questions. Asking “What happened to you?” is, for instance, much better than asking “What is wrong with you?,” she explained in a film about her recovery, entitled “Healing Neen.”
Another crucial step involves educating staffers at public and private agencies to be aware of both the trauma that clients have experienced and what actions or policies may retraumatize them. For example, isolating a rape victim and placing her in leather restraints may draw the victim's mind back to the rape incident; if that happens, the victim is forced to relive the trauma all over again. Trauma survivors have unique vulnerabilities and triggers that trauma-informed care providers seek to understand and address.9
When providing trauma-informed care and services, patience is key, says Neen. Healing won’t happen overnight.
Helping Native Youth
A number of health professionals and activists are working specifically with Native American youth, a population often overlooked by mainstream media and advocacy groups. Dr. Dee Bigfoot, Director of the Indian Country Child Trauma Center and Project Making Medicine at the University of Oklahoma Health Sciences Center, realized several years ago that many problems faced by American Indian and Alaska Native youth stem from childhood trauma such as separation from the family, poverty, and multiple family deaths.
“The Native American community has so many traumas, past and present," said Janet King, director of trauma-informed care implementation at the Bay Area-based Native American Health Center. Most mental health issues, she believes, are responses to a traumatic incident.
"We have always known," said King, "that Natives suffer from specific traumas that are linked to racism experienced in America, and trauma-informed care seemed to be the perfect fit.”
King points specifically to classroom experiences.
“In schools, the history lessons that are taught about the Native American people often contradict what the children have been taught at home. When they question the teacher or administrators, they are often met with hostility. This environment causes many Native children to feel uncomfortable, and decreases their will to learn." Many of these youth are stigmatized or end up dropping out of school, or both.
Trauma-Informed Care in California, and Beyond
The Native American Health Center (NAHC) has been providing trauma-informed care to young people in the San Francisco Bay Area for the past three years. Helped by a grant from the National Child Traumatic Stress Network, NAHC provides counseling with a therapist in a clinical setting, 12-week grief and loss programs, and other services. NAHC staff understand that the earlier they intervene to help a troubled child, the better.
Janet King works hard to secure funding for NAHC projects because, she said, she has seen from experience the positive impact trauma-informed care has had on the lives of Native Americans.
In California as a whole, trauma-informed care has flourished over the past seven years, according to Gabriella Grant, director of the California Center of Excellence for Trauma Informed Care. As awareness of trauma-informed care has grown, as policies have been created and adjusted, and as those policies have been implemented by public and private agencies, “I noticed a change in staff morale, client outcomes, and policies [that made service providers] more accommodating of people who have suffered trauma,” Grant said.10
Grant provides training on trauma-informed treatment to child welfare personnel, school administrators and other professionals who work with children, she said, adding that identifying the specific trauma and hurt experienced by each person seeking services is a top priority.
One model of trauma-informed care, implemented by Project Hope of the District of Columbia, targets girls ages 12 through 18. Girls who have experienced or witnessed physical, sexual, emotional, or community violence are placed in "trauma groups," where they discuss the challenges they face. Each group consists of eight to 10 girls. The idea is that by talking about their situations and working through their issues, the girls can focus on building relationships.
Bayview Child Health Center in San Francisco employs a different model, working with the parents rather than the kids. The staff there provide therapy that helps parents gain insight into how exposure to certain traumas is affecting their children. Parents also learn ways to support and help their children.
Traumatic experiences have effects. Recognizing and understanding those effects, and using that understanding to formulate treatment plans and strategies for youth with behavioral and other problems, lies at the heart of trauma-informed care. Young people – indeed, people of any age – who are struggling to deal with the consequences of trauma early in their lives clearly benefit from care that is supportive and sensitive to the circumstances they encountered throughout their lives.