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Facts About Trauma for Policymakers
Children's Mental Health

Author: Janice L. Cooper
Publication Date: July 2007

Trauma’s Impact

Trauma can result in long- and short-term problems. Research suggests that these can include physical and emotional health conditions and put those exposed to trauma at increased risk for chronic ill health and premature death. 1 For children and youth, in addition to health problems, other consequences of trauma include difficulties with learning, ongoing behavior problems, impaired relationships and poor social and emotional competence. 2 Children and youth exposed to trauma, especially violence, experience more learning and academic difficulties and behavioral and mood-related problems. 3 Research also shows that the younger children are when they experience trauma, the more vulnerable they are to its effects on brain development. 4

Trauma is Pervasive

Many children and youth experience trauma. Depending on their circumstance, between 25-90 percent of children and youth experience events that leave them traumatized. 5 They include:

  • Up to 50 percent of children and youth in child welfare 6
  • Between 60 to 90 percent of youth in juvenile justice 7
  • Between 83-91 percent of children and youth in neighborhoods with high levels of violent crime 8
  • Between 59 to 91 percent of children and youth in the community mental health system 9

While trauma cuts across class and race, low-income children, youth and their families and children, youth and families of color disproportionately experience trauma. 10 Among those disproportionately affected, compared to their peers, children and youth:

  • With suicidal behaviors and risk factors are more likely to experience trauma
  • —  American Indian and Alaska Native youth (2.5 times greater risk) 11

    —  Adolescent Latinas (more than 1.5 times greater risk) 12

    —  Gay, Lesbian, Transgender, Bisexual and Questioning youth (2 times greater risk) 13

  • With substance use disorders have a higher probability of trauma exposure (4 times greater risk) 14

Also significantly impacted are children and youth who experience:

  • Natural disasters or wars (they make up 20% of those who receive treatment) 15
  • Homelessness (50 to 66 percent of homeless youth witness or experience violence) 16

Current Policy and Practice Responses Inadequate

Current policy and practices are characterized by the lack of comprehensive applications of strategies that work.

As with community-based mental health in general, appropriate use of evidence-based trauma-related practices remains limited. 17 Child-serving agencies and their providers miss opportunities to identify children and youth with trauma-related conditions, and to intervene early and effectively. 18

In addition some practices and policies serve to retraumatize or revictimize children and youth. For example research shows that the use of seclusion and restraints has resulted in death and in increased mental health problems. 19 Similarly, boot camps and unlicensed residential schools have been associated with poor, even unorthodox treatment practices that harm children and youth. 20 Poor quality of care in some programs for children and youth has led to staff and peer abuse, thus traumatizing youth. 21

Other practices and policies inadvertently cause harm. For example recent immigration policies have not always taken into account the impact of raids and detention on the children and youth of those arrested. These actions have led to abandoned and often traumatized children and youth. 22 In the same way, housing policies that split families up in order to provide housing contribute to trauma. 23

Some policies while not harmful, serve to undermine effective strategies. For example:

  1. Finance policies that limit services beyond the “indicated child” or fail to cover trauma-focused services and supports
  2. Policies designed to introduce evidence-based trauma interventions that neglect to provide sufficient initial training, funding to support start-up or continued training
  3. Policies and practices that ignore the need to build in resources for collaboration
  4. Trauma-related screening policies that do not factor in community-based service capacity

Effective Practices Exists

The core components of trauma-informed care include: 24

  • Appropriate screening and assessments
  • Effective interventions and supports
  • Culturally and linguistically competent strategies
  • Family and youth engagement
  • Strong organizational capacity, including outcomes monitoring

Some Policy Initiatives Support a Trauma-Focused Approach

There are current strategies to build on. They need support and a commitment to expand as appropriate and reach their full potential. New initiatives are also needed.

Federal

The federal government has implemented effective broad-based and targeted initiatives that are trauma-informed. These include:

  • Youth Suicide Early Intervention and Prevention Strategies and Mental and Behavioral Health Services on Campus grant programs of the Garrett Lee Smith Memorial Act 25
  • National Child Traumatic Stress Network (a 70-center network) that has generated new research and expanded capacity 26
  • National Call to Action to Eliminate Seclusion and Restraint 27
  • Fiscal policy that supports traditional healing practices among the Navajo nation for veterans (does not currently apply to non-veterans) 28

States/Tribal

Among state- and tribal-led efforts to embed trauma-informed practices include:

  • Targeted legislation in Illinois and Massachusetts 29
  • Culturally-based child welfare initiative across tribal governments in North Dakota 30
  • Infrastructure development and support in Oklahoma and Oregon 31
  • Reduction of harmful practices with a specific child focus in Hawaii, Louisiana and Massachusetts 32 (at least 20 states have implemented laws, regulations, or policiesdesigned to reduce and ultimately eliminate the use of seclusion and restraint) 33

Other efforts to improve early identification and treatment through screening and assessment in states include:

  • Screening and assessments in most states (60 percent of states and territories) but the scope is limited and less than 20 percent use standardized screening and assessment tools) 34
  • Training strategies to increase the clinical and support capacity of those who deliver services to children, youth, and their families who have been exposed to trauma (40 percent of states) 35

Unaddressed Challenges

Although nationally there are examples of effective practices, far too many children, youth and their families do not benefit from them. For the vast majority of children and youth, public policies, particularly federal policies, lag behind the science on trauma-informed policies and practices. Current policy and practice responses do not reflect the urgency, depth or quality required by the high level of need, low impact of many current efforts, and, limited community-based service capacity. Funding restrictions and inadequacies in the supply and quality of the workforce along with poor support for prevention and early intervention thwart effective trauma policies and reinforce poor practice. The federal government’s targeted trauma initiatives represent solid first steps. Their impact would be magnified were a more robust, intentional national approach to trauma implemented.

Key Recommendations for Policy Action

  • All federal, tribal, state, and local policies should reflect a trauma-informed perspective. A traumainformed response encompasses a fundamental understanding of trauma and how it shapes an individual who has experienced it.
  • —  Policies should support delivery systems that identify and implement strategies to prevent trauma, increase capacity for early identification and intervention, and provide comprehensive treatment.

    —  Policies should support and require that strategies are designed to prevent and eliminate treatment practices that cause trauma or

    —  Policies should reinforce the core components of best practices in trauma-informed care: prevention, developmentally-appropriate effective strategies, cultural and linguistic competence, and family and youth engagement.

  • Policy and practice reflective of trauma-informed principles must be developmentally appropriate, based on a public health framework, and engage children, youth, and their families in healing.
  • —  Policies should focus on preventing trauma and developing strategies to identify and intervene early for children, youth, and their families exposed to trauma or at-risk of exposure to trauma.

    —  Policies should focus on enhancing child, youth, and family engagement strategies to support informed trauma care delivery.

    —  Policies should support strategies that encompass family-based approaches to trauma intervention.

  • Trauma-informed related policies must include responsive financing, cross-system collaboration and training, accountability, and infrastructure development.
  • —  Policies should ensure that funding is supportive of trauma-informed care and based upon sound fiscal strategies.

    —  Policies should make funding contingent upon eliminating harmful practices that cause trauma and retraumatization across child serving settings.

    —  Policies should support comprehensive workforce investment strategies.

Endnotes

This fact sheet was prepared by Janice L. Cooper. It is based upon Strengthening Policies to Support Children, Youth and Families Who Experience Trauma, a publication of the National Center for Children in Poverty.

1. Dube, S. R.; Anda, R. F.; Felitti, V.; Chapman, D. P.; Williamson, D. F.; & Giles, W. H. (2001). Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: Findings from the adverse childhood experiences study. JAMA, 286(24), pp. 3089-3096.

Felitti, V.; Anda, R.; Nordenberg, D.; Williamson, D. F.; Spitz, A.; Edwards, V.; et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), pp. 245-258.

2. Bogat, T.; DeJonghe, E.; Levendosky, A. A.; Davidson, W. S.; & von Eye, A. (2006). Trauma symptoms among infants exposed to intimate partner violence. Child Abuse & Neglect, 30(2), pp. 109-125.

3. Kim, J. & Cicchetti, D. (2004). A longitudinal study of child maltreatment, mother-child relationship quality and maladjustment: The role of self-esteem and social competence. Journal of Abnormal Child Psychology, 32(4), pp. 341-354.

Thompson, T. & Massat, C. R. (2005). Experiences of violence, post-traumatic stress, academic achievement and behavior problems of urban African-American children. Child and Adolescent Social Work Journal, 22(5-6), pp. 367-393.

4. Weber, D. A. & Reynolds, C. R. (2004). Clinical perspectives on neurobiological effects of psychological trauma. Neuropsychology Review, 14(2), pp. 115-129.

5. National Child Traumatic Stress Network. (2004). Children and trauma in America: A progress report of the National Child Traumatic Stress Network <www.nctsnet.org> (accessed January 4, 2006).

Breslau, N.; Wilcox, H. C.; Storr, C. L.; Lucia, V. C.; & James, A. (2004). Trauma exposure and post-traumatic stress disorder: A study of youths in urban America. Journal of Urban Health, 81(4), pp. 531-544.

6. Yoe, T.; Russell, L.; Ryder, C.; Perez, A.; & Boustead, R. (2005). With all we have to do, what’s trauma got to do with us? A Webinar Conference for SAMHSA System of Care Sites for Children and Adolescents, September 29, 2005.

7. Abram, K.; Teplin, L.; Charles, D.; Longworth, S.; McClleland, G.; & Duncan, M. (2004). Post-traumatic stress disorder and trauma in youth in juvenile detention. Archives of General Psychiatry, 61, pp. 403-410.

Also see Breslau, et al. in endnote 4.

8. See Breslau, et al. in endnote 4.

9. Ford, J.; Racusin, R.; Daviss, W. B.; Ellis, C. G.; Thomas, J.; Rogers, K.; et al. (1999). Trauma exposure among children with oppositional defiant disorder and attention deficit-hyperactivity disorder. Journal of Consulting and Clinical Psychology, 67(5), pp. 786-789.

Silva, R. R.; Alpert, M.; Munoz, D. M.; Singh, S.; Matzner, F.; & Dummit, S. (2000). Stress and vulnerability to posttraumatic stress disorder in children and adolescents. American Journal of Psychiatry, 157(8), pp. 1229-1235.

10. Bassuk, E.; Friedman, S. M.; Batia, K.; Holland, J.; Kelly, A. H.; Olson, L.; et al. (2005). Facts on trauma and homeless children. Los Angeles, CA & Durham, NC: National Child Traumatic Stress Network, Homelessness and Extreme Poverty Working Group.

11. Indian Health Services. (2003). Trends in Indian Country 2001-2002. Rockville, MD: United States Department of Health & Human Services, Public Health <www.ihs.gov/NonMedicalPrograms/IHS_Stats/Trends00.asp> (accessed April 27, 2007).

12. Keaton, D. K.; Kann, L.; Kinchen, S.; Ross, J.; Hawkins, J.; Harris, W.; et al. (2006). Youth Risk Behavior Surveillance—United
States, 2005. MMWR, 55(SS05), pp. 1-108.

13. Russell, S. T. & Joyner, K. (2001). Adolescent sexual orientation and suicide risk: Evidence from a national study. American Journal of Public Health, 91(8), pp. 1278-1281.

14. Cohen, J. A.; Mannarino, A. P.; Zhitova, A. C.; & Capone, M. E. (2003). Treating child abuse-related post-traumatic stress and co-morbid substance abuse in adolescents. Child Abuse & Neglect, 27(12), pp. 1345-1365.

Giaconia, R. M.; Reinherz, H. Z.; Hauf Carmola, A.; Paradis, A. D.; Wasserman, M. S.; & Langhammer, D. M. (2000). Co-morbidity of substance use and post-traumatic stress disorders in a community sample of adolescents. American Journal of Orthopsychiatry, 70(2), pp. 253-262.

15. Abramson, D. & Garfield, R. (2006). On the edge: Children and families displaced by Hurricanes Katrina and Rita face a looming medical and mental health crisis. New York, NY: National Center for Disaster Preparedness & Operation Assist, Columbia University, Mailman School of Public Health.

Mollica, R. F.; McDonald, L.; Osofsky, H.; Calderon-Abbo, J.; & Balaban, V. (2003). The mitigation and recovery of mental health problems in children and adolescents affected by terrorism. Boston, MA: Harvard Medical School and Massachusetts General Hospital.

16. See endnote 10.

Kipke, M. D.; Simon, T. R.; Montgomery, S. B.; Unger, J. B.; & Iversen, E. F. (1997). Homeless youth and their exposure to and involvement in violence while living on the streets. Journal of Adolescent Health, 20, pp. 360-367.

17. Taylor, N.; Siegfried, C. B.; Berkman, M.; Carnes, C.; Friedman, B.; Henry, J.; et al. (2005). Helping children in the child welfare system heal from trauma: A systems integration approach. Los Angeles, CA and Durham, NC: The National Child Traumatic Stress Network. Walrath, C. M.; Sheehan, A.; Holden, E. W.; Hernandez, M.; & Blau, G. (2006). Evidence-based treatments in the field: A brief report on provider knowledge, implementation, and practice. The Journal of Behavioral Health Services & Research, 33(2), pp. 244-253.

18. Hanson, T. C.; Hesselbrock, M.; & Tworkowski, S. H. (2002). The prevalence and management of trauma in the public domain: An agency and clinician perspective. The Journal of Behavioral Health Services & Research, 29(4), pp. 365-380.

Also see Taylor, et al. and Walrath, et al. in endnote 15.

19. United States General Accounting Office (GAO). (1999). Mental health improper restraint or seclusion use place people at risk. (No. GAO/HEHS-99-176). Washington, DC: Government Accounting Office.

20. Miller, C. M. (2006). Minor offenses at camp brought beatings: A smile, a mumble and other forms of nonviolent behavior resulted in force against teenage boys at a Florida Sheriff ’s Boot Camp, A Miami Herald investigation, Miami Herald. Miami, FL: Miami Herald, distributed by Knight/Ridder Tribune News Service.

Friedman, B.; Pinto, A.; Behar, L.; Bush, N.; Chirolla, A.; Epstein, M.; et al. (2006). Unlicensed residential programs: The next challenge in protecting youth. American Journal of Orthopsychiatry, 76(3), pp. 293-303.

21. Synder, H. N. & Sickmund, M. (2006). Juvenile offenders and victims: 2006 National report. Washington, DC: United States. Department of Justice, Office of Justice Programs, Office of Juvenile Delinquency and Prevention.

22. Sanchez, J. W. (2007, 3/12/2007). Split families struggle to cope after Swift Immigration raids. The Salt Lake Tribune <www.sltrib.com/ci_5415879> (accessed April 4, 2007).

Aizenman, N. C. (2007, 4/3/2007). U.S. Immigration raids spurs rear in children. Boston Globe <www.boston.com/news/nation/articles/2007/04/03/us_immigrant_raids_spur_fears_in_children> (accessed April 4, 2007).

23. Homeless Families with Children. (2006). NCH Fact Sheet #12. Washington, DC: National Coalition for the Homeless <www.nationalhomeless.org/publications/facts/families.pdf> (accessed May 12, 2007).

24. Cooper, J.; Masi, R.; Dababnah, S.; Aratani, Y.; & Knitzer, J. (2007). Strengthening policies to support children, youth and families who experience trauma. New York, NY: National Center for Children in Poverty, Columbia University, Mailman School of Public Health.

25. Garrett Lee Smith Memorial Act, 42 USC 290bb-36 (2004).

26. See <www.nctsnet.org/nccts/nav.do?pid=abt_who> (accessed June 12, 2007).

27. Curie, C. (2005). SAMHSA’s Commitment to Eliminating the Use of Seclusion and Restraint. Psychiatric Services, 56(9), pp. 1139-1140.

28. VA to Expand Coverage for Traditional Ceremonies [Electronic Version]. Independent <www.gallupindependent.com/2006/jun/061906vatrdcrm.html> (accessed March 12, 2007).

29. See endnote 24.

30. Ibid.

31. Ibid.

32. Slavin, L. A.; Hill, E.; Le Bel, J.; & Murphy, T. (2006). Efforts by state mental health agencies to improve residential care and minimize seclusion and restraint, 19th Annual Research Conference—A System of Care for Children’s Mental Health: Expanding the Research Base. Tampa, FL.

33. See endnote 24.

34. Ibid.

35. Ibid.