Scowsmith_Spring 2019_Masters Thesis | MAKING SENSE OF THE 70%: AWARENESS OF THE ADVERSE CHILDHOOD EXPERIENCE (ACE) SCORE AND TRAUMA-INFORMED PRACTICES OF SERVICE PROVIDERS IN BUTTE COUNTY - $37.99   Add to cart

Thesis

Scowsmith_Spring 2019_Masters Thesis | MAKING SENSE OF THE 70%: AWARENESS OF THE ADVERSE CHILDHOOD EXPERIENCE (ACE) SCORE AND TRAUMA-INFORMED PRACTICES OF SERVICE PROVIDERS IN BUTTE COUNTY

MAKING SENSE OF THE 70%: AWARENESS OF THE ADVERSE CHILDHOOD EXPERIENCE (ACE) SCORE AND TRAUMA-INFORMED PRACTICES OF SERVICE PROVIDERS IN BUTTE COUNTY ____________ A Thesis Presented To the Faculty of California State University, Chico ____________ In Partial Fulfillment Of the Requirements for the Degree Master of Social Work ____________ by © Kate Maren Scowsmith Spring 2017MAKING SENSE OF THE 70%: AWARENESS OF THE ADVERSE CHILDHOOD EXPERIENCE (ACE) SCORE AND TRAUMA-INFORMED PRACTICES OF SERVICE PROVIDERS IN BUTTE COUNTY A Thesis by Kate Scowsmith Spring 2017 APPROVED BY THE INTERIM DEAN OF GRADUATE STUDIES: ________________________________ Sharon Barrios, Ph.D. APPROVED BY THE GRADUATE ADVISORY COMMITTEE: ________________________________ ________________________________ Dr. Jean Schuldberg, Ed.D. Patty Hunter, LCSW, MSW, Chair Graduate Coordinator ________________________________ Celeste Jones, Ph.D. ___________________________________________ Judy Vang, Ph.D.iii PUBLICATION RIGHTS No portion of this thesis may be reprinted or reproduced in any manner unacceptable to the usual copyright restrictions without the permission of the DEDICATION To all the resolute dreamers, thinkers, conceivers, organizers and believers that step outside their comfort zone for the betterment of others, communities, and the world.v ACKNOWLEDGEMENTS I am forever humbled and amazed by the incredibly supportive community I have found at Chico State: my cohort, within the Social Work department, and those through my internship at Student Health Services. Without their unconditional support, hugs, and listening ears writing this thesis would not have been so substantial. I wish to thank my thesis committee: Patty Hunter, Chair, Dr. Celeste Jones, and Dr. Judy Vang. I extend my warmest regard and gratitude for your expertise, encouragement, and humor throughout this journey. In addition, I also wish to recognize the brilliant support of Dr. Susan Roll and Dr. Sue Steiner. I am thankful for each one of these instructors and members of my committee who have been incredibly generous with their time, wisdom, compassion, and skill in offering an enriching, approachable educational experience. My gratitude extends to Dr. Deborah Stewart and Lauri Evans at CSUC Student Health Services. Both Deborah and Lauri have been a tremendous source of knowledge and support during my internship and have been thoroughly receptive to hearing out and considering my ideas. Dr. Stewart has afforded me numerous opportunities for my personal and professional growth; her encouragement has been invaluable and has made me feel brave. Lauri has always had an open door and heart throughout the year; I cannot thank her enough for her advice and understanding. It has been inspiring to work with Deborah and Lauri, and bear witness to their commitment and contributions towards a thriving, healthy campus culture. Immense gratitude to my parents, Greg and Ann, and my sister, Hannah: for nurturing and cultivating my interests, encouraging my creativity, and wanting me to succeed...also, the laughs and the spontaneous excursions. Thanks to my grandparents for enriching my life in allvi their unique ways, and especially to my grandmothers, Millicent and Geraldine, for exemplifying the exciting possibilities of being strong women. Lastly, love and appreciation to Julie Scalet and the entire Scalet family for the best of times and hanging through the worst of times. Our friendship has been a consistent source of joy, compassion and support that have helped make this thesis possible. Thank you for being TABLE OF CONTENTS PAGE Publication Rights....................................................................................................... iii Dedication................................................................................................................... iv Acknowledgments....................................................................................................... v List of Tables .............................................................................................................. x Abstract....................................................................................................................... xiii CHAPTER PAGE I. Introduction............................................................................................... 1 Background................................................................................... 1x Statement of the Problem.............................................................. 4 Purpose of the Study ..................................................................... 5 Definition of Terms....................................................................... 6 II. Literature Review...................................................................................... 9 Introduction................................................................................... 9 Trauma in the United States...................................................................... 9 Adverse Childhood Experiences Study ........................................ 10 Medical and Health Challenges .................................................... 11 Social and Emotional Challenges ................................................. 13 Cognition and Neurodevelopment ................................................ 13 Vulnerable Populations................................................................. 16 Lasting Impacts of Trauma ........................................................... 19 Interventions for Trauma .............................................................. 21 ACEs, Trauma and Butte County ................................................. 23 Theoretical Bases and Organization ............................................. 24 III. Methodology............................................................................................. 27 Research Design............................................................................ 28 Selection of Survey Participants ................................................... 29 Instrumentation ............................................................................. 29 Data Analysis ................................................................................ 30 Limitations .................................................................................... 24x IV. Findings and Results................................................................................. 34 Introduction................................................................................... 34 Quantitative................................................................................... 36 Qualitative..................................................................................... 36 Themes.......................................................................................... 46 V. Discussion ................................................................................................ 34 Quantitative................................................................................... 34 One-Way Analysis of Variance (ANOVA) .................................. 36 Qualitative..................................................................................... 36 VI. Conclusions and Recommendations ......................................................... 49 Conclusion .................................................................................... 49 Recommendations......................................................................... 50 Implications for Social Work........................................................ 52 References..................................................................................................................... 54 Appendices A. ACEs Pyramid .......................................................................................... 71 B. Trauma-Informed Integrated Care ............................................................ 73x C. Survey Instrument..................................................................................... 75 D. Research Questions................................................................................... 79 E. Trauma-Informed Practice: Approaches and Values............................................................................. 81x LIST OF TABLES TABLE PAGE 1. Participant Demographics: Gender.............................................................. 35 2. Participant Demographics: Age ................................................................... 36 3. Participant Demographics: County.............................................................. 36 4. Participant Demographics: Field of Study/Professional Preparation ..................................................... 37 5. Descriptives for ANOVA-Field of Services and Knowledge of Trauma-Informed Approaches ...................................... 38 6. ANOVA-Field of Service and Knowledge of Trauma-Informed Approaches ................................................................ 38 7. Descriptives for ANOVA-Field of Service and Knowledge of Trauma-Informed Values..................................................... 39 8. How much of an impact do you believe childhood trauma plays in the health and well-being of your clients?........................................................................... 40xii 9. How familiar are you with the Adverse Childhood Experience (ACE) Study?............................................ 40 10. Please share any comments regarding information, training, or policies that would support further integration of trauma-focused approaches in your setting ........................................................................... 41 11. Cross-tabulation between gender and field of practice................................ 44 12. Scale of Provider Understanding ................................................................. 45xiii ABSTRACT MAKING SENSE OF THE 70%: AWARENESS OF THE ADVERSE CHILDHOOD EXPERIENCE (ACE) SCORE AND TRAUMA-INFORMED PRACTICES OF SERVICE PROVIDERS IN BUTTE COUNTY by © Kate Scowsmith 2017 Master of Social Work California State University, Chico Spring 2017 Research has shown that exposure to trauma has long-lasting, pervasive, debilitative effects upon a person’s biological, cognitive, mental, and social functioning over their lifetime (Anda et al., 2006). The Adverse Childhood Experiences (ACE) study was developed to understand potential relationships between childhood events and health outcomes later in life (Larkin, Felitti, & Anda, 2014). Within California, a county breakdown reveals that over 70% of Butte County residents scored at least a one on the ACEs scale (Stevens, 2014). Trauma informed care (TIC) is a strengths based approach that is rooted in an understanding of trauma and responsiveness to trauma (Bassuk et al, 2017). A review of the literature reveals that TIC is well discussed in literature theoretically and through case studies, but there is little research on how TIC is implemented and viewed by providers within different fields (Donisch, Bray, & Gewirtz, 2016). Using a mixed method online survey, this research project examined Buttexiv County providers’ awareness of Adverse Childhood Experience Score (ACES) and trauma-informed practices in the fields of medicine, education and social services serving Butte County (N=164). Recommendations for further study, a discussion of the findings, and implications for social work practice are discussed.1 CHAPTER I INTRODUCTION Background The tremendous and pervasive consequences of unaddressed trauma in people’s lives were most blatant and revealing to me when I worked as a social work intern in home health and hospice. Research has shown that exposure to trauma has long-lasting, pervasive, debilitative effects upon a person’s biological, cognitive, mental, and social functioning over their lifetime (Anda et al., 2006) and can contribute to early mortality rates (Brown et al., 2009). It was a sobering experience working with individuals who were elderly, facing debilitating illnesses, and were at the end of their lives while mitigating circumstances initiated by trauma. Trauma interrupted, ignored or left unaddressed, looks different at the end of life in comparison to the beginning. For eight years, I worked with special education preschoolers and their families in a nurturing, understanding school environment. Many children I worked with had been exposed to adverse experiences, including their family members or other support systems. Typically, when educators knew about trauma, interventions were incorporated into the child’s curriculum. However, outcomes were different if families did not disclose adversities to the school district. While some children received care for their exposure, other children did not get services they could have benefited from them had there been more transparency. Observing this pattern, I began to see tremendous need for a more wide spread, supportive, and consistent approach to serving children and their families more dimensionally. Currently, as a social work intern in a campus student health center, I am able to work in2 an environment that strives to be trauma-informed. The medical chief of staff, who has an extensive background in working with trauma-exposed children, is highly committed towards cultivating a trauma-informed staff: from a patient’s first point of contact to the last. Working in a trauma-informed environment puts theory into practice, a way to see the great possibilities that can be cultivated from promoting safe, trustworthy, collaborative, empowering, interactive, and culturally competent service (Substance Abuse and Mental Health Services Administration [SAMHSA], 2015). The most remarkable benefit I was able to witness from implementing trauma sensitive approaches was the relationships that could be built with clients as they interacted with all fields of service offered at the clinic (medical, case management, social workers, front desk workers, pharmacy, etc.). Learning about the critical role social workers occupy in facilitating a “therapeutic alliance”, a relationship founded on “empathy, congruence, and unconditional positive regard” (Rogers, 1951, p.116), encouraged me to value the benefits of trauma sensitive interactions all the more. Thinking about the vulnerable populations I had worked with (preschool aged children, college students, and those requiring home health and hospice services) also strengthened my belief in utilizing the values of trauma-informed approaches. Preschool is one of the earliest encounters children have with the education system, and their parents or guardians also need that therapeutic alliance with the school system they are entrusting to care for their child. The safety and trust that can be offered through schooling is so critical when taking into account that by four years old, one in four children have either experienced or witnessed a potentially traumatic event (Briggs-Gowan et al., 2010). Additionally, a national sample concluded that 60% of children from 0-17 years old experienced or was witness to some form of victimization (child3 maltreatment, bullying, or assault) within the past year (Finkelhor, Turner, Ormond & Hamby, 2009). Children and their families need strong relationships with the education system not only to establish a therapeutic alliance for all future interactions, but also to find support in the situations they may be potentially encountering when they first engage with the school system. Children exposed to trauma benefit from preschool programs that provide an opportunity for early identification and intervention with on-site treatment and prevention (Bratton, 2014). According to Read et al. (2011), a substantial percentage (66%) of college students entering their first year report a history of trauma that met the criterion within the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013). In a study of 575 college students, Chang, Yu, Chang, O. D., & Hirsch, (2015) found that there may be substantial benefits to cultivating high hope in college students especially for those students exposed to trauma. For many college students that utilize the campus student health clinic, this is their first interaction with medical or mental health services on their own (without parental or guardian support). Establishing a strong therapeutic alliance is so crucial to their immediate needs but also their long-term perception and trust of services they may require in the future. Fostering therapeutic alliances between patient and medical provider extends to all age groups and specialties in medicine; as stated in the General Medical Council “patients must be able to trust doctors with their lives and health”, maintaining trust is one of the guiding principles for physicians (General Medical Council, 2017). Estimates suggest that up to 70% of the general population in the United States have been exposed to trauma (Frissa et al., 2016) with 70%-90% of elderly adults (65 and older) having been exposed (Norris, 1992). In the social services field, the percentage of individuals exposed to trauma in various4 settings is monumental with 90% of individuals seeking mental health services (SAMHSA, 2015). Exposure to trauma during childhood and adolescence is correlated to increased utilization of multiple systems of service (Briggs et al., 2013). Coinciding with my work in the field, I was enriched by coursework and literature within my graduate program that expanded my knowledge base on trauma-informed practices and childhood adversities. The Adverse Childhood Experiences (ACE) study was developed to understand potential relationships between childhood events and health outcomes later in life (Larkin, Felitti, & Anda, 2014). It was found that this relationship was profound, linking early exposure to adverse experiences to many risky health behaviors (smoking, drinking, substance abuse, sexual behaviors, etc.) and health problems (cancer, chronic obstructive pulmonary disease, and heart disease) (Dong et al., 2004). My experiences and education led me to become more interested in trauma-informed approaches on a local level. In 2016, I became involved with a local ACES coalition that was interested in addressing ACEs and interventions within Butte County. Through these meetings, I was exposed to the idea of surveying the local population about their knowledge of the ACE study. As a social worker about to embark into a field where I will certainly encounter traumaexposed individuals, I grew curious about what providers knew about trauma and interventions within their settings. My background within these fields compelled my interest in surveying providers. Statement of the Problem This research project will examine Butte County providers’ awareness of Adverse Childhood Experience Score (ACES) and trauma-informed practices in the fields of medicine, education and social services serving Butte County. Traumatic events experienced in childhood5 have lasting implications on an individual throughout their lifetime: impacting health, education, and social development (Felliti et al., 1998). Within California, a county breakdown reveals that over 70% of Butte County residents scored at least a one on the ACEs scale (Stevens, 2014). With such a high percentage of Butte County’s population being exposed to traumatic experiences, it is essential that providers integrate trauma-informed practices within their respective fields. Through a mixed methods approach, this research will gather data through a survey that will be administered to Butte County professionals over a two month period. This study addressed questions pertaining to the level of awareness of ACE scores amongst professionals, how they vary among disciplines, and how trauma-informed practices are being implemented or not within Butte County service providers. Finally, through a qualitative questionnaire, providers offered their perspectives and feedback on what is needed to integrate trauma-informed approaches in their respective fields. Purpose of the Study In order to best serve populations affected by trauma, a multifaceted study was undertaken to assess local providers and their awareness of trauma-informed practices and adverse childhood experiences. To address the various services individuals access, the study examined trauma-informed practice in the fields of medicine, education, and social services. For patients, clients, and students accessing services who have been exposed to trauma it is pertinent to understand how trauma informed practices are being implemented within agencies serving these individuals. If practitioners are not screening for trauma, or implementing practices that best serve trauma exposed clients, research suggests the consequences of trauma exposure will continue into adulthood (Felliti et al., 1998). The purpose of this study is to explore the extent professionals in the field are implementing trauma informed practices and understand the6 influence of trauma in the lives of the people they serve. Implementing trauma informed practices could help address the high incidence of adverse childhood experiences within Butte County. Definition of Terms Trauma Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma, experienced by individuals, as a result from “an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being (SAMHSA, 2015). For the purpose of this study, this definition of trauma will be utilized. Trauma Informed Care, Trauma-Informed Approach and Trauma-Informed Practice SAMHSA defines Trauma-Informed Care (TIC) as the “adoption of principles and practices that promote a culture of safety, empowerment, and healing” (SAMHSA, 2015). Trauma-Informed Approach is “a program, organization, or system that is trauma-informed: 1. Realizes the widespread impact of trauma and understands potential paths for recovery; 2. Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; 3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and 4. Seeks to actively resist re-traumatization.” (SAMHSA, 2015). For the purpose of this research, Trauma-Informed Practice (TIP) is the application of a Trauma7 Informed Approach and TIC across different fields and settings. Additionally, SAMHSA identifies a set of key principles that a Trauma-Informed Approach should integrate that are adaptable to different settings: 1. Safety 2. Trustworthiness and Transparency 3. Peer support 4. Collaboration and mutuality 5. Empowerment, voice and choice 6. Cultural, Historical, and Gender Issues (SAMHSA, 2015). Trauma-Specific Interventions SAMHSA also identifies trauma-specific interventions, where programs recognize: ● The survivor’s need to be respected, informed, connected, and hopeful regarding their own recovery ● The interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety ● The need to work in a collaborative way with survivors, family and friends of the survivor, and other human services agencies in a manner that will empower survivors and consumers (SAMHSA, 2015). There are many programs that use psychosocial educational empowerment interventions, these are some examples of programs used in public system settings: Addiction and Trauma Recovery Integration Model (ATRIUM); Risking Connection; Sanctuary Model; and Seeking Safety (SAMHSA, 2015).8 Fields: Social Services, Medical, and Education Research was conducted within three different professional disciplines, where the field of: 1. Education is defined as a location or space where “the process of receiving or giving systematic instruction, especially at a school or university” occurs (“Education”, n.d.); 2. Medical is a location or space “requiring or devoted to medical treatment” (“Medical, n.d.); and 3. Social services is a location or space aiming “to promote social well-being” and “organized philanthropic assistance” (“Social Service”, n.d.).9 CHAPTER II LITERATURE REVIEW Introduction The literature review will provide background on childhood trauma in the United States and describe how trauma influences the health and well-being of individuals. Background on the Adverse Childhood Experiences study (ACEs) conducted by Kaiser Permanente between 1995 and 1997 will also be included (Centers for Disease Control and Prevention [CDC], 2016). The significance of trauma upon different aspects of health and well-being will be organized by: 1) Medical and Health Challenges, 2) Social and Emotional Challenges, and 3) Cognition and Neurodevelopment: Impact on Education. The impression trauma has upon vulnerable populations and the generational implications of trauma will be discussed, following a discussion of the global and local efforts to address these implications. Trauma in the United States Approximately 90% of American children have or will experience some form of trauma in their lives (Horner, 2015). According to the U.S. Department of Health & Human Services, almost 700,000 children were mistreated in 2012 with trauma ranging from neglect (experienced by 78% of these children) and physical and sexual abuse (experienced by 27%) (Horner, 2015). The American Psychological Association reports 39%-85% of children in the United States witness community violence; 25%-43% are exposed to sexual abuse; and 7.9 million American children received emergency medical care in 2006 for a variety of unintentional injuries10 (Children and Trauma, 2015). Other forms of trauma, according to The National Child Traumatic Stress Network (Types of Traumatic Stress, n.d.), include community violence, domestic violence, medical trauma, natural disasters, refugee and war zone trauma, school violence, and terrorism. Trauma exists in many forms and within many situations. Much like the history of childhood itself, trauma in children is equally complicated and multifaceted. The experience of trauma affects children across all demographics within the United States, yet the severity and nature of its impact interacts differently within different groups. Children within the additional factors of poverty, racial and ethnic minority groups, and exposure to substance abuse experience a greater likelihood of experiencing trauma as reported by Janice L. Cooper (2007). While exposure may permeate groups differently according to demographics, children who experience trauma present the same symptoms following various degrees of exposure. Adverse Childhood Experiences Study The CDC (2016) describes that between 1995 and 1997, Kaiser Permanente developed and conducted two sessions of data collection with the Adverse Childhood Experiences Study (ACEs). The study was implemented to address growing suspicions that children’s physical ailments were correlated with traumatic experiences (Burke Harris, 2014). Participants were given gender designated surveys, a “Family Health History Questionnaire” and a “Health Appraisal Questionnaire” through the mail (CDC, 2016). The surveys were utilized to gather data on participants’ potential histories of “child abuse and neglect, household challenges, and other socio-behavioral factors” (CDC, 2016). Following the questionnaires, participants were administered surveys where adverse childhood experiences were organized into seven categories: “psychological, physical, or sexual abuse; violence against mother; or living with household11 members who were substance abusers, mentally ill or suicidal, or ever imprisoned” (Felitti et. al, 1998). Answering “yes” to any of the questions within each category is valued as one ACE score (Felitti , 1998). Utilizing the top ten risk factors that lead to higher morbidity and mortality rates in the United States, researchers were able to relate findings from the ACEs study to health outcomes of the participants (Felitti , 1998). Risk factors including smoking, obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, drug abuse, drug abuse of family members, a high number of sexual partners over a lifetime, and history of sexually transmitted disease were assessed in the two questionnaires and results were correlated with the ACE survey (Felitti et al, 1998). The ACEs study and other trauma research has since explored “the biopsychosocial susceptibilities and resiliencies contributing to both health and disease later in life” (Larkin, Felitti, & Anda, 2014, p. 1). This perspective encourages the perception of the individual and the whole, acknowledging that the factors of development and behaviors over a person’s life are developed through cultural and systemic frameworks (Larkin, Felitti, & Anda, 2014, p. 2). A biopsychosocial framework reveals trauma exposure’s influence can be separated into medical and health challenges, social and emotional challenges, and cognition and neurodevelopment. Medical and Health Challenges The Centers for Disease Control and Prevention (CDC) illustrated an individual’s projected outcomes on disease risk factors and quality of life over the course of their lifetime (CDC, 2016; see Appendix A). The pyramid begins at conception with the onset of adverse childhood experiences at the base. As individuals age, moving toward the top of the pyramid, exposed individuals experience impaired social, emotional, and cognitive function, which can12 promote the adoption of risky behaviors that then initiate disease, disabilities, and social problems (CDC, 2016). The pyramid illustrates the destructive, cumulative ways trauma can perpetuate additional challenges and potentially early death over the course of a lifetime. According to Anda et al (2006), childhood trauma exposure is the most significant public health concern in the United States. In Felitti et. al (1998), the Kaiser Permanente’s ACEs study demonstrated that a strong correlation exists between the exposure of adverse childhood experiences and health conditions such as: heart disease, cancer, bronchitis or emphysema, history of hepatitis, bone fractures, and poor self-rated health. More specifically, the higher the ACEs score the more at risk an individual is for more chronic health conditions: 260% more likely to have chronic obstructive pulmonary disease (COPD), 250% more likely to contract hepatitis, 460% more likely to experience depression, among many others (Burke Harris, 2014). A further review of ACEs data suggested a strong correlation between the number of ACEs and risk of premature deaths of family members (Anda, 2009). ACEs impacts other areas of an individual’s health, as studies have found other correlations between adverse childhood experiences and different symptoms and behaviors. Exposure to trauma as a child makes individuals more prone to headaches (Anda, Tietjen, Schulman, Felitti, & Croft, 2010), sleep disturbances (Chapman et al, 2011), premature death (Brown et al, 2007), risky sexual behaviors (Hillis, Anda, Felitti, & Marchbanks, 2001), and childhood autobiographical memory disturbance ([CAMD], Brown et al, 2007). Exposure to traumatic events during childhood create lasting biological implications. Within the last twenty years, more research and interest has shifted from biological understandings of mental health toward accounting for adverse environmental factors (Larkin & Read, 2008).13 Social and Emotional Challenges There is a tremendous body of work that connects childhood trauma to many negative mental health, physical health, and social and emotional outcomes within childhood through to adulthood (Larkin & Read, 2008). Exposure to childhood adversities is linked to psychiatric disorders in adulthood, including: depression, anxiety, substance abuse, eating disorders, posttraumatic stress disorder (PTSD), sexual dysfunction, personality disorders, dissociation, and higher risk for suicide (Larkin & Read, 2008). The CDC (2016) describes a “dose-response” outcome with early trauma exposure, meaning “that as the dose of the stressor increases the intensity of the outcome also increases”. Social and emotional dose-response outcomes from the ACEs study include: depression, alcoholism and alcohol abuse, drug abuse, financial stress, risk for intimate partner violence, multiple sexual partners and risky sexual behavior, suicide attempts, unintended pregnancies and adolescent pregnancy, risk for sexual violence, and poor work performance (CDC, 2016). Essentially, as the stressors of trauma increase so do the detrimental social and emotional outcomes. A strong correlation exists between childhood trauma exposure and elevated risk of psychiatric disorders and suicidal ideation (Afifi et al, 2008). These outcomes carryover to children receiving services. Children receiving different components of social services are more likely to have experienced trauma with 50% in child welfare, 60-90 % in juvenile justice, 83- 91% in neighborhoods with high crime, and 59-91 % in the mental health system (Cooper, 2007). Cognition and Neurodevelopment Maltreatment during childhood can be considered the most influential predictor of poor mental health during the course of a lifetime, greatly increasing risk factors for a expansive range14 of psychiatric challenges emanating during childhood (McCrory, Gerin, & Viding, 2017). Adverse childhood experiences often take place during a sensitive period of development, when a child’s nervous system is going through significant changes in maturation and organization (Gilles, 1999). Research is minimal on the growing number of trauma-exposed children and the educational implications of addressing these challenges in the educational and counseling services fields (O’Neill, Guenette, & Kitchenham, 2010). Children exposed to trauma are at risk for numerous academic and behavioral challenges in classroom settings based on consequences from environment and “disorganized attachment relationships” (O’Neill, Guenette, & Kitchenham, 2010). Compas (2006) describes the “allostatic load” as the result of repeated use of the body’s stress response systems, which create physical disease and disordered emotional and behavioral functioning. Frequent exposure, initially, manifests in physical and psychosocial symptoms; the second process unfolds within neurodevelopment (Compas, 2006). Unfortunately, the areas of the brain most affected, the hippocampus and prefrontal cortex, are the components of the brain that are most utilized for coping, retaining information, and adapting to stress (Compas, 2006). The excessive activation of a child’s stress response system creates impairment of emotional regulation, which then causes a child’s inability to appropriately behave in classroom settings, focus and retain educational material (Mendelson, Tandon, O'Brennan, Leaf, & Ialongo, 2015). For children from 0-6 years old, as reported by the National Child Traumatic Stress Network, trauma influences outcomes at cognitive, behavioral, and physiological levels (Symptoms and Behaviors Associated with Exposure to Trauma, n.d.). For cognitive: poor verbal skills, memory problems, attention and learning deficits, learning disabilities, and poor skill development (Symptoms and Behaviors Associated with Exposure to Trauma, n.d.). Behavioral15 symptoms include: aggression, explosive temper, negative attention seeking, regressive behaviors, reenacting the abuse, excessive screaming or crying, easily startled, inability to trust others, self-blaming, fear and avoidance, irritability and sadness, anxiety, and being withdrawn (Symptoms and Behaviors Associated with Exposure to Trauma, n.d.). Physiological symptoms include low weight, poor appetite, digestion problems, stomach-aches and headaches, sleep disorders, and physically regressive behaviors like bed wetting (Symptoms and Behaviors Associated with Exposure to Trauma, n.d.). Schwartz and Davis (2006) express that children who struggle with emotional attachments because of trauma exposure are more likely to be involved in special education and serious emotional disturbance (SED) classrooms. The cognitive, behavioral, and physiological behaviors that result from trauma exposure in childhood create detrimental consequences for students’ academic outcomes that extend beyond learning disabilities: fear, hyperactivity, aggressive behaviors, somatic issues in younger children, depression and self-harm in adolescents (Gabowitz, Zucker, & Cook, 2008). In an environment teeming with activity, trauma disrupts a child’s ability to enact appropriate responses to stimuli (Van der Kolk, 1989). Experiencing those symptoms create further complications with how children interact with their peers and educators, interfering with a child’s ability to assimilate and adjust to new information (van der Kolk, 1989). Dr. Nadine Burke led a study on adverse childhood experiences of her pediatric patients in Northern California (Burke Harris, 2014). Following a survey of 701 children, the results of her study revealed that participants with an ACE score of four or more were more likely to experience learning and behavioral problems at school (Burke et al, 2011). This statistic was made more alarming by comparing those children with at least four ACEs to children without16 ACEs in regards to learning and behavior problems (51.2% vs. 3% respectively) (Burke et al, 2011). Statistically, trauma exposed youth in school settings are more likely to present with inadequate social skills, an increase of internalizing and externalizing behaviors, and less social interaction (Shonk & Cicchetti, 2001). Additionally, students who are trauma exposed are more likely to have lower grade point averages (Hurt, Malmud, Brodsky, & Giannetta, 2001); decreased graduation rates from high school (Grogger, 1997); score lower on student achievement tests and course grades, and have higher potential for suspension, expulsion, and failure in school (Wolpow, Johnson, Hertel, & Kincaid, 2009). Adverse childhood experiences have a detrimental influence on the probability of individuals later enrolling for college (Filipkowski, Heron, & Smyth, 2016). Individuals who do successfully enroll in college, who have reported experiencing at least one traumatic event in their lives prior to college, report poorer abilities to adjust to college: socially, emotionally, and academically (Banyard & Cantor, 2004). Vulnerable Populations Trauma exposure can affect all individuals, but researchers have worked to identify populations that are most at risk. The statistical extent of childhood trauma is tremendous and it is evident that trauma is the catalyst for a range of mental, social, and physical problems with a particular affect minority and poverty groups (de Arellano & Danielson, 2008). Nationally, the United States ethnic minority populations are expected to surpass non-ethnic minority populations by the year 2050 (U.S. Bureau of the Census, 2003). Given these changing populations in America, there is urgent need for practitioners to be prepared and responsive to the diverse challenges in American communities through culturally competent practices (de17 Arellano & Danielson, 2008). Populations experience the ramifications of trauma differently, for example, of the populations exhibiting suicidal behaviors; Native American populations (including Alaskan Natives) are 2.5 times more at risk; adolescent Latinas are at 1.5 times greater risk; and Gay, Lesbian, Transgender, Bisexual and Questioning youth are 2 times at greater risk (Cooper, 2007). Cooper (2007) also includes that Gay, Lesbian, Transgender, Bisexual and Questioning youth are twice as likely to experience trauma; exposure to substance abuse places a child at four times the risk; and homeless children are 50% to 66% more likely to experience trauma. It is estimated that children experience at least one trauma every year (Finkelhor, Turner, Ormond, & Hamby, 2009). Among low-income populations, homelessness, and interaction with child welfare are highly correlated to exposure to trauma (Bassuk, Unick, Paquette, & Richard, 1996). Manifestations of trauma and accessibility to treatment, uniquely permeate other populations and subgroups: trauma exposed elderly populations had fewer close friends, financial hardships and perceived more treatment-seeking stigma than those elderly not exposed (Pless Kaiser, Seligowski, Spiro III, & Chopra, 2016); trauma survivors encounter unique barriers specific to trauma, especially in the domain of fearing re-traumatization (Kantor, Knefel, & Lueger-Schuster, 2017); the majority of Central American migrants entering the United States border have experienced significant trauma stemming from violence and persecution in their country of origin (Keller, Joscelyne, Granski, & Rosenfeld, 2017); individuals experiencing homelessness have high prevalences of each ACE score (Roos et. al, 2013); maltreatment and adverse experiences elevates risk of incarceration, particularly for women (Roos , 2016); health outcomes, race, and exposure to ACEs are interrelated (Slack, Font & Jones, 2017); and ACEs elevate the odds of HIV risk, particularly for males at one ACE exposure and females at18 three or more exposures (Lin, Deng-Min, & Yookyong, 2016). Another important population to consider are the service providers that administer services to trauma-exposed populations. Russel, Gill, Coyne, and Woody (1993) found that master of social work students, more than any other area of graduate study, were more likely to have experienced adverse experiences in childhood. Rompf and Royse (1994) found that early exposures to trauma were actually associated with the choice of entering the social work field in adulthood. Whether a service provider has been exposed to trauma or not, exposure to populations experiencing the consequences of trauma must be considered. For those who serve trauma-exposed populations, who are in close proximity to the emotions involved in retelling and reenacting traumatic events, secondary trauma is a likely experience (Elwood, Mott, Lohr, & Galovski, 2011). The National Child Traumatic Stress Network (2011) reports that as much as 50% of those in helping professions are at great risk for secondary trauma or experience symptoms of Post-Traumatic Stress Disorder ([NCTSN], 2011). Secondary trauma affects “therapists, counselors, doctors, lawyers, teachers, journalists, friends, family members, and other secondary witnesses to trauma” (Caffrey, 2016). Consequences of overexposure to secondary trauma result in symptoms involving intrusion (replaying images, persistent thoughts), avoidance (avoidance of stimuli stemming from trauma, numbing), and arousal (anxiety symptoms, sleep disturbances, dysregulation) (Figley, 1995). Unaddressed secondary trauma leads to more complex and detrimental problems like job dissatisfaction and low retention levels across fields: according to the National Commission on Teaching and America’s Future (NCTAF), 50% of all new educators leave the profession by their fifth year (Hunt & Carroll, 2003). In social services, turnover rates can range from 30-60% annually and can stem from burnout, job dissatisfaction,19 stress, and lack of supports (Mor Barak, Nissly, & Levin, 2001); and in the medical profession, 30% to 68% of physicians in the United States experience burnout symptoms (Schrijver, 2016). Lasting Impacts of Trauma ACEs experienced on the maternal side carry negative physical and mental health implications for children that linger into adulthood (McDonnell & Valentino, 2016). While trauma exposure is detrimental on the individual level, particular consideration must be taken on the generational level. Maternal ACEs have been shown to be related to prenatal depressive symptoms, higher postnatal depression (McDonnell & Valentino, 2016). Furthermore, expectant mothers who have experienced ACEs are more likely to have infants who present with maladaptive socioemotional symptoms (McDonnell & Valentino, 2016). Research by Folger et. al (2017), found that maternal interpersonal trauma was associated with poor developmental outcomes for infants. Trauma-exposed mothers have psychosocial challenges that materialize within their offspring’s social and emotional development (Folger et al, 2017). Trauma experienced by one individual carries further complications within their support system: the offspring of incarcerated parents are more likely to present with maladaptive behaviors, anger, and symptoms of posttraumatic stress disorder (Bockneck, Sanderson, & Britner, 2009); and children of incarcerated parents are more likely to engage in early substance use (Roettger, Swisher, Kuh, & Chavez, 2011). Childhood trauma exposure leads to mental and physical health outcomes that create dependencies and consistent interactions with other systems: increases the prevalence of prescription pain reliever misuse in adults by 28% (Quinn et. al, 2016); and is associated with increased utilization of multiple systems like health, mental health (including substance abuse), child welfare, and juvenile justice (Abram et al., 2004; Felitti et al., 1998; Hawke, Ford, Kaminer, & Burke, 2009; Jaycox, Ebener, Damesk, & Becker, 2004;20 Keller, Salazar, & Courtney, 2010; Kisiel, Fehrenbach, Small, & Lyons, 2009; Ko et al., 2008). The immediate and long-term effects of childhood trauma not only debilitates major aspects of a person’s functioning, it is inherently disempowering in of itself. To disempower is “to cause a person or a group of people to be less likely than others to succeed” (“disempower”, Merriam, n.d.). As the literature suggests, the lifetime consequences of trauma exposure hinder the success of individuals and groups. Those directly impacted by trauma and anyone dependent upon that person lose opportunities for upward movement and are, therefore, potentially disempowered. Individuals or groups that profit from this disempowered population gain not only the power but also the potential profits of incarcerating, medicating, or controlling this group of people. Human and civil rights groups have increased advocation of incarcerated populations, as sentencing is unjust when applied to trauma-exposed and vulnerable individuals facing complicated physical and mental health challenges (Maschi, Viola, & Koskinen, 2015). The prison system, pharmaceutical companies and social policy are in a position to profit from and control disempowered populations. Thierry Godard (2015) describes the massive prison system in the United States as a $74 billion industry. Richard Anderson (2014) of BBC News reports that pharmaceutical companies earned a 42% profit margin within its multi-billion dollar industry. The systems in place are also positioned to potentially take advantage of the vulnerable populations they are charged to serve. In his book, The Poverty Industry: The Exploitation of America’s Vulnerable Citizens, University of Baltimore law professor Daniel L. Hatcher (2016) writes: “States and their human service agencies are partnering with private companies to form a vast poverty industry, turning America’s most vulnerable populations into a source of revenue”.21 Hatcher (2016) further describes this abuse of power in the realms of social services (i.e. foster care), the medical field (i.e. nursing homes, hospitals that predominantly serve vulnerable populations), and the education system (i.e. schools that serve special education and disabled students). The outcomes of childhood trauma, without intervention, create a population that depend on potentially abusive systems that could profit from their possible disempowerment. Interventions for Trauma The prevalence and major consequences of trauma exposure makes intervention urgent for all fields that serve affected populations. The surveillance of ACEs and public health became globally important when, in May 2009, the World Health Organization (WHO) and the National Center for Chronic Disease Prevention and Health Promotion met in Switzerland to initiate a framework for surveying ACEs and health worldwide (Anda, Butchart, Felitti, & Brown, 2010). Since the original ACEs study by Kaiser Permanente, additional ACE studies have been conducted for over a decade in the United States and have incorporated additional adverse experiences not in the initial study (Greeson et al., 2011). These additional studies have continued to confirm that the ramifications of trauma exposure are a “common pathway to a variety of long-term behavioral, health, and social problems” (Brown et al, 2009). It is essential that “organizations, with the input of service users, must modify their values, principles, and culture to ensure that services, practices, and policies are trauma-informed” (Bassuk, Unick, Paquette, & Richard, 2017). Trauma informed care (TIC) is a strengths based approach that is rooted in an understanding of trauma and responsiveness to trauma (Bassuk et al, 2017). It is also a practice that recognizes the “intersection of trauma with many health and social problems for which people seek services and treatment” (Bowen & Murshid, 2016). Because trauma is impactful22 upon the whole person, efforts to integrate trauma-informed integrated care have been made as “services that unite primary care, mental health, families, and communities while also integrating knowledge of the impact of trauma on all aspects of care” (See Appendix B) ( Dayton et al, 2016). Across fields efforts to implement TIC have been taken in many settings, some include: hospice and palliative care (Ganzel, 2016); youth residential treatment (American Association of Children’s Residential, 2014); child welfare systems (Lang, Campbell, Shanley, Crusto, & Connell, 2016); pediatric medicine (Dayton et al, 2016); and elementary school curriculum (Blitz, Anderson, & Saastamoinen, 2016). Despite the discussion of TIC, there is little research on how TIC is implemented and viewed by providers within different fields (Donisch, Bray, & Gewirtz, 2016). Much of our knowledge about TIC in literature resides in its definition, key principles, and case examples; gaining the insight of providers on TIC could enrich trainings on this practice and advance understandings of TIC across diverse fields of practice (Donisch, Bray & Gewirtz, 2016). In collaboration with SAMHSA, Ellen L. Bassuk (2017) recognized the need to systematically assess TIC implementation at the organizational level over time. Through her TICOMETER (where TIC stands for trauma informed care and “OMETER” for measuring device), organizations are measured psychometrically and evaluate the level they are implementing TIC at one point in time or repeatedly over time (Bassuk, 2017). Additionally, the tool measures the perception of TIC held by all staff within an organization, that include: administrative, clinical, and executive members (Bassuk, 2017). The general lack of research on provider perceptions of TIC, the focus on defining TIC and discussing case examples, and the quantitative approach of the TICOMETER (Bassuk, 2017) highlights a demand for further research on provider perspectives that incorporates a mixed methods approach and more qualitative data.23 ACEs, Trauma and Butte County In California, 61.7% of adults have an ACEs score of one and one in six have experienced four or more (Stevens, 2014). According to the U.S. Census (2015), in Butte County 70% or more of the population has an ACE score of 1 or more (Stevens, 2014). Butte County, a rural domain in Northern California, contains over 225,000 people with 137.7 people per square mile (U.S. Census, 2015). Approximately 55% of the population have household incomes below $50K with $23,867 per capita income (U.S. Census, 2015). It is estimated that 21.8% of the Butte County’s population live below the poverty line, which is 1.4 times the rate statewide and 1.5 times nationwide (U.S. Census, 2015). According to the Butte County Community Health Assessment (BCCHA) (2015-2017), 58% of participants do not perceive Butte County as a healthy community. Most prevalent concerns were environmental issues, drug and alcohol related issues, homelessness, violence, nutrition and health, and public safety (BCCHA, 2015-2017). An estimated 24.5% of Butte County children under the age of 18 live below the federal poverty level, which is higher than the statewide average of 20.9% (BCCHA, 2015-2017). The most prevalent conditions within the Butte County population are: hypertension (high blood pressure), hyperlipidemia (high cholesterol and triglycerides), diabetes, arthritis, and ischemic heart disease (blocked arteries) (BCCHA, 2015-2017). The most common adult mental health diagnoses made by the Butte County Department of Behavioral Health were mood disorders (i.e. depression) at 30.1%, and substance use disorders at 17.6% (BCCHA, 2015-2017). According to the Child Welfare Services Reports for California (2013), the most commonly reported types of child abuse was24 general neglect (67.8%), physical abuse (9.9%), emotional abuse (9.4%), and sexual abuse (9.0%) (as cited in BCCHA, 2015-2017). Theoretical Bases and Organization Trauma Theory In Perry, Pollard, Blakley, Baker, & Vigilante (1995), trauma is described as an experience that transforms lives: “It is the human brain that processes and internalizes traumatic (and therapeutic) experiences…mediates all emotional, cognitive, behavioral, social, and physiological functioning...it is the human brain from which the human mind arises and within that mind resides our humanity”. Trauma theory acknowledges the potentially devastating consequences of early exposure to trauma, yet it embraces hope and the possibility of healing from such exposure. As the brain is capable of being affected by trauma, so is it also affected by hope and healing. Historically, trauma exposure and the human brain were neuroanatomical and psychogenic; exposure to trauma or stressful experiences was a trajectory toward brain abnormality, maladaptive behaviors, mental illness, and distorted perceptions (Farreras, 2017). In The Body Keeps Score, Dr. Bessel Van der Kolk (2014) makes the assertion that while trauma cannot be taken away or undone “what can be dealt with are the imprints of the trauma on body, mind, and soul” (p. 205). Incorporating a more holistic approach, the brain that is exposed to trauma is not the sole determinant of well-being; instead, understanding trauma better causes “us to think differently not only about the structure of the mind but also about the process by which it heals” (van der Kolk, p. 14, 2014). Resiliency Theory25 Unger (2008) extends the argument that trauma can be intervened with hope and healing; taking an ecological perspective, the author acknowledges that those tasked to assist in the process of that intervention can do so through building a system that supports a child’s realization of his or her potential. It is essential to move away from individualized approaches of intervention, as it can position the child as responsible for their own growth through adaptation (Unger, 2008). Through this more expansive perspective of system involvement Unger (2008) defines resilience: 1. First, resilience is the capacity of individuals to navigate their way to resources that sustain well-being; 2. Second, resilience is the capacity of individuals’ physical and social ecologies to provide these resources; and 3. Third, resilience is the capacity of individuals, their families and communities to negotiate culturally meaningful ways for resources to be shared. The definition of resilience in these terms heavily implies that facilitating healing, and resilience, is a communal effort not solely an individual one. Unger (2008) encapsulates a definition of resilience that “emphasizes the need for individuals to exercise enough personal agency to make their way (navigate) to the many resources they require to meet their developmental needs”. This idea places power and responsibility on both the individual and the systems of support that an individual will need to interact with when navigating towards building resilience. Another component of resilience theory is the notion that the study of resilience should be reflexive; resistance of the individual who is building resilience is not necessarily a “disorder” or fault but instead a signal that the service provided is not culturally relevant (Unger, 2008). This places significant responsibility on the services and systems that support individuals seeking help.26 Organizational Theory Dziak (2016) describes organizational theory as “the study of how organizations (groups of people who work toward a shared goal) form, operate, and change”. The theory was initial initially developed to offer structure to operations that were not regulated; as theories evolved, more consideration was taken in emphasizing the humanistic importance to organization (Dziak, 2016). Systems theory emerged in the late twentieth century and addressed more current concerns that influence organizations: environment, cultural norms, social changes, new advancements in technology, and the actions initiated by policy in government (Dziak, 2016). By accounting for more complexity, systems theory observes the patterns that emerge when components interact (Lalande & Baumeister, 2014). Through the scope of interactional systems, it can be understood that one subject is not acting solely on its own but instead reliant and shaped by the bigger system (Lalande & Baumeister, 2014). In consideration of the systems that serve trauma exposed populations, it is important to account for the many interactions that occur between individual and systems and the systems themselves.27 CHAPTER III

Preview 4 out of 96  pages

avatar-seller
Academiks

The benefits of buying summaries with Stuvia:

Guaranteed quality through customer reviews

Guaranteed quality through customer reviews

Stuvia customers have reviewed more than 450,000 summaries. This how you know that you are buying the best documents.

Quick and easy check-out

Quick and easy check-out

You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.

Focus on what matters

Focus on what matters

Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!

$ 37.99
  • (0)
  Add to cart