October 2019Vol. 20, No. 8Print issueSpotlight on Trauma-Informed Care and Adverse Childhood Experiences

Issue Spotlight

• Preventing Adverse Experiences in Child Welfare

  Preventing Adverse Experiences in Child Welfare

  Written by Jerry Milner and David Kelly

  As a field, when we most commonly think about and discuss trauma-informed care, we usually think in terms of adverse experiences that have already occurred. We are trained on how to recognize trauma and how to provide clinical interventions to parents and children who have experienced trauma at some point in their lives. This approach of looking back to understand how to move forward has helped us to become more conscientious and effective in working with individuals who have experienced trauma so that we are less likely to compound it. Such efforts have helped us make some progress in developing more effective ways to serve and support people who have experienced adversities and the trauma that so often follows.

  All of this is helpful, and all such efforts are clearly relevant to our work in child welfare.

  However, we should be equally, if not more, committed to thinking about how we can be proactive in going after the sources of trauma and adversity to prevent them from happening in the first place. We can apply our knowledge about prevalent causes of adversity and trauma that lead children and families to the child welfare system and organize ourselves with strength of purpose to address those causes.

  A truly trauma-informed system should be one that looks forward to preventing trauma as well as looks backward at trauma that has already occurred.

  Screening and scoring adverse childhood experiences (ACEs) is an area that receives considerable energy in the field. We know that the ACEs scores for many, if not most, of the parents and children that make contact with child welfare are likely to be high. While some ACEs are beyond the scope of child welfare and may be unavoidable (e.g., the death of a parent), many are brought about by the lack of protective capacities of parents in caring for their children.

  When we, as a broad child and family serving system—not only the child welfare agencies—work together to create environments and conditions where families can thrive and children are free from harm, we work in support of building and strengthening protective capacities. And when we strengthen the protective capacities of parents, we create the potential for fewer ACEs in the lives of children that require "fixing" through clinical interventions.

  For example, when we universally link parents and newborn infants with home visiting programs from the beginning, we have incredible opportunities to help those children avoid traumatic experiences and enable parents to not be unduly affected by their own adversity. When we make community-based family resource centers available to all families in a community, we have opportunities to support them before avoidable traumatic events overtake them. But when we remove children from their families—even when necessary for safety reasons—we often create additional adversity that is compounded when children move from home to home and remain in care for extended periods of time. Inadequate parent-child contact while a child is in out-of-home placement is an additional source of adversity and trauma, as is emancipating after years of foster care without the connections, relationships, and skills to make it in the world. These things may not be officially on the list of ACEs, but they comprise sources of avoidable trauma for so many in the child welfare system. We have to go on the offensive against the sources of adversity and trauma if we expect to have a true trauma-informed or trauma-oriented system.

  Over the past 2 years, we have visited family resource centers, family enrichment centers, and family support centers in multiple states and have seen the range of supports they provide families. We have heard directly from families that speak to how these community resources have helped them in times of need to remain healthy, enhance their skills, and decrease their social isolation. 

  We have also had the pleasure to go on home visits with visiting programs and watched as young mothers asked questions and received support in their own homes. We have witnessed the strength of relationships between visitors, like Summer in Albany and Faith in South Carolina, and young parents trying to raise their children safely.

  Until we organize around and commit to strengthening families—all families—to gain resiliency and the protective capacity needed to care for their children safely as well as provide families with the supports they need to make it through difficult times, adversity, trauma, and ACEs scores will continue to be high.  If we are serious about being trauma informed, we have to be serious about reducing adversity in the first place not just scoring and trying to fix it after it has happened.

• Adverse Childhood Experiences: The Time for Prevention Is Now so Every Child Can Thrive

  Adverse Childhood Experiences: The Time for Prevention Is Now so Every Child Can Thrive

  Written by Christopher M. Jones, PharmD, DrPH, MPH, CAPT, U.S. Public Health Service, director of strategy and innovation, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention
  
  In our neighborhoods and communities, we don't always know what is behind the faces we see. We don't know the experiences that adults or children may have had—abuse or neglect, growing up around substance misuse, or witnessing violence in their home or communities.

  We also don't realize that these potentially traumatic experiences, referred to as adverse childhood experiences, or ACEs, are more common than people think. In fact, a recent study from the Centers for Disease Control and Prevention (CDC) showed that 62 percent of adults surveyed across 23 states had experienced at least one ACE, and nearly 25 percent had experienced three or more ACEs. This is concerning because research tells us that ACEs can disrupt healthy brain development, compromise immune systems, and lead to substance use and other unhealthy behaviors. ACEs are also linked to chronic health conditions and other negative health outcomes later in life. At least 5 of the top 10 leading causes of death are linked to ACEs, including cancer, diabetes, heart disease, and suicide. Beyond the impacts on health, ACEs also negatively affect life opportunities, like educational and occupational achievement. The effects of ACEs add up over time, which means as the number of ACEs a person has increases, so does their risk for negative outcomes. We need to address these patterns or they could continue into adulthood, potentially affecting both this generation and the next.

  So, what can be done? How we can address the trauma and early adversity that children are currently facing? We can recognize the signs of distress that children and youth may be experiencing, like displaying "acting-out" behaviors, struggling with school, or participating in risky behaviors (e.g., alcohol or drug use, high-risk sexual behavior).

  Health-care providers can help reduce these behaviors and turn things around for individuals in the following ways:

  • Anticipating and recognizing current risk in children and history of ACEs in adults and referring them to effective, trauma-informed services
  • Connecting children and adults to victim-centered services, such as housing support, social support, and community resources
  • Recommending effective therapeutic treatments that address depression, anxiety, posttraumatic stress disorder, and other symptoms of distress
  • Linking children and adults to family-centered treatment approaches that address parental substance use and offer a range of preventive services, including parenting education and training

  By intervening and breaking the cycle of adversity, we can ensure that ACEs are not passed on to future generations.

  While advancing trauma-informed care for children and adults is essential, it is only one component of comprehensive ACEs prevention. There are also things we can do to prevent ACEs from happening in the first place. We know that all children and families face challenges. We can shift the focus from individual responsibility to community solutions in the following ways:

  • Strengthening economic supports to families
  • Promoting social norms that protect against violence and adversity, such as those that support parents and positive parenting and those that foster connectedness and healthy relationships
  • Ensuring a strong start for children with home visitation programs and high-quality child care to build a foundation for future learning and opportunity
  • Teaching skills to parents and youth to help them handle stress, manage emotions, and tackle everyday challenges
  • Connecting youth to caring adults and activities to improve their future outcomes and buffer against difficulties at home, school, or in the community 

  So, while we don't always know what is behind the faces we see, we can create neighborhoods, communities, and a world in which every child can thrive.
  
  For more information about the CDC's National Center for Injury Prevention and Control's ACEs prevention effort, visit https://www.cdc.gov/violenceprevention/pdf/preventingACES-508.pdf.

• Getting to the Roots of Trauma

  Getting to the Roots of Trauma

  Written by Melissa T. Merrick, Ph.D., president and CEO, Prevent Child Abuse America

  I am a clinical psychologist by training. That means I am very comfortable helping one child, one family at a time, and that will always be critically important work in our quest for providing trauma-informed services. I also received 9 years of on-the-job training in public health and population-level best practices at the Centers for Disease Control and Prevention (CDC), and for 7 of those years I served as the lead scientist for the adverse childhood experiences (ACEs) portfolio of work. At the CDC, we focused our work on building and disseminating the best available evidence for preventing early adversity like child abuse and neglect before it begins, prioritizing primary prevention solutions. And now, in this new role as the president and CEO of our nation's oldest nonprofit focused on preventing child abuse and neglect, I realize that our collective efforts as a multidisciplinary, multisystem field have not gotten deep enough into the roots of what breeds trauma and its many ugly, unhealthy outcomes. 

  Just last week, Prevent Child Abuse America held its national conference, with nearly 1,000 practitioners, researchers, and policymakers in attendance from our nearly 600 Healthy Families America sites and affiliates and our nationwide state chapter network, with a guiding theme of "Moving Upstream." With more than 100 symposia, workshops, poster presentations, and other sessions, we were intentional to call for a new narrative—that child abuse and neglect and other ACEs could be prevented in the first place through comprehensive approaches and trauma-informed systems. We intentionally acknowledged that prevention can only happen in partnership and that we all have a role to play in stopping early adversity before it begins. All of that is true, and we are so proud of the energy and conversations that took place in support of thriving children, families, and communities. But I think my biggest lesson of the week came unintentionally, during the last session of the conference.

  What we had planned as a sharing session on policy and practice considerations that our home visiting network and state chapters have been experiencing turned into an overwhelming and courageous sharing of the breadth of traumatic experiences children and families are facing every day in our country. For example, family support specialists detailed how helping a family that fears deportation to apply and secure passports for their young children is often the most immediate need for the achievement of family emotional stability and security; or how it is hard to recommend nutritious foods or connect families with social support in their communities when some families fear being racially profiled while at the grocery stores and parks in their communities; or how family support specialists themselves, members of the communities in which they serve families, are subject to these sorts of fears and discrimination, too. It was a sobering conversation that will bind everyone in that room forever because it turned our evidence-based practices and trauma-informed approaches on their heads.

  If we are to ever be truly trauma informed in our care, we must first get to the roots of trauma. The last time I checked, fear of immigration raids and being racially profiled and discriminated against were not items on the ACE scale, nor were growing up in poverty or without access to affordable high-quality child care and education. Yet, our kids and families are increasingly exposed to these types of traumatic experiences that set them on trajectories for poor health and decreased productivity and prosperity in and of themselves—never mind the exacerbating impact these unmeasured, unspoken adversities have on ACEs. It struck us all in that room that even our most tested and rigorously researched prevention efforts cannot begin to take effect until the immediate needs of families are met, and I would argue we can never truly meet those immediate needs until we make our work about getting to the roots of trauma—the roots of discrimination, racism, income inequality, poverty, historical trauma and oppression, and other structural and social determinants of health and prosperity.  

  A trauma-informed approach, therefore, requires that we identify and address the many barriers to thriving communities, families, and children that exist and repeat across generations. And we must do this trauma-informed work together, across sectors and disciplines and all party lines. We know that children, families, and communities can be resilient and can thrive if we create the conditions and context for such resilience and prosperity. Prevention is possible if we work in partnership, not only with other professionals and sectors but with families and communities so that their lived experiences are reflected in our interventions and prevention approaches. 

  Until we get to the roots of trauma, we cannot be truly trauma informed.

• Unnecessary Removals: The Most Unjust Adverse Childhood Experience

  Unnecessary Removals: The Most Unjust Adverse Childhood Experience

  Written by Christopher Church, staff attorney for the CHAMPS Clinic, University of South Carolina School of Law

  Just over 100 years ago, President Taft appointed Julia Lathrop to lead the newly established Children's Bureau—the first federal agency devoted to the welfare of children. In establishing the agency's priorities, Director Lathrop focused on data-driven strategies to promote children's health and well-being, such as measuring infant mortality and funding strategies to reduce it. Director Lathrop also framed her priorities through a social justice lens, noting the Children's Bureau was "an expression of the nation's sense of justice, and the justice of today is born out of yesterday's pity."

  Using data and justice as North Stars, I am filled with curiosity as to what Director Lathrop would think about the state of child welfare today. The Children's Bureau now uses a nearly $8 billion annual budget to strengthen families and prevent child maltreatment, to protect children when maltreatment has occurred, and to ensure that every child has a safe and legal connection to a caring adult. They promote these priorities through, among other activities, monitoring of state and tribal child welfare systems, funding research and innovation to build an evidence base of programs and practices, and providing technical assistance and training to local child welfare professionals. But has this activity expressed our nation's sense of justice? This issue's spotlight on trauma-informed care and adverse childhood experiences pulls me to think about the child welfare system's own infliction of adverse childhood experiences. In the spirit of Julia Lathrop, I want to examine the involuntary separation of children and families for the purpose of protection in foster care through a data-driven justice lens.

  Removal is child welfare's most drastic and most protective safety intervention. It should be a last resort for state agencies charged with protecting children from harm. While there is a strong legal basis underpinning removal's limited use, there are also clinical reasons to invoke it sparingly. Dr. Monique Mitchell's research, as discussed in Does Anyone Know What is Going On? Examining Children's Lived Experience of the Transition into Foster Care, documents the ambiguity and loss that children suffer the moment they are separated from their parents and how this threatens child well-being. At removal, children can experience structural ambiguity (e.g., What is foster care?), placement reason ambiguity (e.g., Why am I in foster care?), relationship ambiguity (e.g., Who is this case manager? Who are these foster parents?), temporal ambiguity (How long will this last?), and ambiguous loss (e.g., Why can't I see my parents?). These are questions that haunt children moment by moment as they are physically separated from their parents. The research on the harm inflicted by separating children from their parents is so unambiguous that Harvard Professor of Pediatrics, Dr. Charles Nelson, told the Washington Post, "If people paid attention at all to the science, they would never do this." But we do this as a matter of routine in the name of child protection—more than 250,000 times per year.

  I am not here to suggest that children should never be separated from their parents in the name of child protection. Removal is a critically important safety intervention for child welfare professionals. However, the data we routinely collect on children and families involved in the child welfare system raise the possibility that our system is not appropriately calibrated to minimize harm by removing children from their parents only when absolutely necessary.

  First, the variance in removal rates across geographies is concerning. During the 2017 federal fiscal year (FFY), the rate at which Virginia (the state with the nation's lowest removal rate) and neighboring West Virginia (the state with the nation's highest removal rate) removed children for purposes of foster care placement differed by a factor of 10. I am not sure what the correct number of removals is for any jurisdiction, but I do not believe our nation's child welfare system should be designed to allow one state to remove 10 times as many children as another. To the extent your mind is drawn to explanatory variables such as child poverty or opioid use, I assure you the relationship between foster care removal rates and poverty or caretaker drug use rates does little to explain differences of this magnitude. Our child welfare system is far too complicated to be explained by a handful of simple correlations.

  Second, removal to foster care is only supposed to take place if a judicial officer finds it would be contrary to the welfare of the child to remain in the home and that reasonable efforts were made to prevent the need for removal. The Children's Bureau requires states to submit biannually a wealth of demographic and programmatic data regarding the children and families in foster care. In these data, there is no requirement to document a contrary-to-the-welfare finding or the reasonable efforts the state agency made to prevent a removal. If preventing removals were a priority, our system would require states to report how often, and by what means, they achieve it.

  Third, removals often fall into the class of emergencies: a late-night call from law enforcement, or a situation where time would not allow the agency to seek judicial authority prior to the removal. Existing removal data call that narrative into question. Removal data from 18 states, spanning more than 237 aggregate years' worth of data, reveal that 93 percent of removals occur during the business week, with only 7 percent occurring on the weekend. Nearly two-thirds of the removals during the 2017 FFY implicated neglect as a reason for removal, the most commonly cited removal reason. For whatever situation or context neglect is serving as a proxy, it conjures up less of a sudden onset of a severe condition requiring immediate action and more of a chronic, long-standing environmental stressor.

  Finally, for at least a decade, roughly 1 out of 10 children removed to foster care were discharged within 30 days of removal. During the 2017 FFY, most of these children spent about 2 weeks in care—an unfamiliar environment—before ultimately being returned to a family member. Is it not likely that some portion of those 22,000 children that spent less than a month in foster care never needed to be separated from their parents? What safety threat could be so imminent and impervious to remediation through reasonable efforts but otherwise cured within a couple weeks of their removal?

  Based on what we know about the harm of removal—the grief and loss suffered the moment children are separated from their families—local child welfare professionals should seriously consider whether their removal gate is carefully calibrated to make sure no child unnecessarily passes through it. The data suggest that our systems are not so carefully calibrated. When child welfare professionals consider the decision to remove a child from their parents, they must carefully balance the harm of removal against the risks of staying in the home. They must not "err on the side of caution," as is oft repeated, especially if that means removing the child from their parent. There is nothing cautious about blithely making such a decision.

  Sometimes removing a child from their parents' custody is absolutely necessary. I am reminded of one of the early lines in Justice Blackman's dissent in DeShaney v. Winebago: "Poor Joshua!" he lamented.  Joshua was one such child where removal was necessary. But the progeny of DeShaney does not justify abdicating responsibility for using removal as an intervention of last resort. Long before Justice Blackman penned his DeShaney dissent, Director Lathrop reminded us children need justice, not pity. Justice requires objective assessments of child safety, thorough exploration of the best alternatives to removal, and careful scrutiny by judicial officers prior to effectuating a removal. In the absence of those elements occurring, we will contribute to the number of adverse childhood experiences our nation's most vulnerable children suffer.