Healing the Invisible Scars of Maltreated Kids

The Background
Ensuring the safety of children with a history of maltreatment is a local and global priority. The World Health Organization notes that maltreatment is often underreported but estimates that 1 billion children have experienced it. In an attempt to ensure the child’s continued safety, many children are removed from their family of origin creating disrupted attachments as they are displaced into foster or kinship (aka out-of-home) care. The most recent count by UNICEF estimated 2.7 million children are displaced. Despite being removed from their known abusive or neglectful home, studies of children in out-of-home care do not support the evidence of improved outcomes but more negative trajectories when prolonged. Unfortunately, caregivers are often unprepared with insufficient support and training to manage the child’s needs. This combination of maltreatment, out-of-home care, and insufficiently trained and supported caregivers contributes to long-term consequences for the child and society.

Childhood maltreatment and out-of-home care can result in neuroanatomical and functional abnormalities with associated arousal dysregulation and epigenetic changes. This phenomenon lends to increased risks of physical health problems, including greater risk of all-cause mortality. It also contributes to disparities in behavioral health outcomes like depression, suicide, PTSD, substance use and other risky behaviors. The adult who aged out of the child welfare system is at increased risk for poorer socioeconomic outcomes.

The child’s difficulties strain the caregiver’s wellbeing ultimately increasing the risk of placement disruption. Placement instability contributes to high child welfare expenditures. Collectively, child welfare expenditures, medical expenses, legal costs, and associated lost productivity tax the economy, slowing economic growth and societal development worldwide.

Current practices to improve behavioral health outcomes of child with a history of maltreatment include out-of-home care, caregiver training and education, and direct behavioral health services. Typical foster parent training is multimodal, broadly covering a variety of topics related to family dynamics, trauma and loss, parenting and discipline, and child development. Foster parent training has been shown to be an effective means in improving outcomes for both the caregiver and child. Unfortunately, as previously mentioned, these are insufficient. At this time, Arizona mandates that all licensed foster parents, not kinship parents, must complete Foster Parent College. I would like to point out that there is not a component specifically on how to diffuse a situation in which a child is becoming aggressive or agitated.

The Problem
Being in the vicinity of, the target of, or the one intervening when someone is agitated or aggressive is stressful. I became familiar with the resulting ANS stimulation from my years working in psychiatric hospitals and correctional facilities. To help us (the staff) ensure everyone’s safety in a trauma-informed manner during these behavioral health crises, we were required to implement verbal de-escalation in which we were trained and certified. In my clinic practice as an NP, I found myself attempting to teach the principles of this training to the caregivers and parents during our brief psychiatric/med mgmt. appt. But, there was just never enough time to practice these skills.

What we know in the scientific literature:

(1)    Foster parent training is necessary for improved behavioral health outcomes of OOH children, therefore it is mandated by regulatory agencies (Arizona DCS, 2018; NCTSN, n.d.; SAMHSA, 2014; U.S. Department of HHS, ACF, ACYF, Children’s Bureau, 2017; WHO, 2016); and

(2)    Verbal de-escalation is necessary as an alternative to the use of force and control (because of its ability to retraumatize), therefore verbal de-escalation training is mandated by regulatory agencies (Joint Commission, 2017; National Institute for Health and Care Excellence [NICE], 2015; SAMHSA, 2014).

(3)    Verbal de-escalation is best practice for externalizing behavior (aka agitation and aggression), yet it is rarely included in the training provided to caregivers of out-of-home children.

Conceptually, trauma and disrupted attachments experienced by a child leads to health disparities, including behavioral health problems. These health disparities of the out-of-home child contribute to caregiver stress, increasing the risk for maladaptive parenting, negative attribution, and harsh discipline. The consequences of caregiver stress can cause retraumatization and exacerbated behavioral health problems of the child, including externalizing behavior (agitation and aggression), yielding destabilized wellbeing of the caregiver, placement disruptions for the child, increased health care and child welfare costs, and cessation of the provision of foster/kinship care leading to a shortage of caregivers. Ultimately this process leads to exacerbated behavioral health problems for the out-of-home child that persists into adulthood.

Insufficient parenting training and resources are frequently cited as contributing factors. Foster parent training without verbal de-escalation training is insufficient to prevent or manage the externalizing behaviors of agitation and aggression.

The Solution
The primary purpose of this project is to promote the behavioral health outcomes and placement stability for OOH children. Its secondary purpose is to improve parenting skills and attitudes, increase confidence and improve the wellbeing of the caregiver. This can be accomplished by making verbal de-escalation training available and accessible to foster parents AND kinship parents (in addition to the standard foster parent training).

Focusing efforts on the foster and kinship parents will work to attain this goal. The project’s theoretical underpinnings are derived from Family Process Theory, 1st described by Murray Bowen in 1950s. This theory proposes the family is a complex, interdependent unit with intense emotional connections and reactivity that are biologically driven for the purpose of survival. The individual’s emotions, behaviors, and personality are best understood in the context of their family system. The theory provides an appropriate framework for this project as the family is a major influencer of the individual’s wellbeing and functioning. This supports the rationale that intervening with the caregiver will alter the family dynamics, influencing the wellbeing of the child.

This project has the ability to influence nursing practice and healthcare by eliminating health disparities by promoting behavioral health outcomes of out-of-home children, promoting the child’s safety by decreasing retraumatization, and promoting excellence in practice by implementing evidence-based practices for this population.

For the children... We can help.


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Miriam Espinoza 
Yuma, AZ
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