In Foster Care, Treating the Trigger

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Brooklyn, NY - 01/20/15 - A girl at Crossroads Juvenile Center does an exercise in expressing feelings in a scenario where she "failed a math test."

On the seventh floor of an office building in mid-town Manhattan, dozens of foster care workers sat quietly, listened and took notes. They had been here for hours listening to Adam Brown, a clinical psychologist at NYU’s Child Study Center.

“What we covered was...a semester long undergraduate course in intro to trauma done in an hour,” he told them.

Brown is also a professor, but his lecture that day was not theoretical. These workers deal with some of the most vulnerable children in the city — kids with difficult pasts and presents — who often act out in disturbing ways. They have short fuses and blow up unexpectedly, withdraw and grow depressed, or sometimes just run away.

Brown and his colleagues were helping the workers understand why.

“Often what happens is, people say, ‘This child is crazy, it’s out of the blue, there’s no rhyme or reason for it!’ ” said NYU Doctor Glenn Saxe. 

But according to these mental health professionals, there is always a reason. The outbursts are triggered by something that is reminding these children of a past trauma.

“Maybe not consciously,” Saxe explained.  “But it evokes these ancient systems of the brain and body, and the child in that moment is fighting for their life." 

It could be a tone of voice, a glance, a particular odor or something even more subtle than that.  There could be many triggers because this trauma is complicated and complex.  A child may have been abandoned and abused but also been exposed to drug abuse or had a parent sent to jail.

So far the NYU team has taught hundreds of foster care workers — about 20 percent of the system citywide. They also train foster parents so the parents don’t get frustrated and ask that a child be removed from their home. The training is supposed to help make them more empathetic and tolerant of a child’s behavior.

Doctor Linda Mayes, a scientist from the Child Study Center at Yale, said troublesome patterns of behavior can begin to form early in life.  She described what happens to a stressed out baby when there is no one around to soothe it.

“Their brain is constantly bathed in stress hormones,” she said. It’s a healthy and natural response as long as it’s temporary.  Mayes said the problem arises when the child is never made to feel safe and they stay feeling distressed. 

“In a long term exposure sense, it does change the way the brain develops,” said the scientist.  “They are constantly on a kind of alert. They’re not able to think about process, learn from their world in another way.” 

For foster children, that is often a default position. And in the most difficult cases, a young person could end up in a juvenile detention facility such as Crossroads, in Brownsville, Brooklyn.

Run by the Administration for Children’s Services, it holds kids who were under 16 when they were arrested and accused of a crime. These kids are considered high risk; right now, there’s 55 being held here. 

Inside a classroom, five teenage girls were seated at a table. Isaiah Pickens from Bellevue Hospital stood up front and demonstrated breathing techniques. He is part of a program that screens youth for trauma and engages them in group therapy.

Like normal teenagers, some of the girls looked bored.  But one 15-year-old, Yasmine, was eager to explain how she often fights at school. 

“[If] somebody I don’t like keeps saying stuff, saying stuff, saying stuff or they just walk into the room, I want to fight,” she said. 

Pickens explained that often, when a child has experienced trauma, they explode and don’t recognize what it is they’re actually feeling. He took them through a game of emotional charades. The girls took turns acting out different emotions.

Pickens told them in those moments of volatility, to stop and notice what they’re feeling.

“Once you start to recognize them, you can keep from acting out,” he said.

The juvenile counselors that monitor and stay with the kids all day also get trauma training. They are the staff who respond when a child acts out. Kibian Wharton says often, case files will include notes on what makes a child act out.

“Those triggers are usually walking behind somebody, because a lot of kids don’t feel comfortable when somebody is walking behind them because they don’t feel safe,” she said.

But the trauma therapy only goes for three sessions and records show other treatment is lacking. Citywide, data shows that half the kids in juvenile detention were referred for mental health services in 2013, but more than 40 percent of those kids didn’t receive them.

ACS says that’s because they often leave before they’re able to see someone. But that could be one reason why 60 percent of kids in detention have been there before.

In clinics and hospitals across the city, screening kids for trauma is rare, according to Dr. Jennifer Havens, director of Child and Adolescent Psychiatry at Bellevue. 

“Because often in mental health environments, people say I don’t want to ask and re-traumatize kids,” she said. 

Havens, who oversees the program at Crossroads, believes trauma should be talked about openly and a child should be educated on how common it is. 

In adults, Post-Traumatic Stress Disorder is usually associated with soldiers returning from war.  Havens said it shows up differently in kids.

“It’s causing a huge amount of confusion in my field,” she said.

The end result, Havens believes, is that too many kids get the wrong diagnosis and get put on drugs they don’t need.

“Those kids you see with five diagnoses on six medications, very often what is common to those kids is a lot of traumatic exposure…self-destruction, volatility,” Havens went on to explain. “All that confuses a lot of people and they end up with the wrong diagnoses, like bipolar disorder. So we’ve tried to correct that here at Bellevue.”

Havens said Bellevue was using a new PTSD screening tool with the youth at Crossroads.

About 1,500 kids have been screened over the last year and a half, and one out of six show significant symptoms of PTSD — four times the rate of the general population, Havens said.  But she said the group sessions at Crossroads only last two weeks, not enough time for complete treatment.

“But at least I can help the kid understand that’s what they’ve got...and that the things that happened to them are affecting them, and if they want to deal with that, they have to deal with those things,” she said.

16-year-old Quadell was just beginning to deal with the source of his pain.

“Mad upset at the world because, I didn’t have no father,” he said.

He has been at Crossroads five months; his father passed away just before he got here. In detention, he was quick to fight. But after he started talking more with counselors, something changed.

“It was just like, I remembered something and I just said ‘Naaah’ and just walked away and played basketball,” he said.

The sessions helped. In a pattern of troublesome behavior, it was one small break.