Texas Child Protection Law Bench Book
August 2015 edition
Trauma Informed Care
Introduction
A traumatic experience is an event that threatens someone’s life, safety, or well-being and overwhelms one’s capacity to cope. Some examples include:
• Child maltreatment
• Witnessing violence
• Natural disasters
• Loss of loved ones
• Serious accidents
• Medical trauma
A. Trauma Impacts a Child’s Development and Health
1. Altered Biological Stress Systems and Neural Circuitry/Structure
• Difficulties with poor emotional regulation, focus and self-control (when in fight or flight mode, the brain loses executive functions that do not serve fight or flight, like higher learning and problem-solving which contribute substantially to school success)
• Anxious and avoidant behaviors
• Potential impacts to self-efficacy
2. Disruptions in Attachment Behavior
• Disruptions in relationships
• Distrust of people in authority, seen as threats
3. Changes in Social Development and Understanding of Social Stimuli
• Altered encoding and interpreting of social stimuli
• Hostile attribution bias (child perceivers negative motives, facial expressions, body language)
• Larger repertoire of aggressive responses
• Aggression as an acceptable response
• Difficulties belonging and playing well with others
4. Behaviorally, Trauma Can Look Like Attention Deficit Hyperactivity Disorder
(ADHD), Oppositional Defiant Disorder (ODD), and/or Conduct Disorder and Can Lead to:
• Substance use/abuse
• Aggression
• Numbness
• Risk taking
• Delinquency and adult offending
B. Current Challenges
• Alarmingly high rates of childhood trauma exposure, Post Traumatic Stress Disorder (PTSD) and victimization among children in foster care.
• Trauma concerns are frequently overlooked. Consistent observations suggest that denial of PTSD and blaming of its victims are not isolated omissions or distortions, but a pattern that spans over time, crosses national and cultural boundaries, and defies accumulated knowledge.
C. Trauma-Informed Practices
1. Increase Accessible and Effective Trauma Services Through Education and Collaboration Among the Many Stakeholders (mental health providers, caseworkers, foster parents, caregivers at kinship placements and residential treatment centers, judges, attorneys, CASAs, medical community, law enforcement)
Collaboration leads to:
• Better screening (brief, focused inquiry) at initial contact;
• More detailed assessments (a more in-depth exploration by a trained mental health professional of the nature and severity of the traumatic events, and current trauma-related symptoms);
• More specialized, evidenced-based treatments (with mental health professionals);
• Less misdiagnosis of schizophrenia, psychosis NOS, borderline personality disorder, and conduct or oppositional-defiant disorder;
• Fewer psychoactive medications, restraints and seclusions; and
• More self-reporting of trauma by children and youth survivors.
◦ children and youth become educated about effects of trauma, e.g. violent physical abuse in childhood may not be disclosed because it is thought of as “discipline” or “normal”
◦ the fear, guilt or shame of perceived mental illness is lessened once child is able to connect the trauma and its effects
◦ promote positive neurological effects on the foster youth’s immune function and overall physical health through disclosure of and confrontation of trauma
2. Create Environment of Safety, Respect, Honesty, and Humility to Nurture Healing, Rehabilitation, and Resiliency
• Communicate to the children in foster care that their caregivers believe abuse and violence are significant events. Survivors’ healing stories often begin with the experience of being believed, taken seriously and protected by an adult.
• Develop a shared understanding of the role that trauma has played in shaping the survivor’s life. Connect trauma concerns with the rest of the child’s problems and goals, and understand that experiences of physical, sexual, and emotional abuse can shape fundamental patterns of perceiving the world, other people, and oneself.
• Identify current circumstances that may trigger trauma responses, e.g., unexpected touching, threats, loud arguments, violations of privacy or confidentiality, being in confined spaces with strangers, or sexual situations.
• Determine potential contraindications to use of restraint (and other coercive measures).
• Be watchful for other less obvious triggers that become evident as you know the child better and as he or she recognizes and can express her or his individual stress responses more accurately.
• Enable children to understand their strengths (adaptive capacities) as well as weaknesses that have grown out of their responses to horrific events, rather than seeing their “symptoms” and “disorders” as evidence of fundamental defects. Identify with child the resources such as social support, self-esteem and resilience, self-comforting, sense of meaning and purpose – to help them to recognize and draw on underused strengths.
• Help children and youth identify strategies helpful in the past in dealing with overwhelming emotions. Place priority on child’s preferences regarding self-protection and self-soothing needs by using de-escalation preference surveys.
3. Increase Visitation
Minimize the trauma from removal and attachment disruption by increasing visitation with parents, siblings and other close family (especially in children ages zero to three) to provide meaningful and consistent connections with appropriate family members.
4. Promote Comforting and Calming Techniques
Encourage collaborative service plan. If crisis occurs again, caregivers in foster homes and residential can draw on the child’s own knowledge of what has previously helped and hurt. Prepare for de-escalation in foster homes and residential treatment centers.
5. Provide Ongoing Support for Caregivers
Responses of care giving adults to traumatic events are significant. Survivors often report the debilitating effects of being disbelieved, or having their accounts minimized or dismissed.
6. Encourage Foster Youth Connection with Healthy Adults
Facilitate connections with “persons of character”, e.g. CASAs.
7. Help Reduce Barriers to Youth Participating in Positive Activities of Interest
Problem-solve transportation issues preventing youth from engaging in positive afterschool activities, tutoring, etc.
D. Restraint and Seclusion Guidelines
Many trauma-informed care trainings promote specific strategies including self-care approaches, peer-provided services, arts programs, and comfort rooms to enhance healing and as means to avoid the use of restraint and seclusion. In Texas, the Administrative Code offers the following guidelines on restraining and secluding children in General Residential Operations and Residential Treatment Centers:
1. Restraint/Seclusion May Only Be Used:
• As last resort
40 Tex. Admin. Code § 748.2455(a)(1)(2); 40 Tex. Admin. Code § 749.2055(a)(1)(2); 40 Tex. Admin. Code § 748.2551(a); and 40 Tex. Admin. Code § 749.2151
• After less restrictive and more positive measures have been tried and failed
40 Tex. Admin. Code § 748.2455(a)(1)(2); 40 Tex. Admin. Code § 749.2055(a)(1)(2); 40 Tex. Admin. Code § 748.2551(a); and 40 Tex. Admin. Code § 749.2151(a)
• Only in an emergency situation
40 Tex. Admin. Code § 748.2455(a)(1)(2); 40 Tex. Admin. Code § 749.2055(a)(1)(2); 40 Tex. Admin. Code § 748.2401(5); and 40 Tex. Admin. Code § 749.2001(5)
(Definition of emergency situation)
• Where immediately necessary
40 Tex. Admin. Code § 748.43(17); 40 Tex. Admin. Code § 749.43(18) (Definition of EBI) 40 Tex. Admin. Code § 748.2401(5); and 40 Tex. Admin. Code § 749.2001(5) (Definition of emergency situation)
• To prevent imminent probable death or substantial bodily harm
40 Tex. Admin. Code § 748.43(17); 40 Tex. Admin. Code § 749.43(18) (Definition of Emergency Behavioral Intervention (EBI)); 40 Tex. Admin. Code § 748.2401(5); 40 Tex. Admin. Code § 749.2001(5) (Definition of emergency situation); 40 Tex. Admin. Code § 748.43(47); and 40 Tex. Admin. Code § 749.43(56) (Definition of substantial bodily harm)
• NEVER as punishment, retaliation, convenience, treatment, or means of compliance
40 Tex. Admin. Code § 748.2463 and 40 Tex. Admin. Code § 749.2063
2. Types of Restraints That May Be Administered with Restrictions:
• Physical restraint
40 Tex. Admin. Code § 748.2451(a)(2); 40 Tex. Admin. Code § 749.2051(a)(2); 40 Tex. Admin. Code § 748.2401(7); and 40 Tex. Admin. Code § 749.2001(7) (Definition)
• Emergency medication
40 Tex. Admin. Code § 748.2451(a)(3); 40 Tex. Admin. Code § 749.2051(a)(3); 40 Tex. Admin. Code § 748.2753 (simultaneous use with another EBI); 40 Tex. Admin. Code § 749.2233 (simultaneous use with personal restraint); 40 Tex. Admin. Code § 748.2401(4); and 40 Tex. Admin. Code § 749.2001(4) (Definition)
• Seclusion
40 Tex. Admin. Code § 748.2451(a)(4); 40 Tex. Admin. Code § 748.2651; 40 Tex. Admin. Code § 748.2401(10); 40 Tex. Admin. Code § 749.2001(10) (Definition); and 40 Tex. Admin. Code § 749.2051(b)
• Mechanical restraint
40 Tex. Admin. Code § 748.2451(a)(5); 40 Tex. Admin. Code § 748.2701; 40 Tex. Admin. Code § 748.2703; 40 Tex. Admin. Code § 748.2755 (simultaneous use with emergency medication); 40 Tex. Admin. Code§ 748.2401(6); 40 Tex. Admin. Code § 749.2001(6) (Definition); and 40 Tex. Admin. Code § 749.2051(b)
3. Restraint/Seclusion May Only Be Administered by:
• Qualified caregiver
40 Tex. Admin. Code § 748.2453 and 40 Tex. Admin. Code § 749.2053
• Trained in emergency behavior interventions
40 Tex. Admin. Code § 748.947; 40 Tex. Admin. Code § 749.947; 40 Tex. Admin. Code § 748.903; 40 Tex. Admin. Code § 749.903; 40 Tex. Admin. Code § 748.863(a); 40 Tex. Admin. Code § 749.863(a); 40 Tex. Admin. Code § 748.901; and 40 Tex. Admin. Code § 749.901
• Whose duties include the direct care, supervision, guidance, and protection of child
40 Tex. Admin. Code § 748.43(5) and 40 Tex. Admin. Code § 749.43(7)
4. A Child Must Be Released from a Restraint:
• IMMEDIATELY if an emergency health situation arises
40 Tex. Admin. Code § 748.2553(4)(A); 40 Tex. Admin. Code § 748.2553(5)(A); 40 Tex. Admin. Code § 748.2603; and 40 Tex. Admin. Code § 749.2203
• IMMEDIATELY once the danger is over
40 Tex. Admin. Code § 748.2553(2)(C) and 40 Tex. Admin. Code § 749.2153(2)(C)
• Once maximum time allowed is reached
40 Tex. Admin. Code § 748.2553(2)(E); 40 Tex. Admin. Code § 749.2153(2)(E); and 40 Tex. Admin. Code § 748.2553(4)(D)
|
Type of Emergency Behavior Intervention |
The caregiver must release the child: |
|
(1) Short personal restraint |
(A) Immediately when an emergency health situation occurs during the restraint. The caregiver must obtain treatment immediately; or (B) Within one minute, or sooner if the danger is over or the disruptive behavior is de-escalated. |
|
(2) Personal restraint |
(A) Immediately when an emergency health situation occurs during the restraint. The caregiver must obtain treatment immediately; (B) Within one minute of the implementation of a prone or supine hold; (C) As soon as the child's behavior is no longer a danger to himself or others; (D) As soon as the medication is administered; or (E) When the maximum time allowed for personal restraint is reached. |
|
(3) Emergency medication |
Not applicable. |
|
(4) Seclusion |
(A) Immediately when an emergency health situation occurs during the seclusion. The caregiver must obtain treatment immediately; (B) As soon as the child's behavior is no longer a danger to himself or others; (C) No later than five minutes after the child begins exhibiting the required behaviors; (D) When the maximum time allowed for seclusion is reached; (E) If the child falls asleep in seclusion. In this situation, the caregiver must: (i) Unlock the door; (ii) Continuously observe the child until he awakens; and (iii) Evaluate his overall well-being; or (F) If the child is receiving emergency care services: (i) As soon as the child is no longer a danger to himself or others; (ii) Upon the arrival of a medical professional; or (iii) Upon assistance from law enforcement or the fire DFPS. |
|
(5) Mechanical restraint |
(A) Immediately when an emergency health situation occurs during the restraint. The caregiver must obtain treatment immediately; (B) As soon as the child's behavior is no longer a danger to himself or others; (C) No later than five minutes after the child begins exhibiting the required behaviors; (D) When the maximum time allowed for mechanical restraint is reached; or (E) If the child falls asleep in the mechanical restraint. In this situation, the caregiver must release the child from the restraint and continuously observe the child until he awakens and evaluate him. |
The maximum amount of time for a restraint/seclusion:
• Physical Restraint – under the age of 9, 30 minutes; 9 or over, 1 hour
• Seclusion – <9, 1 hour; ≥9, 2 hours; < cumulative total of 2 hrs./12 hr. period
• Mechanical Restraint – <9, 30 minutes; ≥9, 1 hour; <cumulative total of 1 hr./12 hr. period
|
Figure: 40 Tex. Admin. Code § 748.2801 |
|
|
Types of Emergency Behavior Intervention |
The maximum length of time is: |
|
(1) Short personal restraint |
One minute. |
|
(2) Personal restraint |
(A) For a child under nine years old, 30 minutes; (B) For a child nine years old or older, one hour; or (C) A prone or supine personal restraint hold may not exceed one minute. |
|
(3) Emergency medication |
Not applicable. |
|
(4) Seclusion |
(A) For a child under nine years old, one hour. (B) For a child nine years old or older, two hours. |
|
(5) Mechanical restraint |
(A) For a child under nine years old, 30 minutes. (B) For a child nine years old or older, one hour. |
When restraining/secluding, a written order is required:
• By a licensed physician when administering emergency medications
40 Tex. Admin. Code § 748.2501(3) and 40 Tex. Admin. Code § 749.2101(3)(A)
• By a licensed psychiatrist when administering mechanical restraints
40 Tex. Admin. Code § 748.2501(5)
• By a licensed psychiatrist, physician, or psychologist when administering seclusion when using successive restraints
40 Tex. Admin. Code § 748.2501(2); 40 Tex. Admin. Code § 749.2102(2)(A); 40 Tex. Admin. Code § 748.2751(3); and 40 Tex. Admin. Code § 749.2231(a)
• When using restraints simultaneously
40 Tex. Admin. Code § 748.2501(2); 40 Tex. Admin. Code § 749.2101(2)(A); 40 Tex. Admin. Code § 748.2753(a)(3) and (b); 40 Tex. Admin. Code § 749.2233(a) (Emergency medications with personal restraint); and 40 Tex. Admin. Code § 748.2755(a)(3) and (b) (Mechanical restraints with emergency medications)
• When maximum length of time allowed is exceeded
40 Tex. Admin. Code § 748.2805; 40 Tex. Admin. Code § 749.2283(2)
• Also see: 40 Tex. Admin. Code § 748.2505; 40 Tex. Admin. Code § 749.2105 (content of written orders); 40 Tex. Admin. Code § 748.2507; 40 Tex. Admin. Code § 749.2107 (PRN orders); and 40 Tex. Admin. Code § 748.2807 (verbal orders to exceed maximum time allowed)
|
Type of Emergency Behavior Intervention |
Are written orders required to administer the intervention for a specific child? |
Who can write orders for the use of the intervention for a specific child? |
|
(1) Short personal restraint |
NO. |
Not applicable. |
|
(2) Personal restraint |
NO. However, successive restraints, a restraint simultaneous with emergency medication, and/or a restraint that exceeds the maximum time limit all require orders as specified in this subchapter. PRN orders are also permitted under §748.2507 of this title (relating to Under what conditions are PRN orders permitted for a specific child?). |
Not Applicable. |
|
(3) Emergency medication |
YES. |
A licensed physician. |
|
(4) Seclusion |
YES, except written orders are not required when you provide emergency care services to the child placed in seclusion. |
A licensed psychiatrist, psychologist, or physician. |
|
(5) Mechanical restraint |
YES. |
A licensed psychiatrist. |
A review is triggered when:
• Restrained four times in a seven day period
40 Tex. Admin. Code § 748.2901(2)(A) and 40 Tex. Admin. Code § 749.2331(2)(A)
• Emergency medications used three times in a thirty day period
40 Tex. Admin. Code § 748.2901(3) and 40 Tex. Admin. Code § 749.2331(3)
• Secluded >twelve hours or three times in a seven day period
40 Tex. Admin. Code § 748.2901(4) **NOTE: Not applicable to foster care placements.
• Mechanically restrained > three hours or three times in a seven day period
40 Tex. Admin. Code § 748.2901(5) **NOTE: Not applicable to foster care placements.
Restraint/Seclusion that is NOT allowed:
*Foster care placements may never administer chemical restraints, mechanical restraints, or seclusion.
• Mechanical restraint may not be simultaneously used with seclusion or pursuant to
PRN order
40 Tex. Admin. Code § 748.2757 and 40 Tex. Admin. Code § 748.2507(5)
• No chemical restraints
40 Tex. Admin. Code § 748.1119(1); 40 Tex. Admin. Code § 749.1021(1); 40 Tex. Admin. Code § 748.2451(b); 40 Tex. Admin. Code § 749.2051(b); 40 Tex. Admin. Code § 748.2401(1); and 40 Tex. Admin. Code § 749.2001(1) (Definition)
• Prone or supine restraints except for a personal restraint for 1 minute or less
40 Tex. Admin. Code § 748.2605(b); 40 Tex. Admin. Code § 749.2205(b) & (c); 40 Tex. Admin. Code § 748.2461(b)(1); 40 Tex. Admin. Code § 749.2061(b)(1); 40 Tex. Admin. Code § 748.2553(2)(B); 40 Tex. Admin. Code § 749.2153(2)(B); 40 Tex. Admin. Code § 748.2801(2)(C); and 40 Tex. Admin. Code § 749.2281(2)(C)
Also see other relevant provisions:
• 40 Tex. Admin. Code § 748.1119 and 40 Tex. Admin. Code § 749.2021 (techniques prohibited)
• Tex. Admin. Code § 748.2303 and 40 Tex. Admin. Code § 749.1953 (may not use or threaten corporal punishment)
• 40 Tex. Admin. Code § 748.2307 and 40 Tex. Admin. Code § 749.1957 (methods of punishment prohibited)
• 40 Tex. Admin. Code § 748.2605 and 40 Tex. Admin. Code § 749.2205 (prohibited physical restraint techniques)
• 40 Tex. Admin. Code § 748.2705 (types of mechanical & other restraint devices prohibited)
E. References
Ten Things Every Juvenile Court Judge Should Know About Trauma and Delinquency
at http://www.ncjfcj.org/sites/default/files/trauma%20bulletin_0.pdf.
Roadmap to Seclusion and Restraint Free Mental Health Services, U.S. DFPS of Health And Human Services at http://store.samhsa.gov/shin/content//SMA06-4055/SMA06-4055-A.pdf
Position Statement on Seclusion and Restraint, National Association of State Mental Health Program Directors (NASMHPD) at http://www.mentalhealthamerica.net/go/position-statements/24