Children Affected by Trauma and Alcohol Exposure A Profile of the Southwestern Michigan Children’s Trauma Assessment Center Features
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Features  |   November 01, 2003
Children Affected by Trauma and Alcohol Exposure
Author Notes
  • Yvette D. Hyter, is an assistant professor of speech-language pathology at Western Michigan University. Her clinical expertise includes family-centered and transdisciplinary assessment and intervention services for children from diverse cultural and linguistic backgrounds. Her research focuses on social communication and pragmatic language development and disorders. Contact her by e-mail at yvette.hyter@wmich.edu.
    Yvette D. Hyter, is an assistant professor of speech-language pathology at Western Michigan University. Her clinical expertise includes family-centered and transdisciplinary assessment and intervention services for children from diverse cultural and linguistic backgrounds. Her research focuses on social communication and pragmatic language development and disorders. Contact her by e-mail at yvette.hyter@wmich.edu.×
  • James Henry, has worked over 23 years with abused and neglected children. He is currently an associate professor at Western Michigan University’s School of Social Work, and the project director for CTAC. Contact him by e-mail at james.henry@wmich.edu.
    James Henry, has worked over 23 years with abused and neglected children. He is currently an associate professor at Western Michigan University’s School of Social Work, and the project director for CTAC. Contact him by e-mail at james.henry@wmich.edu.×
  • Ben Atchison, is professor and graduate program coordinator of occupational therapy at Western Michigan University. His work with children and families spans 25 years with particular expertise in developmental intervention for infants and young children. Contact him by e-mail at ben.atchison@wmich.edu.
    Ben Atchison, is professor and graduate program coordinator of occupational therapy at Western Michigan University. His work with children and families spans 25 years with particular expertise in developmental intervention for infants and young children. Contact him by e-mail at ben.atchison@wmich.edu.×
  • Mark Sloane, has been a board-certified practicing pediatrician for 21 years, and has been interested in behavioral and developmental pediatrics for 19 years. He is considered a local, area, and regional expert in the diagnosis and treatment of pediatric disorders of mood, behavior, learning, and attention. Contact him by e-mail at mzsloa@hotmail.com.
    Mark Sloane, has been a board-certified practicing pediatrician for 21 years, and has been interested in behavioral and developmental pediatrics for 19 years. He is considered a local, area, and regional expert in the diagnosis and treatment of pediatric disorders of mood, behavior, learning, and attention. Contact him by e-mail at mzsloa@hotmail.com.×
  • Connie Black-Pond, has extensive experience in assessment and treatment of traumatized children. Her history of providing expertise in the Kalamazoo area has contributed to effective linkages with specialized child service sectors, including child welfare, protective services, family court, and community mental health providers. Contact her by e-mail at poly@net-link.net.
    Connie Black-Pond, has extensive experience in assessment and treatment of traumatized children. Her history of providing expertise in the Kalamazoo area has contributed to effective linkages with specialized child service sectors, including child welfare, protective services, family court, and community mental health providers. Contact her by e-mail at poly@net-link.net.×
  • Kathryn Shangraw, is a recent graduate from Western Michigan University’s speech-language pathology program. During her graduate studies she participated in CTAC, gaining valuable insight into working with children who have experienced abuse, neglect, or prenatal exposure to alcohol. She currently works for Kindering Center in Bellevue, WA. Contact her by e-mail at katieshangraw@hotmail.com.
    Kathryn Shangraw, is a recent graduate from Western Michigan University’s speech-language pathology program. During her graduate studies she participated in CTAC, gaining valuable insight into working with children who have experienced abuse, neglect, or prenatal exposure to alcohol. She currently works for Kindering Center in Bellevue, WA. Contact her by e-mail at katieshangraw@hotmail.com.×
Article Information
Swallowing, Dysphagia & Feeding Disorders / Special Populations / Genetic & Congenital Disorders / School-Based Settings / Professional Issues & Training / Language Disorders / Social Communication & Pragmatics Disorders / Attention, Memory & Executive Functions / Features
Features   |   November 01, 2003
Children Affected by Trauma and Alcohol Exposure
The ASHA Leader, November 2003, Vol. 8, 6-14. doi:10.1044/leader.FTR2.08212003.6
The ASHA Leader, November 2003, Vol. 8, 6-14. doi:10.1044/leader.FTR2.08212003.6
Children exposed to abuse, neglect (i.e., maltreatment) and Fetal Alcohol Spectrum Disorders (FASD) frequently have difficulties in multiple areas of functioning including sensory integration, fine and gross motor movements, social cognitive functioning, and processing social-emotional information.
These children are also at risk in all areas of language development. They often have delays in grammar and vocabulary comprehension and production, minimal conversational skills, limited receptive and expressive syntactic skills (such as difficulty with grammatical morphemes and complex sentence construction), and delayed semantic skills including difficulties with multiple word and sentence meanings. Fetal alcohol exposure also affects communication, speech, and language development.
Prenatal exposure to alcohol disrupts development of the central nervous system resulting in cognitive dysfunction, memory and learning problems, poor problem-solving abilities, attention deficits, state regulatory disorders, information processing disorders, and poor comprehension of word meanings and grammar. The disrupted development can cause secondary disabilities such as externalizing behavior problems (e.g., oppositional or hyperactive-impulsive behaviors), internalizing behavior problems (e.g., withdrawal or depression), school failure or low academic achievement, and mental health issues.
Abuse, neglect, and prenatal alcohol exposure particularly interrupt the ability to use social communication skills. Two critical components of social communication are pragmatic language skills and social cognition, specifically, theory of mind, which allows one to infer mental states of others. Difficulties in pragmatic language skills such as conversation and negotiation, engaging in positive peer interactions, and discourse organization skills, can increase the child’s risk of developing socioemotional problems. These difficulties have the potential to negatively affect a child’s ability to function in educational settings and to develop healthy social relationships.
Social cognitive skills result in the ability to predict others’ motivations and goals, which in turn can be used to modify one’s own behavior. These skills are critical for children who have externalizing behavior problems resulting from maltreatment. The limited available empirical research suggests that children who have been maltreated are less able to take the perspectives of others, and are less accurate in their ability to recognize others’ emotional expressions.
If children have adequate pragmatic and social cognitive skills, they will be able to use language appropriately for the communication context, determine which behaviors should be used in that particular context, and predict the responses or behaviors of the communication partner for the purposes of shaping their subsequent interactions with this partner.
The Southwest Michigan Children’s Trauma Assessment Center
In Michigan it is reported that 27,000 children endure abuse and/or neglect each year. Since 2000, the Southwestern Michigan Children’s Trauma Assessment Center (CTAC) in Kalamazoo, Michigan, has had the opportunity to provide comprehensive assessment services to more than 900 children who are most at risk for long-term impairment across all domains. Of the children assessed by CTAC, 97% have experienced maltreatment (i.e., abuse and neglect), and 95% of this population have experienced traumagenic effects. Child welfare agencies refer 78% of children to CTAC; 66% are in foster care/relative placements and 28% are in adoptive homes. Additionally, more than 30% of the children determined by CTAC staff to be at least moderately traumatized have also met criteria for FASD.
CTAC was organized in 1999 following a needs survey distributed to 10 counties (240 participants) within Southwest Michigan. Of the respondents, 95% indicated a strong need for a comprehensive assessment center for children who had been traumatized by abuse and neglect. The doors to CTAC opened in 2000 after the Western Michigan University School of Social Work was awarded a $20,000 grant from a local foundation. The three major components of CTAC are service provision, education/training, and research.
Service Provision
Our service component consists of a transdisciplinary team of university faculty (from the areas of speech-language pathology, social work, and occupational therapy), two professionals (a pediatrician and social work therapist), and the ir respective residents and students. This team is responsible for providing comprehensive assessments to children who have been traumatized by abuse and neglect, and who may have been prenatally exposed to alcohol or other substances. The combination of assessments for trauma and prenatal alcohol exposure is unique, as these assessments have typically been disconnected due to the need for specialized training in each area, and difficulty in developing and maintaining transdisciplinary teams. When the team formed in 1999, it already included expertise in the area of assessing children who have been abused and neglected. Team members, however, pursued additional training through the Chicago Research Triangle in 2000 and the University of Washington in 2001 to gain expertise on assessing FASD.
Two concepts—family-centered practices and a transdisciplinary model of collaborative assessment and intervention—from federal policy in the Individuals with Disabilities Education Act of 1997 guided the formation of the CTAC mission. The primary mission of CTAC is to determine the effects of maltreatment on child health and development through comprehensive, transdisciplinary team assessment, and to provide recommendations and consultations to the child’s caregivers, teachers, caseworkers, and other parties involved with the child’s care. In addition to this initial assessment and consultation, the CTAC team provides follow-up services to support caregivers in implementing recommendations.
The CTAC team believes that an assessment that relies on familial input is essential to understanding the child’s current levels of functioning. As a result, an ethnographic interviewing process is used to collect information and insights from family members or the child’s foster family if the child is in foster care. Children with traumatic histories have multiple and complex problems, and as a result require multi-layered and multifaceted solutions. Systematic analysis is required to understand complex problems; consequently, the best practice for this population is a transdisciplinary assessment model to conduct comprehensive assessments across multiple domains.
The assessments focus on neurodevelopmental issues including traumatic effects (e.g., disassociation, alexithymia—that is, difficulty processing and describing feelings or distinguishing between feelings and bodily sensations), social communication and pragmatic language skills, and social interaction (e.g., internalizing and externalizing behaviors). The transdisciplinary process of CTAC includes collectively identifying and defining the child’s strengths and needs; cooperatively identifying ways to support those strengths and generating solutions to the child’s needs; sharing responsibility for child outcomes by expanding and exchanging knowledge with other team members; and debriefing immediately after assessments to develop recommendations for services, as well as to process the emotional nature of the assessments.
Education and Training
Education and training is the second component of CTAC. Each semester, nine graduate and undergraduate students (three each from the departments of speech-language pathology, social work, and occupational therapy) are trained to understand and assess the effects of and interactions among abuse, neglect, and prenatal exposure to alcohol. In addition to the students from Western Michigan University, pediatric residents also participate in CTAC on a monthly basis. The CTAC student team participates in training modules focused on family-centered processes, transdisciplinary teaming, the assessment protocol, interpretation of assessment results, and report writing. They also collaboratively participate in assessments under the direction of the CTAC faculty and professional staff. More than 60 students have been trained at CTAC and, after graduating, many continue to work with children who have traumatic histories.
Frequently the behavior of children who have been maltreated or who have prenatal exposure to alcohol has been misinterpreted as willful disobedience, which creates social stigmatization and lowered self-esteem. Therefore, it is imperative that caregivers, parents, and professionals living and working with this population understand and recognize the neurobiological, psychological, and developmental effects that children with traumatic histories have experienced.
Adjusted expectations and the implementation of effective strategies at home and in the classroom can improve social, emotional, and educational outcomes. To increase the likelihood of academic success for the children served by CTAC, the staff often attends Individual Education Plan (IEP)committee meetings to recommend developmentally appropriate interventions. As educators and other service providers increase their understanding of traumagenic effects, they can become more empathic, and are less likely to view children as being willfully disobedient. Consequently, they develop appropriate interventions that target traumagenic effects of maltreatment and FASD.
During the past three years, more than 30 training sessions on childhood trauma, prenatal alcohol exposure, the attachment process, and intervention strategies with traumatized children have been provided in eight different counties within Southwest Michigan.
Research
The third component of CTAC is research. Members of the CTAC team have been developing a database on all children served since 2000. Data on 800 (i.e., 89%) of the 900 children served by CTAC have been included in this database thus far, and CTAC is in the initial stages of documenting descriptive information from the data collected. Initial analyses support that significant developmental harm, dysregulation of behavior and mood, and social problems exist for this population of traumatized and prenatally exposed children. Moreover, children with both traumatization and prenatal alcohol exposure had statistically significantly greater delays in several areas including language, memory, visual and cognitive processing, and attention.
CTAC has been designated as a Fetal Alcohol Syndrome (FAS) Diagnostic Site by the University of Washington’s Diagnostic Prevention Network for children with FAS. CTAC is one of five contracted FAS-DPN clinics (along with 11 community projects) providing outcome data to the Michigan Department of Community Health on FASD assessments. These data are used for program evaluations and funding decisions by the Michigan legislature. CTAC utilizes the outcome summaries to evaluate and guide the further direction of the program. Additionally, CTAC is officially one of the four regional centers in Michigan designated by the Michigan Department of Community Health as a FAS center for data collection and public information resource.
Future Plans
The upcoming year will be one of substantial growth for CTAC. The first three years primarily consisted of building our capacity to provide comprehensive assessments to an underserved population, and to provide in-home follow-up consultations on a limited basis. Additionally, CTAC staff was able to provide support to caregivers and educators involved with children who have traumatic histories.
During the upcoming year we plan to increase our ability to consistently provide in-home follow-up consultations. These consultations now are provided by an occupational therapist. One goal is to include the participation of social work and speech-language pathology students in some of the home visits.
CTAC was contracted recently to provide training sessions this year to community service providers. This training will focus on the traumagenic impact of childhood maltreatment and prenatal alcohol exposure, as well as intervention strategies. We would like to extend this training to area school personnel.
Finally, we are in the process of interpreting the descriptive data analyzed from the CTAC database, and will be disseminating this information through professional presentations and journal articles. Also, CTAC faculty and staff will work this year to standardize some of the assessment procedures to strengthen the data collection, analysis, and dissemination processes.
Impact of Abuse, Neglect, and Alcohol Exposure on Child Development

More than 2.5 million children in the United States are victims of abuse and/or neglect every year, and every year more than 500 children die from abuse. Abuse is defined as behavior that puts the child’s physical, mental, and/or emotional health and development at risk. Neglect is the continued failure to provide vital and appropriate care and protection, such as food, housing, clothing, and health care. Many of the children who suffer abuse and neglect are placed in foster care. In the United States, more than 580,000 children are being cared for outside of their biological homes, and more than half of these children are10 years of age or younger. In addition, there is a high prevalence (50%-70%) of parental substance abuse for children entering foster care. As a consequence, it is estimated that 550,000 to 750,000 infants in the United States are born with exposure to alcohol every year. Moreover, studies have found that children who experience fetal alcohol exposure are two to three times more likely to be abused than those without fetal alcohol exposure.

  • Area of Impact, Manifestation of Difficulties
  • Language and Speech, • Delays in grammar, • Delays in vocabulary comprehension/production, • Limited receptive and expressive syntactic skills (grammatical morphemes, complex sentence construction), • Delayed semantic skills (multiple word and sentence meanings), • Minimal conversational skills, • Impaired social communication skills; pragmatic language and social cognition
  • Cognition,
    • Memory and learning problems
    • Poor problem-solving abilities
    • Attention deficits
    • Information processing difficulties
  • Sensory Integration,
    • Oversensitive/under sensitive to touch, movement, sights, sounds
    • Easily distracted
    • Activity level unusually high or low
    • Inability to calm self
    • High co-occurrence with learning disabilities
  • Motor, • Fine Motor,
    • Reduced control of distal musculature, resulting in motor planning problems (impulsivity)
    • Difficulty in printing/writing
    Gross Motor,
    • Poor motor coordination and sequencing abilities
    • Poor body position sense/balance
    • Neurological signs (e.g., associated mouth movements during writing).
    Visual Motor
    • Difficulty programming a motor response based upon direct visual input (inability to sense where fingers are in space)
    • Problems copying from chalkboard/overhead
  • Physical/Medical,
    • Pre/postnatal growth deficiency
    • CNS involvement or brain malformations resulting in neurological abnormalities, developmental delay, behavioral dysfunction, intellectual impairment, and structural abnormalities
    • Minor facial anomalies such as short palpebral fissures, long and flattened midface, long and flattened philtrum, and thin upper lip
    • Failure to thrive
    • Malnutrition
    • Physical harm due to abuse or lack of supervision
    • Untreated illnesses/injuries
    • Altered release of growth-regulating hormones, impacting development of the body and brain
  • Socioemotional,
    • Demonstrate less affection
    • Increased likelihood for hyperactivity
    • Aggressive
    • Discipline problems in school
    • Poor self-image
    • Increased likelihood for alcohol, drug abuse, destructive behavior, suicide
    • Inappropriate sexual behavior
    • Difficulty forming close, lasting relationships
Concerns of Some Children at the Southwest Michigan Children's Trauma Assessment Center
  • A 10-year-old-boy who when asked, "Tell me the best thing that's ever happened to you" responded, "I don't know of any." And when he was asked about the worst thing that has ever happened to him, he responded with, "there are so many I don't even know where to start."

  • A five-year-old girl who was beaten beyond recognition when she was 24 months old. Although her physical body has healed, the internal scares continue to be insurmountable, as she expresses her anguish, not with words, but with self-mutilation.

  • A nine-year-old boy who spent the first seven years of his life living in a cage, being forced to engage in lewd acts with animals, and being punished daily with a cattle prod for soiling his pants. So badly damaged, this child lacked the coordination to play a simple game of catch. After multiple attempts to catch a ball he says, "Can we stop now? It's just too hard."

  • A 16-year-old boy had recently received a blow to his head by a lead pipe, which was dealt by his father. Yet this special boy didn't want to leave his home; he didn't want to risk having the abuse turning to his younger brothers. In the meantime, he clung to his dreams, saying, "I want to become a better man, to prove I'm better than the person my [parents] think I am."

Assessment Protocol
  • <3.0, 3–5.11, 6–8.11, 9–15

  • Medical Examination, X, X, X, X

  • General Physical Examination, X, X, X, X

  • Facial Dysmorphology Measurements for Fetal Alcohol Spectrum Disorder, X, X, X, X

  • Ethnographic Interview, X, X, X, X

  • Neurodevelopmental Assessments

  • Sensory Profile, X, X, X, X

  • Early Intervention Developmental Profile (EIDP), X

  • Preschool Developmental Profile (PDP), X

  • Pediatric Early Elementary Examination (PEER), X

  • Pediatric Examination of Educational Readiness (PEEX), X

  • Pediatric Examination of Educational Readiness at Middle Childhood (PEERAMID), X

  • ADHD Rating Scale, X, X, X

  • Kaufman Brief Intelligence Test, X, X, X

  • Emotional/Behavioral/Social

  • Attachment Behavior Observations, X

  • Reactive Attachment Disorder Questionnaire (RADQ), X, X, X, X

  • Psychosocial Interview, X, X, X

  • Draw-A-Person (DAP), X, X, X

  • Conners’ Teacher Rating Scale, X, X, X

  • Conners’ Parent Rating Scale - R:L, X, X, X

  • Vineland Adaptive Behavior Scales, X, X, X, X

  • In-home and/or Classroom Observations, X, X, X

  • Alexithymia Scale for Children, X, X

  • Children’s Depression Inventory (CDI), X, X

  • Multidimensional Anxiety Scale for Children (MASC)

  • Pragmatic Language Protocol, X, X, X

  • Grice’s Conversational Maxims

  • Narrative Assessment: Story Retelling, X, X, X

  • Narrative Assessment: Story Regeneration, X, X

  • Social Cognitive Skills: First Order Belief Attribution, X

  • Social Cognitive Skills: Second Order Belief Attribution, X

  • Social Cognitive Skills: Third Order Belief Attribution, X

  • Trauma Assessment

  • Trauma Symptom Checklist for Children (TSCC), X, X

  • Child Behavior Sexual Inventory, X, X, X, X

  • Traumagenic Impact of Maltreatment Scale, X, X, X, X

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November 2003
Volume 8, Issue 21