The Cost of Caring:
Secondary Traumatic Stress and the Impact of Working with High-Risk Children and Families

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Lesson 1: Introduction to Secondary Trauma

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Case 3: Chronic, moderate stress and a ‘trigger’ incident: Clinical work with maltreated and traumatized children.

The ChildTrauma Academy’s interdisciplinary team has worked day after day with high-risk children: children living in foster care after being neglected or abused by their biological families; child witnesses to violence, children living through car accidents, cancer treatment, fires, and tornadoes.  For many of these children and families there are no resources or services available to act on the recommendations of the clinical team. Child mental health services are scant and, all too often, sub-standard. Enrichment or special educational opportunities for high-risk children are difficult to arrange. Optimal adult to child supervision ratios in foster care are almost unheard of (in Texas as many as 10 children can be in one foster home). Very young children with profound developmental delays requiring one on one caregiving will be placed in ‘therapeutic’ foster homes where there are five other children under the age of five – with only one adult caregiver during the day. This can lead to a sense of frustration and futility. In other cases, children in foster care will be moved from placements against our better recommendations. The decisions regarding the health and welfare of these children are often out of the hands of the clinical team. And when hours of clinical work seem to be ignored by a judge, caseworker or supervisor, the sense of hopelessness can eat away at effectiveness and motivation.

Against this background, a child protection worker referred Brenda, a four-year-old child to our clinic. This young girl was the third in a sibship of five. The other siblings were in other placements. Following severe emotional and physical neglect, Brenda was chronologically age four at time of removal but was functioning like a two year old – undersocialized and developmentally delayed. She was placed in the home of an experienced and caring foster family who, at that time, had no other children in their home aside from their two teenage biological children. Within the first nine months, with lots of attention, consistency, nurturing and predictability, Brenda blossomed. She erased many of her developmental delays and was approaching age-appropriate motor and behavioral functioning. The foster family was seriously considering adopting her. Things looked great for Brenda and the clinical team felt they needed to see her only once a month – to track her progress.

And then, somewhere, someone made the decision that the family should not be broken up. The caseworker could either move Brenda into a new placement with all of the other sibs or ask the foster family to take in the siblings. The siblings were moved into the foster family. The clinical team knew nothing of this move until a month later at the next visit when the foster family reported a plateau in her progress and, some tantrums and new behavioral problems. The next month, Brenda regressed. She had much less attention in this new situation. Her siblings, older and younger, demanded the attentions of the foster family. The dilution in attention and the increase in the chaos in the foster home just exacerbated her already considerable situation.

The team tried to get the foster family or caseworker or supervisor to understand how Brenda’s condition – indeed the capacity of any of these five children to improve – was dependent upon the amount of consistent, predictable and nurturing attention they received. But none of the team’s efforts could change the harsh reality of the situation. The system says the siblings must remain together. Ultimately, the situation deteriorated to the point where the foster family asked the caseworker to take all these children. And, for the fourth time in a year, these children were moved to another placement. They were together, but as a group, their needs were too much for any single foster family. Each of these children needed more attention, more consistency, more predictability and more nurturing than could possibly be provided by a single overwhelmed foster family. With the move, Brenda was "lost to follow-up." The tantalizing progress she made and the recaptured potential she demonstrated only made the situation feel worse to the clinical team. Frustration, anger and a sense of hopelessness about the system permeated the discussions of this girl – the poster child of an ailing foster care/child protective system.

Unfortunately, the sad reality for many maltreated and traumatized children is that there are no good choices. The clinical, academic and dispositional decisions are typically choices between a bad and a worse situation. Any clinicians working with these children and in these systems will be faced with many situations like those above. It is imperative that the effectiveness and motivation of the clinician is maintained. This can be a challenge.



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