When Age Doesn't Match Stage: Challenges and Considerations in Services for Transition-Age Youth with Histories of Developmental Trauma

Abstract: This article examines the difficulties that transition-age youth with complex mental histories are poised to face without the life skills, long-term services, and supportive networks needed to function successfully in adulthood.

"When Age Doesn't Match Stage: Challenges and Considerations in Services for Transition-Age Youth with Histories of Developmental Trauma" (2015)

By Margaret E. Blaustein & Kristine M. Kinniburgh

Philip is 19 years old. He has been in the care of child welfare since the age of 10 and has lived in 8 placements and attended 5 schools. When he graduates next month, his eligibility for his group home will end. Although his clinician has been trying to support him in applying for further services, resources are limited, and waiting lists are long. Philip's caseworker is new, and he is not her top priority. Philip has little family to speak of. His father died three years ago; his mother continues to struggle with mental illness. His younger sister was adopted and he does not have contact with extended family.

Philip is motivated, hard-working, and wants to have a different life than his parents, but – like them – he struggles to cope with his anxiety and depression. He becomes overwhelmed in the face of pressure and either freezes or explodes, which has made employment seem unattainable.

Philip is 30 days from independence.

Trauma-Impacted Transition-Age Youth

In the past decade, there has been a shift in the field of traumatic stress. Children who have suffered chronic early abuse, neglect, and chaotic parenting were for far too long not seen, and then seen only through the lens of adult and acute traumatic events. While there is now growing recognition of the toxic nature of trauma and adversity on developmental processes there is still too large a gap between knowledge and policy, particularly as it relates to one of our most vulnerable populations: those young adults who, like Philip, become "adult" in chronology but lack the developmental capacities and external supports that will allow them to thrive in the adult world.

In this next year, thousands of youth like Philip will fall through the cracks. One in ten children discharged from foster care is discharged to emancipation, rather than to a placement resource, often after years in state care.¹ While some will succeed despite the long odds, many more will become statistics of other systems: mental health, homelessness, unemployment, and chronic disability.^{2 3 4} Thousands more will transition out of juvenile justice systems close to their age of legal majority, many without support networks.⁵ These youth, almost entirely made up of young people with histories of abuse and neglect6 are at risk for numerous negative outcomes including re-arrest and transition into the criminal justice system.

In defining this population, it is crucial to establish who these youth are. They are young adults who have often intersected with numerous systems in childhood. They have complex diagnostic pictures and – because of that complexity – may receive denials of eligibility from multiple adult service systems leaving these most complicated youth devoid of any supports.

Developmental Trauma in Adolescence and Early Adulthood

Complex developmental trauma has been defined as the experience of childhood-onset, chronic adversity which is interpersonal in nature, and often occurs or co-occurs in the context of the child's primary caregiving system.^{7 8 9} Expert consensus and research suggest that developmental trauma both drives significant mental health and child welfare service utilization^{8, 10} and leads to pervasive impacts across developmental domains.¹¹

The expression of developmental trauma varies across individuals, but there are core domains of influence that are generally agreed upon. These include the following:

Regulation: Trauma-impacted adolescents may struggle with understanding, tolerating, and managing feelings and physiological states. Without age-appropriate coping skills, these youth may rely upon unhealthy strategies (substance use, high-risk behaviors, self-injury) or withdraw.

Relationships: Forming and maintaining safe connections is challenging for trauma-impacted youth. Interpersonal difficulties may stem from belief systems – for instance, a profound felt sense of vulnerability in relationships and distrust of others – and/or may stem from skills deficits in development of mutually satisfying interactions. Mistrust may lead some youth to isolate while others may fill relational needs in ways that leave them vulnerable to further victimization.

Identity: Self-perception is strongly affected by experience and relationships, and youth with a history of trauma have an understanding of self that is often marked by negativity, confusion, and fragmentation. They may feel damaged and incapable, and may approach new tasks with a deep lack of faith in their own ability to succeed. A common outcome is a loss of the ability to perceive the self in the future – along with the possibilities that future typically holds for youth.

Information Processing: Broadly, trauma influences reflective capacities: the individual's ability to take in, make meaning about, and act on internal and external information in a goal-oriented way. Trauma-impacted youth often struggle with executive functions. They may also have difficulty with many skills that support cognitive capacities – for instance, the ability to seek and tolerate support in problem-solving.

The Distorted Lens: The Impact of Mis-Attuned Expectations

It is increasingly accepted that the period we think of as adolescence extends beyond 18, the age of legal majority, and into the early 20's. In normative development, late adolescence is a phase of growth and exploration. With access to a widening world of peers and community and growing capacity for independent functioning, superimposed upon often intense emotional experience, changes in physiology, and as-yet-not-fully-developed prefrontal cortical functioning, late adolescents may operate as "almost adults" in appearance, but still need support to navigate both their internal and external worlds successfully.

All of us lose access to emerging skills during stressful times: when we shift jobs, homes, relationships, and/or roles we fall back on coping strategies which have served us in earlier, more solid periods of our life. Emerging skills are available only when there are sufficient resources to access them. This is particularly true for children and adolescents, whose skill sets are often qualitatively distinct from one stage to the next. Concretely, this means that as youth transition out of their childhood world into their adult world, they may show a temporary regression in skills and capacity.

Luckily, many young people have a safety net. For transition-age youth in the system, this safety net disappears. Adding insult to injury is the societal expectation that these youth be ready to face the world independently when the age of majority is reached, an expectation often not placed upon their more resourced peers. Indeed, the very language of "independence" that is used to describe services during this stage suggests the expectation that the 17- to 19-year-old youth will be functioning in the absence of supports.

As an analogy, imagine that someone who has no idea how to swim is thrown off a bridge into a rushing river after having been shown a video of someone treading water. Though she tries to keep her head above water, the current is too strong and she has no idea how to translate the observed video into action. As she starts to drown, a crowd gathers and insults her for her lack of skill. Eventually a lifeline is thrown and she grabs it, but when she is pulled ashore she is told she will be charged for the resources that ensured her survival.

In many ways, this is the story of Philip, and many of his peers.

Changing the Story: Supporting Trauma-Impacted Transition-Age Youth

In considering ways to change this story, we must consider where in the process we want to intervene: do we start after Philip is drowning in the water, by planning a better rescue? Do we want to give him better skills up on the bridge, before throwing him in? Or do we want to start far earlier, support him as we go, and rather than throw him off a bridge, perhaps enter the water with him?

To support system-involved youth in successful transition, we must have a paradigm shift: rather than considering transition as occurring only during the final years of adolescence, we must nurture and create opportunities for growth as early as is feasible.

At minimum, if we are to do right by youth whose lives have been held by care systems then we need to consider ways to achieve the following:

1. Develop a toolbox: The literature on resilience identifies key qualities and capacities that predict healthy functioning in early adulthood including:
   • Affect management: Ability to tolerate and manage emotion,
   • Executive control: Capacity to make thoughtful choices,
   • Awareness of self: Frame of self that is coherent and generally positive,
   • Relational skill: Ability to access, make use of, and maintain relational resources, and
   • Life skills: Ability to engage in self-care and use independent daily living skills.
   In intervention for trauma-impacted youth, far too often we zoom in for our treatment, focusing on symptom management, and playing crisis manager rather than resilience developer. Instead, our lens needs to become a wide-angled one. Early childhood intervention should include evaluation and enhancement of developmental and life skills as a primary intervention target for this population. We can and should begin to build and support these capacities at age- and stage-appropriate levels at the start of a youth's involvement in the system, rather than at the end of it.
2. Identify long-term resources: One primary goal of child-treating systems is the achievement of permanency and safety for youth in stable homes. When youth fail to transition to such placements successfully, we often select a starkly dichotomous choice: preparation for independence. Rather than considering solitary as the logical counterpart to nurtured, we must redefine permanency and consider ways to build permanent attachment resources for all children in care, regardless of placement. These resources may serve multiple functions over time: mentor, coach, and cheerleader as youth navigate their worlds.
3. Create a network: As youth enter into late adolescence a key goal should be identifying, accessing, and connecting to a wide support network. Systems that provide comprehensive services to high-risk populations should serve as models of an efficient way to offer this continuum of care; in the absence of such a singular resource, agencies that support this population might consider formation of linked networks to facilitate access to services.
4. Enhance intensive supports for those youth that require them: Many youth transitioning out of care can be successfully supported in functioning at increasingly age-appropriate levels with coaching, support resources, and opportunities, and consequently have the capacity to develop autonomous, successful functioning over time. Other youth, however, may have more significant challenges: for instance, diagnostic pictures complicated by significant mood or reality-testing disturbances, or trauma exposures and responses overlaid upon significant developmental or cognitive challenges. For these youth, more intensive supports are required; for example: longer-term housing and congregate care, intensive treatment supports, and opportunities for skills training and for job placement. These resources are few, the need is great, and the bar for accessing them is often placed too high. It behooves us to examine ways to shift our system of care so that intensive supports become more readily accessible. This may include a redefining of adaptive skills to include those in the toolbox above.

For youth like Philip, the conclusion of their story has often been predetermined – by the youth, by the system, and by society. But as with all our young people there should be no limit to the number of possible paths their lives may take. The age of legal majority (the exiting of childhood) must not be thought of as an endpoint by our child-treating systems, but rather as a milestone along the way – a meaningful one, to be sure, but one of many. With this view, we can conceptualize our services and supports as both building toward, but also continuing well beyond this marker.

Philip and his peers deserve no less.

References

1. U.S. Department of Health and Human Services. (2012). Child welfare outcomes 2009-2012, Report to Congress. Retrieved from Administration of Children and Families website: http://www.acf.hhs.gov/sites/default/files/cb/cwo09_12.pdf
2. Courtney, M., Dworsky, A., Lee, J., & Rapp, M. (2010). Midwest evaluation of the adult functioning of former foster youth: Outcomes at age 23 and 24 – Executive summary. Retrieved from Chapin Hall, University of Chicago website: http://www.chapinhall.org/sites/default/files/Midwest_Study_ES_Age_23_24.pdf
3. Goerge, R., Bilaver, L., Joo Lee, B., Needell, B., Brookhart, A., & Jackman, W. (2002). Employment outcomes for youth aging out of foster care: Final report. Chapin Hall Center for Children, University of Chicago. Retrieved from the U.S. Department of Health and Human Services Assistant Secretary for Planning and Evaluation website: http://aspe.hhs.gov/hsp/fostercare-agingout02
4. Reilly, T. (2003). Transition from care: Status and outcomes of youth who age out of foster care. Child Welfare: Journal of Policy, Practice, and Program, 82(6), 727-746.
5. Snyder, H., & Sickmund, M. (2006). Juvenile offenders and victims: 2006 national report.Washington, DC: U.S. Department of Justice, Office of Justice Programs. Retrieved from the Office of Juvenile Justice and Delinquency Prevention website: http://www.ojjdp.gov/ojstatbb/nr2006/downloads/NR2006.pdf
6. Abram, K., Teplin, L., Charles, D., Longworth, S., McLelland, G., & Dulcan, M. (2004). Postraumatic stress disorder and trauma in youth in juvenile detention. Archives of General Psychiatry, 61, 403-410.
7. Cook, A., Blaustein, M., Spinazzola, J., & van der Kolk, B. (Eds.). (2003). Complex trauma in children and adolescents: A white paper. Retrieved from the National Child Traumatic Stress Network website: http://www.nctsnet.org/sites/default/files/assets/pdfs/ComplexTrauma_All.pdf
8. D'Andrea, W., Ford, J., Stolbach, B., Spinazzola, J., & van der Kolk, B. (2012). Understanding interpersonal trauma in children: Why we need a developmentally appropriate trauma diagnosis. American Journal of Orthopsychiatry, 82, 187-200.
9. van der Kolk, B. (2005). Developmental Trauma Disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35, 401-408.
10. Spinazzola, J., Habib, M., Knoverek, A., Arvidson, J., Nisenbaum, J., Wentworth, R., . . . Kisiel, C. (2013, winter). The heart of the matter: Complex trauma in child welfare. In Trauma-Informed Child Welfare Practice (pp. 8-9, 37). Retrieved from the Trauma Center website: http://www.traumacenter.org/products/pdf_files/Complex_Trauma_in_Child_Welfare_S0002.pdf
11. Kisiel, C., Fehrenbach, T., Torgersen, E., Stolbach, B., McClelland, G., Griffin, G., & Burkman, K. (2014). Constellations of interpersonal trauma and symptoms in child welfare: Implications for a developmental trauma framework. Journal of Family Violence, 29, 1-14.

Suggested Citation

Blaustein, M. E., & Kinniburgh, K. M. (2015). When Age Doesn't Match Stage: Challenges and Considerations in Services for Transition-Age Youth with Histories of Developmental Trauma. Focal Point: Youth, Young Adults, and Mental Health, 29, 17-20. Portland, OR: Research and Training Center for Pathways to Positive Futures, Portland State University.