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Interview: Trauma-Informed Care with Transition-Age Youth

New approaches can help young adults overcome adverse childhood experiences.

Last month, an article titled “The Tragedy of Baltimore” in the New York Times Magazine described the upsurge in violence in a city long known for its “blight, suburban flight, segregation, drugs, racial inequality, [and] concentrated poverty.” At the center of the storm are transition-age youth, who too often face long odds and challenging futures in the communities where they live.

BaltoPhoto/public domain
Source: BaltoPhoto/public domain

I recently had the opportunity to talk with Patricia Cobb-Richardson, MS. For the past 20 years, she has worked in New York City, Delaware, and now Baltimore developing and leading programs that aim to leverage the protective factors and resilience of young adults in communities challenged by chronic toxic stress and trauma borne of gun violence, substance use, poverty, structural racism, and mass incarceration. In our recent interview, Patricia shared her work and perspective on trauma-informed care. What follows is a transcript of our conversation, which has been edited for length and clarity.

RJE: Most of your work is with “transition-age youth.” Who are they and what’s important to know about them?

PCR: Generally, we consider transition-age youth to be young adults who are between 18 and 25 years old. I began working with young adults because I saw so many young people with behavioral health problems who had aged out of the foster care system and ended up homeless. Those kids made me look more closely at the problems in the system that failed them. They appeared to lack the skills to succeed as adults in the community. They weren’t finding jobs and frequently became part of the criminal justice system.

What I realized over time was that the early adverse childhood experiences (ACEs) that we now understand in terms of toxic stress were the primary cause of their lack of skills. They struggled with interpersonal relationships, sustaining employment, securing housing, and achieving academic goals. All of these are important components of adult life and these young people were often blamed for failing to achieve them. What was needed was a public health understanding of the ways in which systems, policies, and structural factors combine to prevent youth from achieving their goals. The expression “It’s not what’s wrong with you but rather what happened to you” reflects this public health perspective.

These youth are in a system that wasn’t designed for them. They aren’t children but they’re not yet fully adults either. It’s not surprising that three out of four who are referred for behavioral health treatment do not access that treatment. Of particular concern to me is the fact that many of these young men and women are dealing with multiple factors impacting their development. They’ve experienced childhood trauma, community violence, and poverty, and for some a disconnection from family, community, and culture.

Again, we’re talking about individuals who’ve been exposed to multiple adverse experiences in childhood, and we know this has both physical and emotional consequences. These young people have difficulty regulating their emotions and engaging in effective problem-solving. They tell us that just showing up to work on time is extremely difficult and sometimes they have inexplicable conflicts at work. Sometimes they adapt to these stressors by using substances to manage their anxiety and feelings of sadness. The challenges they’re facing may seem on the surface so easy to others, but it’s not so for them.

RJE: You referred to adverse childhood experiences, or ACEs. Can you say more about them?

PCR: The CDC and Kaiser-Permanente in California launched a long-term program of research identifying ten stressful experiences that affect children. These experiences affect the developing brain and can have lasting impact. We can think of toxic stress as any event or circumstance that overwhelms an individual’s capacity to adjust. We face small discomforts every day. The weather is bad, we’re hungry, we’re late for something, and so on. But stress becomes truly toxic when it seriously threatens our actual physical or emotional well-being. So, you’re separated from your parent due to abuse or neglect. Or you go to bed without enough to eat night after night. Or you sleep on the street because it’s less dangerous than living at home. These are examples of what we mean by ACEs. Our brains release certain chemicals to help us survive. But even though these hormones may enable us to run faster or ignore pain, over time they can also interfere with healthy development. More and more research is showing how powerfully toxic stress affects the developing brain, and what the long-term effects of that stress look like on our physical health and well-being across a lifetime.

One important takeaway from ACEs research for me is that even though these adverse experiences occur everywhere, they are more prevalent, disproportionately, in spaces defined by concentrated poverty, inadequate housing, community violence, and homelessness. It should also be noted that there are institutional structures that maintain inequity and lead to more toxic stress. Many of the youth I work with are living in these environments. Because ACEs have such a profound impact on health and well-being, all youth-serving systems need to consider toxic stress and provide trauma-informed care.

“Trauma-informed care” is a framework that integrates scientific knowledge about neurobiology, epigenetics, ACEs, and resilience into our service delivery systems of care—including behavioral health, physical health, education, and criminal justice. By bringing knowledge of trauma into the development of programs, policies, and practices, we mitigate, prevent, or buffer individuals, families, and communities from the effects of toxic stress.

RJE: So how do mental health professionals fit into this arena?

PCR: Many mental health professionals are very engaged in addressing the effects of ACEs and trauma. Many are trained in trauma treatment methods and trauma-related mental health issues. On national, state, and local levels, mental health professionals are also doing incredible work in advancing trauma-informed approaches in schools, prisons, and diverse healthcare settings.

However, when I focus on transition-age youth, I see we have a long way to go before we will have a system that meets their needs. Recent studies have brought to our attention the fact that the young adults who we’ve been talking about are not only likely to experience homelessness, but they’re also increasingly likely to suffer from anxiety, depression, and self-harm. All young people should have access to resources that ensure that they will have a real chance to succeed.

I think we need to be innovative in our approaches and learn from young adults themselves. Most importantly, we must invite them to inform us about their experiences and their perspectives and ideas for effective services. It’s not about parachuting in as an “expert” with a “cure.” If we see them as the experts on what they need, we change the relationship, for the better. They can and should be the drivers of their own success.

Effective programs need to offer choices. Youth voices should be everywhere. What we really need to do is create youth-driven “integrated models” where young adults can go to get help with their diverse behavioral health needs. The best frameworks address early symptoms of anxiety and depression. If addressed early, they can potentially forestall a lifetime of mental health challenges. Since stigma is often a barrier to seeking help, it’s important to provide integrated models that offer many of the resources youth and young adults want in a space where they are active in everything from design to oversight to service delivery.

BaltoPhoto/public domain
Source: BaltoPhoto/public domain

RJE: Are there specific models and programs that you’d recommend to others?

PCR: Sure, I can mention a few. Along with other colleagues, I’ve set up a number of psycho-educational groups using techniques that come from the “Sanctuary Model.” These “SELF Community Conversations” have been very effective in creating a structure for working with traumatized youth and young adults in various group settings. In Baltimore, we’ve helped to set up groups for young adults experiencing homelessness, young adults in workplace settings, in foster care independent living programs, in the criminal justice system, and with community outreach programs addressing youth exposed to violence.

There are also some exciting models designed specifically for youth between 12 and 25—like “headspace” in Australia and the “Foundry” model from British Columbia—that show a great deal of promise. These models include dedicated spaces—both physical and virtual—and focus on early identification of adolescents and young adults who are experiencing emotional distress. These youth are offered opportunities to explore and address their concerns—and develop their coping skills—in an integrated, supportive setting that recognizes and respects their culture, communication styles, and agency. The goal is to create healthy and capable adults by collaboratively tackling issues as soon as they arise, rather than waiting until they’ve gotten worse and may be much harder to fix. The “allcove” program at Stanford University for teens and young adults is based on the headspace concept as well.

Our adult mental health system is crisis-driven, targeting individuals whose problems have too often already derailed them. The overriding idea with these newer models is to address early signs of emotional distress in a youth-designed, accessible, and safe space.

RJE: Are there any final thoughts you’d like to share?

PCR: This is what I see. When transition-age youth experience the adult mental health system, they find it incongruent with their own perspective. And in the case of African-American and other youth who are marginalized in our society, often the adult system can be experienced as culturally blind, rejecting, and irrelevant.

I think we are moving towards frameworks that are more developmentally and culturally appropriate. In these trauma-responsive approaches, youth are involved in all aspects of services to ensure sustainability and relevance. I’m really inspired by these integrated approaches where everything from behavioral health, physical health, and sexual health, to peer support, work, and academic support are all available within a single distinct setting. It’s very exciting to be a part of it.

RJE: Thank you, Patricia.