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Vicki Boatright, P.C.C. Erin M. Rafter, Ph.D.
Outline <ul><li>What is trauma? </li></ul><ul><li>Factors and effects of trauma </li></ul><ul><li>Symptoms and Diagnosis <...
Case Study <ul><li>9 year old Caucasian boy </li></ul><ul><li>Oppositional and defiant—talks back to teachers, refuses to ...
What is Trauma?  <ul><li>A  traumatic event  is a life experience that involves  actual or perceived threats to the safety...
What is Trauma? <ul><li>The outcome of traumatic life experiences can result in overwhelming feelings of terror, horror, e...
Sources of Trauma: <ul><li>Sexual Abuse </li></ul><ul><li>Physical Abuse </li></ul><ul><li>Emotional Abuse </li></ul><ul><...
General Statistics  (Hodas, 2006) <ul><li>Child Abuse estimates have increased from 186-1993: neglect by 102%, physical ab...
Statistics cont. (Hodas, 2006) <ul><li>The U.S. has highest rates of childhood homicide, suicide, and gun related deaths a...
Factors Effecting Impact <ul><li>Many forms of trauma </li></ul><ul><li>Many factors effect the impact on child </li></ul>...
Family Impact <ul><li>Overwhelmed with own reactions to trauma and loss </li></ul><ul><li>Compromised relationship with th...
School Impact (Steele, 2002) <ul><li>More than half of abused children have school difficulties </li></ul><ul><li>More tha...
Reactions to Trauma: <ul><li>Individuals react differently to trauma and stressors </li></ul><ul><li>Environment, IQ, supp...
Childhood Traumatic Stress <ul><li>Children vary in how they respond to traumatic events.  Some children recover quickly w...
Childhood Traumatic Stress <ul><li>CTS can have wide ranging effects on a person’s overall functioning, including cognitiv...
Childhood Traumatic Stress <ul><li>Researchers and mental health professionals have known for years that trauma can dramat...
Impact of trauma: <ul><li>Adverse Childhood Events (ACES) Study </li></ul><ul><ul><li>Collected between 1995-97 </li></ul>...
ACES Study <ul><li>Kaiser-Permanente- San Diego </li></ul><ul><li>Mailed survey after medical evaluation </li></ul><ul><li...
Neurology of Trauma <ul><li>Explanation of neurobiology of trauma experiences, including explanation of sensory involvemen...
Trauma and the Brain  <ul><li>Exposure to a traumatic event activates physiological responses that alter the neurological ...
Trauma and the Brain Amygdala  - The brains emotional computer and alarm system Hippocampus  - Brains storage for our most...
Trauma and the Brain <ul><li>Amygdala  - The brains emotional computer and alarm system </li></ul><ul><li>Hippocampus  - B...
Trauma and the Brain <ul><li>Amygdala  – associates incoming sensory experiences with emotions </li></ul><ul><li>Hippocamp...
Trauma and the Brain <ul><li>Traumatic experiences cause such an overload of stress responses in the body, the individual’...
Trauma and the Brain <ul><li>We often attribute behavioral problems in children to non-compliance, assuming that they have...
Common Symptoms <ul><li>Anxiety/fears </li></ul><ul><li>Helplessness </li></ul><ul><li>Difficulty concentrating </li></ul>...
Assessment <ul><li>Factors to consider </li></ul><ul><ul><li>Misdiagnosis </li></ul></ul><ul><ul><li>Factors behind behavi...
Diagnosis <ul><li>Establish experience of trauma and level of impact on child and/or family </li></ul><ul><li>If reported ...
Movement to New childhood diagnosis <ul><li>Developmental Trauma Disorder (DTD) possible in 2011 DSM-V. </li></ul><ul><li>...
Let’s get real in understanding this schtuff. <ul><li>Writing Exercise Activity </li></ul>
Trauma Informed Care (TIC) <ul><li>“ the recognition of the pervasiveness of trauma and a commitment to identify and addre...
Implementation of TIC <ul><li>RELATIONSHIP with the child </li></ul><ul><li>Coordinated services </li></ul><ul><li>Attribu...
The Theoretical Mindset: (Saakvitne et al, 2000) <ul><li>Symptoms are Adaptations </li></ul><ul><li>Trauma shapes beliefs ...
Considerations of service ( (Saakvitne et al, 2000) <ul><li>Goals: </li></ul><ul><ul><li>Building a growth-promoting relat...
Key Components (Hodas,2006) <ul><li>Respect by decreasing Shame and Humiliation </li></ul><ul><ul><li>How do you ALLOW a c...
4 questions to ask from G. Hodas, 2006 <ul><li>Is the view of behavior as “pathology or manipulation” or active efforts to...
BEHAVIOR MANAGEMENT  with Child/AdolescentTrauma Survivors <ul><li>3-PART PROCESS :   </li></ul><ul><li>Specific technique...
BEHAVIOR MANAGEMENT  with Child/AdolescentTrauma Survivors <ul><li>Often, we get caught up in our reactions, and lose sigh...
MANAGING OUR REACTIONS <ul><li>Our goal is to EDUCATE, not HUMILIATE. We often respond out of our own frustration, and we ...
Honoring Survivors <ul><li>We want to build spirits, not break them. </li></ul><ul><li>We want to create new strengths, no...
BEHAVIOR MANAGEMENT  with Child/AdolescentTrauma Survivors <ul><li>Beyond the Basics Handouts </li></ul>
References <ul><li>Hodas, G. R. (2006). Responding to Childhood Trauma: The promise and practice of trauma informed care. ...
References <ul><li>National Center for Children Exposed to Violence  www.nccev.org </li></ul><ul><li>Becker, Daniel (2003)...
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Trauma In Children

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Presentation by Erin Rafter, PhD and Vicki Boatright, L.P.C.C. to educate professionals working with youth affected by trauma

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Transcript of "Trauma In Children"

  1. 1. Vicki Boatright, P.C.C. Erin M. Rafter, Ph.D.
  2. 2. Outline <ul><li>What is trauma? </li></ul><ul><li>Factors and effects of trauma </li></ul><ul><li>Symptoms and Diagnosis </li></ul><ul><li>Creating Trauma Informed Care </li></ul><ul><li>Utilizing a strengths based model </li></ul><ul><li>Approaches to Trauma Informed Care </li></ul><ul><li>Interventions </li></ul>
  3. 3. Case Study <ul><li>9 year old Caucasian boy </li></ul><ul><li>Oppositional and defiant—talks back to teachers, refuses to do assignments, laughs at serious issues, aligns other students against teachers, does not accept responsibility for his actions. </li></ul><ul><li>Instigates others, aggressive, picks fights with peers, bullies others. </li></ul><ul><li>Destroys property. </li></ul><ul><li>Engages in fire setting. </li></ul><ul><li>Manipulates, lies, blames others, causes trouble for no reason. </li></ul><ul><li>Hospitalized twice—both times determined to be “just a behavioral problem.” </li></ul>
  4. 4. What is Trauma? <ul><li>A traumatic event is a life experience that involves actual or perceived threats to the safety and well-being of an individual or to someone close to the individual. </li></ul><ul><li>Traumatic life experiences can overwhelm a person's coping strategies, causing extreme emotional, psychological and physiological distress. </li></ul><ul><li>From: (www.nctsnet.org) </li></ul>
  5. 5. What is Trauma? <ul><li>The outcome of traumatic life experiences can result in overwhelming feelings of terror, horror, extreme fear and helplessness. </li></ul><ul><li>Traumatic experiences may be single occurrences; recurring events of a similar nature; or multiple unrelated events. </li></ul><ul><li>Exposure to traumatic events may impact the direct victim(s) as well as others who are indirectly exposed to the event. </li></ul>
  6. 6. Sources of Trauma: <ul><li>Sexual Abuse </li></ul><ul><li>Physical Abuse </li></ul><ul><li>Emotional Abuse </li></ul><ul><li>Neglect </li></ul><ul><li>Serious Accident </li></ul><ul><li>Natural Disaster </li></ul><ul><li>Assault/Rape </li></ul><ul><li>Change in Family dynamic </li></ul><ul><li>Moving </li></ul><ul><li>War—Combat experience </li></ul><ul><li>Witnessing/learning of traumatic event </li></ul><ul><li>Hostage/torture </li></ul><ul><li>Horrific death/loss of a loved one </li></ul><ul><li>Serious surgery/medical diagnosis </li></ul><ul><li>Witnessing Domestic Violence </li></ul><ul><li>Drug use in home </li></ul>
  7. 7. General Statistics (Hodas, 2006) <ul><li>Child Abuse estimates have increased from 186-1993: neglect by 102%, physical abuse 42%, sexual abuse 83%, and emotional neglect 333%. </li></ul><ul><li>Approx. 4 million adolescents have been victims of serious physical assault, and 9 million witnessed serious violence during their lives. </li></ul><ul><li>African-American youth seem to be the ethnic group most often exposed to violence, followed by Latinos, and Caucasians, regardless of economic status. </li></ul>
  8. 8. Statistics cont. (Hodas, 2006) <ul><li>The U.S. has highest rates of childhood homicide, suicide, and gun related deaths among industrialized countries. </li></ul><ul><li>In 1999, 12-18 yr. old students living in urban AND suburban environments were equally vulnerable to serious violent crime at school. </li></ul><ul><li>Childhood abuse is correlated with higher truancy and increases the likelihood of arrest as a juvenile by 53%, (arrest for a violent crime increases by 38%). </li></ul>
  9. 9. Factors Effecting Impact <ul><li>Many forms of trauma </li></ul><ul><li>Many factors effect the impact on child </li></ul><ul><ul><li>Age, past trauma & duration, mental health, social support, gender, severity and type of trauma, resiliency and protective factors </li></ul></ul><ul><li>Many types of effects: </li></ul><ul><ul><li>Physical </li></ul></ul><ul><ul><li>Emotional </li></ul></ul><ul><ul><li>Short-term </li></ul></ul><ul><ul><li>Long-term </li></ul></ul>
  10. 10. Family Impact <ul><li>Overwhelmed with own reactions to trauma and loss </li></ul><ul><li>Compromised relationship with the child </li></ul><ul><li>Inadequate Parenting skills </li></ul><ul><li>Depression/Substance abuse </li></ul><ul><li>Financial Difficulties </li></ul><ul><li>Previous traumatic exposure </li></ul>
  11. 11. School Impact (Steele, 2002) <ul><li>More than half of abused children have school difficulties </li></ul><ul><li>More than a quarter of abused children receive special education services </li></ul><ul><li>Research indicates trauma can decrease cognitive abilities and IQ </li></ul><ul><li>Children more likely to be unemployed as adults </li></ul>
  12. 12. Reactions to Trauma: <ul><li>Individuals react differently to trauma and stressors </li></ul><ul><li>Environment, IQ, support system (present or not present), safety?, perceived strengths, mental status/health, age, gender, developmental level </li></ul><ul><li>History of trauma </li></ul><ul><li>PERCEPTION & RESILIENCY </li></ul><ul><li>From (Nader, 2008) </li></ul>
  13. 13. Childhood Traumatic Stress <ul><li>Children vary in how they respond to traumatic events. Some children recover quickly with few complications, while others demonstrate more extreme reactions called childhood traumatic stress (CTS) . </li></ul><ul><li>CTS can occur when children and adolescents affected by traumatic situations have difficulty resuming their usual life activities and become overwhelmed in their ability to cope. </li></ul><ul><li>Some children develop more enduring psychological conditions, such as post traumatic stress disorder (PTSD), depression, anxiety and a variety of behavioral disorders. These conditions can persist into adulthood and cause lifelong difficulties for some people. </li></ul>
  14. 14. Childhood Traumatic Stress <ul><li>CTS can have wide ranging effects on a person’s overall functioning, including cognitive, emotional, physical, and behavioral aspects. While some children “bounce back” after adversity, other children experience significant disruptions in their development, leading to profound long-term consequences. </li></ul><ul><li>From www.nctsnet.org </li></ul>
  15. 15. Childhood Traumatic Stress <ul><li>Researchers and mental health professionals have known for years that trauma can dramatically alter a child’s cognitive, emotional, physical, and behavioral functioning. </li></ul><ul><li>More recent research has shown that neurological changes caused by trauma leave younger children more vulnerable to persistent functional difficulties. </li></ul><ul><li>Repeated exposure to a number of traumatic events can magnify the effect on brain and nervous system development, resulting in developmental impacts on all levels. </li></ul>
  16. 16. Impact of trauma: <ul><li>Adverse Childhood Events (ACES) Study </li></ul><ul><ul><li>Collected between 1995-97 </li></ul></ul><ul><ul><li>17,337 participants (9,508 originally) </li></ul></ul><ul><ul><li>Found that maltreatment is a risk factor for overall negative health </li></ul></ul><ul><ul><li>The impact has remained the same since 1900’s (despite improvements in health care). </li></ul></ul><ul><ul><li>From Felitti et al. 1998 </li></ul></ul>
  17. 17. ACES Study <ul><li>Kaiser-Permanente- San Diego </li></ul><ul><li>Mailed survey after medical evaluation </li></ul><ul><li>10 risk factors as causes of morbidity were identified </li></ul><ul><li>Negative coping strategies (smoking, alcohol/drugs, overeating, sexual behaviors used to cope), lead to chronic use </li></ul><ul><li>From Felitti et al. 1998 </li></ul>
  18. 18. Neurology of Trauma <ul><li>Explanation of neurobiology of trauma experiences, including explanation of sensory involvement; effects on cognitive functioning; functioning of the amygdala (sp) fight, flight or freeze; persistent states of arousal; implicit and explicit memory; use of sensory interventions to link an implicit memory linguistically to a contextual framework. </li></ul>
  19. 19. Trauma and the Brain <ul><li>Exposure to a traumatic event activates physiological responses that alter the neurological functioning of an individual. </li></ul><ul><li>Traumatic experiences trigger a state of arousal in the body—a heightened state of alertness and fearfulness for one’s safety. </li></ul><ul><li>Short-term and prolonged arousal can affect cognitive and behavioral functions. </li></ul><ul><li>In an arousal state, changes in the brain are triggered by a variety of stress related functions. </li></ul>
  20. 20. Trauma and the Brain Amygdala - The brains emotional computer and alarm system Hippocampus - Brains storage for our most recent conscious memories Thalamus - Translates sights, sounds, smells into the language of the brain Prefrontal cortex - Where information is used to make decisions about cognitive and emotional responses
  21. 21. Trauma and the Brain <ul><li>Amygdala - The brains emotional computer and alarm system </li></ul><ul><li>Hippocampus - Brains storage for our most recent conscious memories </li></ul><ul><li>Thalamus - Translates sights, sounds, smells into the language of the brain </li></ul><ul><li>Prefrontal Cortex - Processes information by cross-referencing and making various associations between experiences </li></ul>
  22. 22. Trauma and the Brain <ul><li>Amygdala – associates incoming sensory experiences with emotions </li></ul><ul><li>Hippocampus – files experiences into long-term memory </li></ul><ul><li>When a traumatic experience occurs, the hippocampus is unable to classify and organize information properly. Cognitive processing of information is inhibited, as passageways to the Prefrontal Cortex are blocked. </li></ul><ul><li>When the amygdala is aroused, stress hormones are released, causing the individual to go into “fight”, “flight” or freeze” states of arousal. </li></ul><ul><li>Typical processes for storing memories is altered as cognitive functioning is shut down. Information remains perceptual (smells, sights, sounds) and does not get stored through verbal language. </li></ul>
  23. 23. Trauma and the Brain <ul><li>Traumatic experiences cause such an overload of stress responses in the body, the individual’s normal system of processing sensory information is completely overwhelmed. </li></ul><ul><li>Survivors of trauma often become hypersensitive and easily triggered into a state of arousal, sensing threat in what other’s consider to be innocuous situations. </li></ul><ul><li>The survivor’s fear “alarm system” becomes triggered by sensory experiences that they may have no verbal language to describe. </li></ul>
  24. 24. Trauma and the Brain <ul><li>We often attribute behavioral problems in children to non-compliance, assuming that they have the capacity to perform to our expectations. </li></ul><ul><li>A child or adolescent survivor who is in a state of hyper-arousal due to perceived threats in their environment may not have the cognitive or emotional capacity to perform to our expectations in certain situations. </li></ul><ul><li>We must begin to think in terms of building capacities instead of requiring compliance. </li></ul>
  25. 25. Common Symptoms <ul><li>Anxiety/fears </li></ul><ul><li>Helplessness </li></ul><ul><li>Difficulty concentrating </li></ul><ul><li>Depression </li></ul><ul><li>Behavioral outbursts </li></ul><ul><li>Withdrawal/Social Difficulties </li></ul><ul><li>Substance use </li></ul><ul><li>Hypervigilance </li></ul><ul><li>Attachment difficulties </li></ul><ul><li>Sexualized behaviors </li></ul><ul><li>Sleep difficulties </li></ul><ul><li>Dissociation </li></ul><ul><li>These symptoms can vary based upon type of trauma and duration of trauma </li></ul>
  26. 26. Assessment <ul><li>Factors to consider </li></ul><ul><ul><li>Misdiagnosis </li></ul></ul><ul><ul><li>Factors behind behavior </li></ul></ul><ul><ul><li>Mindset of the child and family (POV) </li></ul></ul><ul><ul><li>Extent of trauma experiences </li></ul></ul><ul><ul><li>On-going trauma </li></ul></ul><ul><ul><li>Cognitive level </li></ul></ul><ul><ul><li>Development of a safety plan/intervention plan </li></ul></ul>
  27. 27. Diagnosis <ul><li>Establish experience of trauma and level of impact on child and/or family </li></ul><ul><li>If reported in duration of treatment, then re-evaluate assessment </li></ul><ul><li>Consider developmental level and environment </li></ul><ul><li>Referral for Trauma Assessment for differential diagnosis and recommendations </li></ul>
  28. 28. Movement to New childhood diagnosis <ul><li>Developmental Trauma Disorder (DTD) possible in 2011 DSM-V. </li></ul><ul><li>Meant to reflect how children are influenced by relationships and context of their development </li></ul><ul><li>Group from National Child Traumatic Stress Network </li></ul><ul><li>From DeAngelis 2007 </li></ul>
  29. 29. Let’s get real in understanding this schtuff. <ul><li>Writing Exercise Activity </li></ul>
  30. 30. Trauma Informed Care (TIC) <ul><li>“ the recognition of the pervasiveness of trauma and a commitment to identify and address it early, whenever possible.” G. Hodas, 2006 </li></ul><ul><li>What is the relationship between a child’s current behavior/functioning and past trauma experience? </li></ul><ul><li>Promoting resilience, recognizing strengths, treating the child and family with consideration for the past and current functioning (reality of the situation) </li></ul>
  31. 31. Implementation of TIC <ul><li>RELATIONSHIP with the child </li></ul><ul><li>Coordinated services </li></ul><ul><li>Attribution of behavior </li></ul><ul><li>Involvement of caregivers </li></ul><ul><li>Doesn’t have to be SPECIALIZED. It is about the mindset of the providers </li></ul><ul><li>Happens on Multiple levels </li></ul><ul><ul><li>Direct care, within unit, organizational levels </li></ul></ul>
  32. 32. The Theoretical Mindset: (Saakvitne et al, 2000) <ul><li>Symptoms are Adaptations </li></ul><ul><li>Trauma shapes beliefs about identity and world view </li></ul><ul><li>Using a trauma framework can address mental health </li></ul><ul><li>Collaboration between client and provider </li></ul><ul><li>Four important components to offer client: respect, information, connection, HOPE </li></ul><ul><li>Providers need to support each other </li></ul><ul><li>You will be affected too. </li></ul>
  33. 33. Considerations of service ( (Saakvitne et al, 2000) <ul><li>Goals: </li></ul><ul><ul><li>Building a growth-promoting relationship </li></ul></ul><ul><ul><li>Learning about trauma and oneself </li></ul></ul><ul><ul><li>Understanding oneself with empathy </li></ul></ul><ul><li>Safety </li></ul><ul><ul><li>Definition of safety </li></ul></ul><ul><li>Addressing Shame & Blame </li></ul><ul><ul><li>Addressing defensiveness </li></ul></ul><ul><ul><li>Conflict management </li></ul></ul>
  34. 34. Key Components (Hodas,2006) <ul><li>Respect by decreasing Shame and Humiliation </li></ul><ul><ul><li>How do you ALLOW a child to “Save face” </li></ul></ul><ul><ul><li>Maintaining rules/expectations while providing options for child </li></ul></ul><ul><ul><li>Maintain respect for child even when not shown to you </li></ul></ul><ul><li>Increase understanding of child and caregivers of trauma </li></ul><ul><li>Build a de-escalation plan with child and family </li></ul>
  35. 35. 4 questions to ask from G. Hodas, 2006 <ul><li>Is the view of behavior as “pathology or manipulation” or active efforts to cope with challenging circumstances? </li></ul><ul><li>So focused upon compliance that it limits flexibility, therefore limits on benefits to child and staff? </li></ul><ul><li>Seek to increase understanding (of child AND staff) of connection between past trauma and current behaviors? </li></ul><ul><li>Such a focus on managing behavior that it interferes with helping child developing skills and greater personal mastery? </li></ul>
  36. 36. BEHAVIOR MANAGEMENT with Child/AdolescentTrauma Survivors <ul><li>3-PART PROCESS :   </li></ul><ul><li>Specific techniques/strategies to gain compliance. </li></ul><ul><li>Communication that encourages cooperation. </li></ul><ul><li>Managing our own reactions to the child’s behavior. </li></ul><ul><li>Most adults are looking for #1. They want the miracle strategy; the silver bullet; the miracle cure. </li></ul><ul><li>The irony in this is, if you do #2 and #3 well, #1 will come naturally. </li></ul><ul><li>  </li></ul>
  37. 37. BEHAVIOR MANAGEMENT with Child/AdolescentTrauma Survivors <ul><li>Often, we get caught up in our reactions, and lose sight of our role as a teacher. We expect compliance, JUST BECAUSE! </li></ul><ul><li>  Compliance—Getting someone to do what you want them to do. </li></ul><ul><li>  Cooperation—Collaborative process that makes everyone a winner. </li></ul><ul><li>  </li></ul>
  38. 38. MANAGING OUR REACTIONS <ul><li>Our goal is to EDUCATE, not HUMILIATE. We often respond out of our own frustration, and we seek to “Teach them a lesson!” instead of truly educating them to make good decisions. </li></ul><ul><li>Our reactions should be based on REDUCING THE CHILD’S SENSE OF TREAT, rather than breaking their spirit. </li></ul>
  39. 39. Honoring Survivors <ul><li>We want to build spirits, not break them. </li></ul><ul><li>We want to create new strengths, not destroy old habits. </li></ul><ul><li>We want to expand the survivor’s understanding and awareness of the world, not eliminate their current perceptions. </li></ul><ul><li>And we want to engage with survivors, honoring their amazing ability to grow. </li></ul><ul><li>--BZTAT </li></ul>
  40. 40. BEHAVIOR MANAGEMENT with Child/AdolescentTrauma Survivors <ul><li>Beyond the Basics Handouts </li></ul>
  41. 41. References <ul><li>Hodas, G. R. (2006). Responding to Childhood Trauma: The promise and practice of trauma informed care. White Paper for the Pennsylvania Office of Mental Health and Substance Abuse Services www.nsvrc.org </li></ul><ul><li>Saakvitne, K., Gamble, S., Pearlman, L., & Lev, B. (2000). Risking Connection®: A Training Curriculum for Working with Survivors of Child Abuse, Baltimore, MD: Sidran Institute Press. </li></ul><ul><li>Steele, W. (1997). Trauma Response Kit: Short Term Intervention Model. TLC Institute, Grosse Pointe Woods, MI </li></ul><ul><li>Nader, K (2008).Understanding and Assessing Trauma in Children and Adolescents. Taylor & Francis, New York:NY. </li></ul><ul><li>DeAngelis, T. (2007). A new diagnosis for childhood trauma? Monitor on Psychology, 38 , 32. </li></ul>
  42. 42. References <ul><li>National Center for Children Exposed to Violence www.nccev.org </li></ul><ul><li>Becker, Daniel (2003). Trauma & Adolescence I: The Nature & Scope of Trauma. The Group for the Advancement of Psychiatry. www.findarticles.com </li></ul><ul><li>National Child Traumatic Stress Network, www.nctsn.org </li></ul><ul><li>Felitti, Anda, et al.(1998). The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine , 14, 245-258. </li></ul><ul><li>Steele, W. (2002). Trauma’s Impact on Learning and Behavior: A Case for Interventions in the Schools. TLC Journal, 2. www.tlcinstitute.org </li></ul><ul><li>For more resources, please see handout. </li></ul>
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