The document outlines the nature of trauma, its sources, symptoms, and effects on children, particularly highlighting a case study of a 9-year-old boy exhibiting severe behavioral issues linked to past traumatic experiences. It emphasizes the importance of trauma-informed care approaches that recognize the impact of trauma on children's behavior and development, advocating for strategies that build resilience and cooperation rather than merely enforcing compliance. The document also discusses the neurological aspects of trauma and the critical need for supportive interventions in educational and caregiving settings.

1. Vicki Boatright, P.C.C. Erin M. Rafter, Ph.D.

2. Outline What is trauma? Factors and effects of trauma Symptoms and Diagnosis Creating Trauma Informed Care Utilizing a strengths based model Approaches to Trauma Informed Care Interventions

3. Case Study 9 year old Caucasian boy 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. Instigates others, aggressive, picks fights with peers, bullies others. Destroys property. Engages in fire setting. Manipulates, lies, blames others, causes trouble for no reason. Hospitalized twice—both times determined to be “just a behavioral problem.”

4. What is Trauma? 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. Traumatic life experiences can overwhelm a person's coping strategies, causing extreme emotional, psychological and physiological distress. From: (www.nctsnet.org)

5. What is Trauma? The outcome of traumatic life experiences can result in overwhelming feelings of terror, horror, extreme fear and helplessness. Traumatic experiences may be single occurrences; recurring events of a similar nature; or multiple unrelated events. Exposure to traumatic events may impact the direct victim(s) as well as others who are indirectly exposed to the event.

6. Sources of Trauma: Sexual Abuse Physical Abuse Emotional Abuse Neglect Serious Accident Natural Disaster Assault/Rape Change in Family dynamic Moving War—Combat experience Witnessing/learning of traumatic event Hostage/torture Horrific death/loss of a loved one Serious surgery/medical diagnosis Witnessing Domestic Violence Drug use in home

7. General Statistics (Hodas, 2006) Child Abuse estimates have increased from 186-1993: neglect by 102%, physical abuse 42%, sexual abuse 83%, and emotional neglect 333%. Approx. 4 million adolescents have been victims of serious physical assault, and 9 million witnessed serious violence during their lives. African-American youth seem to be the ethnic group most often exposed to violence, followed by Latinos, and Caucasians, regardless of economic status.

8. Statistics cont. (Hodas, 2006) The U.S. has highest rates of childhood homicide, suicide, and gun related deaths among industrialized countries. In 1999, 12-18 yr. old students living in urban AND suburban environments were equally vulnerable to serious violent crime at school. 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%).

9. Factors Effecting Impact Many forms of trauma Many factors effect the impact on child Age, past trauma & duration, mental health, social support, gender, severity and type of trauma, resiliency and protective factors Many types of effects: Physical Emotional Short-term Long-term

10. Family Impact Overwhelmed with own reactions to trauma and loss Compromised relationship with the child Inadequate Parenting skills Depression/Substance abuse Financial Difficulties Previous traumatic exposure

11. School Impact (Steele, 2002) More than half of abused children have school difficulties More than a quarter of abused children receive special education services Research indicates trauma can decrease cognitive abilities and IQ Children more likely to be unemployed as adults

12. Reactions to Trauma: Individuals react differently to trauma and stressors Environment, IQ, support system (present or not present), safety?, perceived strengths, mental status/health, age, gender, developmental level History of trauma PERCEPTION & RESILIENCY From (Nader, 2008)

13. Childhood Traumatic Stress 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) . 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. 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.

14. Childhood Traumatic Stress 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. From www.nctsnet.org

15. Childhood Traumatic Stress Researchers and mental health professionals have known for years that trauma can dramatically alter a child’s cognitive, emotional, physical, and behavioral functioning. More recent research has shown that neurological changes caused by trauma leave younger children more vulnerable to persistent functional difficulties. 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.

16. Impact of trauma: Adverse Childhood Events (ACES) Study Collected between 1995-97 17,337 participants (9,508 originally) Found that maltreatment is a risk factor for overall negative health The impact has remained the same since 1900’s (despite improvements in health care). From Felitti et al. 1998

17. ACES Study Kaiser-Permanente- San Diego Mailed survey after medical evaluation 10 risk factors as causes of morbidity were identified Negative coping strategies (smoking, alcohol/drugs, overeating, sexual behaviors used to cope), lead to chronic use From Felitti et al. 1998

18. Neurology of Trauma 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.

19. Trauma and the Brain Exposure to a traumatic event activates physiological responses that alter the neurological functioning of an individual. Traumatic experiences trigger a state of arousal in the body—a heightened state of alertness and fearfulness for one’s safety. Short-term and prolonged arousal can affect cognitive and behavioral functions. In an arousal state, changes in the brain are triggered by a variety of stress related functions.

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. 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 - Processes information by cross-referencing and making various associations between experiences

22. Trauma and the Brain Amygdala – associates incoming sensory experiences with emotions Hippocampus – files experiences into long-term memory 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. When the amygdala is aroused, stress hormones are released, causing the individual to go into “fight”, “flight” or freeze” states of arousal. 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.

23. Trauma and the Brain Traumatic experiences cause such an overload of stress responses in the body, the individual’s normal system of processing sensory information is completely overwhelmed. 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. The survivor’s fear “alarm system” becomes triggered by sensory experiences that they may have no verbal language to describe.

24. Trauma and the Brain We often attribute behavioral problems in children to non-compliance, assuming that they have the capacity to perform to our expectations. 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. We must begin to think in terms of building capacities instead of requiring compliance.

25. Common Symptoms Anxiety/fears Helplessness Difficulty concentrating Depression Behavioral outbursts Withdrawal/Social Difficulties Substance use Hypervigilance Attachment difficulties Sexualized behaviors Sleep difficulties Dissociation These symptoms can vary based upon type of trauma and duration of trauma

26. Assessment Factors to consider Misdiagnosis Factors behind behavior Mindset of the child and family (POV) Extent of trauma experiences On-going trauma Cognitive level Development of a safety plan/intervention plan

27. Diagnosis Establish experience of trauma and level of impact on child and/or family If reported in duration of treatment, then re-evaluate assessment Consider developmental level and environment Referral for Trauma Assessment for differential diagnosis and recommendations

28. Movement to New childhood diagnosis Developmental Trauma Disorder (DTD) possible in 2011 DSM-V. Meant to reflect how children are influenced by relationships and context of their development Group from National Child Traumatic Stress Network From DeAngelis 2007

29. Let’s get real in understanding this schtuff. Writing Exercise Activity

30. Trauma Informed Care (TIC) “ the recognition of the pervasiveness of trauma and a commitment to identify and address it early, whenever possible.” G. Hodas, 2006 What is the relationship between a child’s current behavior/functioning and past trauma experience? Promoting resilience, recognizing strengths, treating the child and family with consideration for the past and current functioning (reality of the situation)

31. Implementation of TIC RELATIONSHIP with the child Coordinated services Attribution of behavior Involvement of caregivers Doesn’t have to be SPECIALIZED. It is about the mindset of the providers Happens on Multiple levels Direct care, within unit, organizational levels

32. The Theoretical Mindset: (Saakvitne et al, 2000) Symptoms are Adaptations Trauma shapes beliefs about identity and world view Using a trauma framework can address mental health Collaboration between client and provider Four important components to offer client: respect, information, connection, HOPE Providers need to support each other You will be affected too.

33. Considerations of service ( (Saakvitne et al, 2000) Goals: Building a growth-promoting relationship Learning about trauma and oneself Understanding oneself with empathy Safety Definition of safety Addressing Shame & Blame Addressing defensiveness Conflict management

34. Key Components (Hodas,2006) Respect by decreasing Shame and Humiliation How do you ALLOW a child to “Save face” Maintaining rules/expectations while providing options for child Maintain respect for child even when not shown to you Increase understanding of child and caregivers of trauma Build a de-escalation plan with child and family

35. 4 questions to ask from G. Hodas, 2006 Is the view of behavior as “pathology or manipulation” or active efforts to cope with challenging circumstances? So focused upon compliance that it limits flexibility, therefore limits on benefits to child and staff? Seek to increase understanding (of child AND staff) of connection between past trauma and current behaviors? Such a focus on managing behavior that it interferes with helping child developing skills and greater personal mastery?

36. BEHAVIOR MANAGEMENT with Child/AdolescentTrauma Survivors 3-PART PROCESS : Specific techniques/strategies to gain compliance. Communication that encourages cooperation. Managing our own reactions to the child’s behavior. Most adults are looking for #1. They want the miracle strategy; the silver bullet; the miracle cure. The irony in this is, if you do #2 and #3 well, #1 will come naturally.

37. BEHAVIOR MANAGEMENT with Child/AdolescentTrauma Survivors Often, we get caught up in our reactions, and lose sight of our role as a teacher. We expect compliance, JUST BECAUSE! Compliance—Getting someone to do what you want them to do. Cooperation—Collaborative process that makes everyone a winner.

38. MANAGING OUR REACTIONS 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. Our reactions should be based on REDUCING THE CHILD’S SENSE OF TREAT, rather than breaking their spirit.

39. Honoring Survivors We want to build spirits, not break them. We want to create new strengths, not destroy old habits. We want to expand the survivor’s understanding and awareness of the world, not eliminate their current perceptions. And we want to engage with survivors, honoring their amazing ability to grow. --BZTAT

40. BEHAVIOR MANAGEMENT with Child/AdolescentTrauma Survivors Beyond the Basics Handouts

41. References 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 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. Steele, W. (1997). Trauma Response Kit: Short Term Intervention Model. TLC Institute, Grosse Pointe Woods, MI Nader, K (2008).Understanding and Assessing Trauma in Children and Adolescents. Taylor & Francis, New York:NY. DeAngelis, T. (2007). A new diagnosis for childhood trauma? Monitor on Psychology, 38 , 32.

42. References National Center for Children Exposed to Violence www.nccev.org Becker, Daniel (2003). Trauma & Adolescence I: The Nature & Scope of Trauma. The Group for the Advancement of Psychiatry. www.findarticles.com National Child Traumatic Stress Network, www.nctsn.org 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. Steele, W. (2002). Trauma’s Impact on Learning and Behavior: A Case for Interventions in the Schools. TLC Journal, 2. www.tlcinstitute.org For more resources, please see handout.