TRAUMA-INFORMED CARE IN SCHOOLS

Transcription

1 TRAUMA-INFORMED CARE IN SCHOOLS Colorado Association of School Nurses 2017 State Conference Marcela Torres, Ph.D. Institute of Behavioral Science University of Colorado, Boulder DISCLOSURE No conflicts of interest Neither I nor my immediate family members have any affiliations or financial interests in any of the corporate organizations involved with commercial products to which my presentation may refer or with any corporate organizations offering financial support for this CE activity. marcela.torres@colorado.edu 1

2 SESSION AIMS Identify signs of trauma in children and youth in a school environment Build knowledge of factors that contribute to resilience for students exposed to trauma or adversity Learn and practice specific strategies (practical applications) to your role as a school nurse Know about trauma treatment that is available in the community TRAUMA Trauma is the unique individual experience of an event or enduring conditions in which the individual's ability to integrate his/her emotional experience is overwhelmed and the individual experiences (either objectively or subjectively) a threat to his/her life, bodily integrity, or that of a caregiver or family member. (Saakvitne, K. et al, 2000). marcela.torres@colorado.edu 2

3 TOXIC STRESS Harvard Center on the Developing Child ( CHILDHOOD TRAUMA PREVALENCE Child abuse and trauma exposure is prevalent Approximately 70% youth in United States have experienced at least one potentially traumatic event by age 17. Higher exposure rates in child welfare (85%) and juvenile justice (90%) youth. Children are often multiply traumatized 38.7% experienced 2 or more direct victimizations 15% have experienced at least 6 different events Children often do not disclose these events Finkelhor et al., 2009, 2013; Costello, Erkanli, Fairbank, & Angold, 2008; Copeland, Keeler, Angold, & Costello, 2007; Finkelhor, Ormrod, & Turner, 2009; Kilpatrick et al., 1998; Kellogg, 2014; Saunders, 2012 marcela.torres@colorado.edu 3

4 IMPACT OF TRAUMA & TOXIC STRESS Child abuse and trauma is a risk factor for psychiatric and medical problems in childhood, adolescence, and adulthood: Psychiatric problems (e.g., depression, PTSD, substance use) Academic failure, social difficulties, delinquency, aggression, crime Physical illness (e.g., obesity, chronic lung disease, diabetes, cancer, poor self-rated health) Copeland et al., 2007; Felitti et al., 1998 ACES: ADVERSE CHILDHOOD EXPERIENCES STUDIES The ACE Studies consist of ongoing collaborative research between the Centers for Disease Control and Prevention in Atlanta, GA, and Kaiser Permanente in San Diego, CA. Original study (conducted in the mid-90s) included 17,000 adults receiving physical exams and completing ACEs surveys and surveys about current health status and behaviors. This group continues to be followed over time, including some of their children. marcela.torres@colorado.edu 4

5 ADVERSE CHILDHOOD EXPERIENCES 10 ITEMS Verbal abuse Physical abuse Sexual abuse Witness to domestic violence Emotional neglect Physical neglect Household member incarcerated Household member with significant mental illness Household member with substance abuse Parental separation or divorce 5

6 POST-TRAUMATIC STRESS Intrusion Intrusive thoughts/ images/ memories Distress to cues/ triggers Flashbacks/ reexperiencing Distressing dreams Re- enactment Avoidance Of memories, feelings, thoughts related to trauma Of people, places, objects, situations that remind students of the trauma Negative Cognitions & Mood Negative beliefs: self/ others Self blame, shame Negative emotional state Detachment Diminished activities interest Difficulty experiencing positive emotions Arousal & Reactivity Irritability Angry outbursts Reckless/ selfdestructive behavior Hypervigilance/ Startle Response Difficulty concentrating Sleep disturbance 6

7 THE BRAIN AND BODY ADAPT TO THE CHILD S ENVIRONMENT Growth/promotion orientation Trust THE WORLD IS A SAFE PLACE Cooperation Focused attention Self protection Long life expectancy vs. THE WORLD IS A DANGEROUS PLACE Survival orientation Distrust Manipulation Hypervigilance/distraction Risk taking Short life expectancy What outcomes do you expect when children perceive school or their environment as safe vs. dangerous? Slide courtesy of Colorado Office of Behavioral Health WHAT ARE TRIGGERS? A trigger is a reminder of past traumatizing events. Many things can be a possible trigger for someone. They can be EXTERNAL or INTERNAL Students responses to seemingly neutral events and interactions with people may reflect a trauma response. Students may have adopted long-term patterns that reflect their efforts to adapt to traumatizing life experiences. These behaviors and patterns reflect strategies that survivors have developed to keep themselves safe that is, they reflect strength and resiliency. Credit: National Center on Domestic Violence, Trauma and Mental Health marcela.torres@colorado.edu 7

8 WHAT MIGHT A TRAUMA RESPONSE LOOK LIKE AT SCHOOL? Increased anxiety Increased aggression Increased impulsivity Decreased sociability Reduced ability to regulate emotional states Problems with relationships Reckless or oppositional behaviors Difficulty concentrating THE GOOD NEWS Resilience is real! Resilience = a set of processes that enables good outcomes in spite of serious threats (Masten, 2001). Resilience includes the ability to persist or adapt to challenges and recover from adversity. marcela.torres@colorado.edu 8

9 RESILIENCE Resilience happens when a child s health and development are tilted in the positive direction, even when a heavy load of negative forces is stacked on the other side. -Harvard Center on the Developing Child VIDEO: THE SCIENCE OF RESILIENCE marcela.torres@colorado.edu 9

10 WHAT PROMOTES RESILIENCE? Decades of research have identified a common set of factors: Supportive adult-child relationships *** A sense of self-efficacy, perceived control, mastery Opportunities for building adaptive skills (e.g. SEL) and self-regulatory capacities Access to sources of faith, hope, and cultural traditions VIDEO: HOW RESILIENCE IS BUILT marcela.torres@colorado.edu 10

11 RESILIENCE AND SCHOOL MENTAL HEALTH Planning for school mental health should take into account avenues toward the promotion of healthy families, the enhancement of childhood resilience and protective factors, strategies to reduce systemic issues in schools that impact healthy development and learning, and the promotion of partnerships between the school and community that improve access to health and mental health services. p.16 (SAMHSA 2015; Center for Mental Health in Schools 2005) Promoting resilience is about creating a web of support around students by enabling as many positive points of contact in a student s day as possible. This work begins by developing a culture of care necessary for children's social and emotional competencies to develop. It provides tools to foster those social and emotional competencies in ourselves and the students we work with. It begins with us, the adults. marcela.torres@colorado.edu 11

12 A TRAUMA-SENISITIVE SCHOOL IS. a safe and respectful environment that enables students to build caring relationships with adults and peers, self-regulate their emotions and behaviors, and succeed academically, while supporting their physical health and well-being. (Lesley University and Massachusetts Advocates for Children, 2012) Trauma-Informed Care TRAUMA-INFORMED CARE IN SCHOOLS A purposeful, supportive approach to individuals exposed to trauma which can operate on many levels, system-wide Prioritizes physical and emotional safety, building trust and empowerment Includes, but not limited to: Successfully address the trauma-based needs of students Practices Trauma treatment Treatment specifically designed to treat trauma symptoms (e.g., Trauma Focused Cognitive Behavioral Therapy) Included in a trauma-informed approach when necessary Only a small portion of trauma informed care Credit: COACT Colorado marcela.torres@colorado.edu 12

13 PRACTIC AL APPLIC ATIONS Building social and emotional capacities and enhancing supportive adult-student relationships Trauma screening, assessment and psychoeducation IT BEGINS WITH US Let's Connect marcela.torres@colorado.edu 13

14 WHY THE FOCUS ON EMOTION? Emotions serve an important role When we are aware, they can serve as helpful guides to ensure that our needs are met. Research demonstrates that children who are aware of their emotions and can cope with emotions in healthy ways show better adjustment in: o o o o o Social skills with peers School and academic functioning Ability to navigate challenging situations Mental health functioning Family relationships THE ROLE OF ADULTS Adults are the most important teachers of emotion for children. Modeling is as important (if not more important) than direct instruction. marcela.torres@colorado.edu 14

15 NEUROSCIENCE OF EMOTIONS When we are experiencing intense emotions, the emotional centers of our brain are activated. These areas set our minds and bodies into motion quickly! This is true for both adults and children. Traumatized children experience this fight-flight-freeze reaction more often and are more easily triggered than others. NEUROSCIENCE OF EMOTIONS Labeling our emotions helps to shift brain activity from the Emotion Response Center (Amygdala) to the Reasoning Center of the brain (Prefrontal Cortex) I feel The Prefrontal Cortex helps us to slow down, think, plan and make decisions using information about the situation and our emotions. Based on findings from: Lieberman, Eisenberger, Crockett, Tom, Pfeifer, & Way (2007) marcela.torres@colorado.edu 15

16 HAND-TO-HEART BREATHING PRACTICE Place your hand on your heart Tune in and ask yourself, What feelings and body sensations are here? What is going on for me right now? Place your other hand on your belly Take a slow deep breath all the way into your belly. Follow your breath all the way in and all the way out, all the way in and all the way out, until you experience a calming sensation. Bring awareness back to the student Bring your awareness back to interacting with the student. Notice how you feel in the interaction. CHILDREN NEED OUR SUPPORT TO BUILD THEIR EMOTIONAL AWARENESS When both adults and children are aware of how they are feeling, it is easier to connect, support and problem-solve. I feel. It seems that you are feeling. marcela.torres@colorado.edu 16

17 Connection Skills Notice Listen Appreciate Label feelings Emotion Support Validate Empathize Normalize Be present Emotion Coaching Extending Children s Understanding of Emotion Coping Strategies Problem-Solving 2016 Let's Connect CONNECTION SKILLS Guiding Question: How do I let the student know that I SEE her, I HEAR her, that I want to learn about she FEELS? How do I keep the ball rolling? We can choose what we learn from students based on the questions we ask. marcela.torres@colorado.edu 17

18 CONNECTION SKILLS Notice and acknowledge what makes each student special and unique. Notice what excites them or stresses them out. Notice who they are. Thank students for sharing with you. Appreciate who they are. Use interested body language and a warm, inviting tone. Make eye contact. Nod to invite more sharing. Reflect, repeat and describe to keep conversation going. Summarize what you understood Let's Connect CONNECTION TRAPS o Skipping hand-to-heart tune-in o Distraction o Disengaged or closed body posture o Tone of voice o Too many questions o Impatience o Doubting or minimizing o Criticism or blame o Lecturing or making a point o Focusing on disruptive behavior 2016 Let's Connect marcela.torres@colorado.edu 18

19 EMOTION SUPPORT Guiding Question: How do I let the student know that I understand his perspective, his feelings/behaviors/reactions make sense? That other kids and people might feel the same way EMOTION SUPPORT Validate Empathize Express that feelings make sense Be present You aren t alone I understand why you feel that way Others (kids / families / people in your position) would feel the same way marcela.torres@colorado.edu 19

20 EMOTION SUPPORT TRAPS Trying to fix too soon Minimizing Silver linings It s not a big deal. You ll be okay. Don t be so upset. At least Judgmental questions or tone You were mad!!?? Doubt/Disbelief You really felt sad about that!? Invalidating Body language Rolling eyes, shaking head, arms crossed Hanging out to dry Criticism/blame No response to a child sharing important feelings Maybe if you hadn t, you wouldn t feel so sad EMOTION COACHING Guiding Question: How do I convey that ALL feelings are okay; Help the student use coping strategies or to respond with different behaviors next time? marcela.torres@colorado.edu 20

21 EMOTION COACHING Extending Students Understanding of Emotion Coping Strategies Problem-Solving Danielle Mahoney, a literacy coach, leads a mindfulness session at a public school in Jackson Heights, N.Y. PHOTO: KEITH BEDFORD FOR THE WALL STREET JOURNAL EMOTION COACHING Help students understand the causes of their feelings What made you feel this way? I wonder if you felt that way because. Help students identify mixed or complex emotions What else do you feel in this situation? Sometimes anger goes along with hurt or sad Help the student understand that feelings have a purpose Let them know all feelings are important. marcela.torres@colorado.edu 21

22 A REMINDER The single most effective protective factor is the consistent presence of one or more caring adults, therefore parents and other close caregivers ultimately hold the greatest power in their hands. As a provider who cares for families, you can remind parents of this powerful ability to buffer trauma s negative effects and to help them leverage it. (Sesame Street Caring in Communities, 2017) RESOURCES FOR FAMILIES marcela.torres@colorado.edu 22

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25 SCREENING FOR TRAUMA Why screen for trauma? Trauma exposure is very prevalent Children often don t disclose on their own Many kids and families want to address trauma but don t know how to bring it up AREAS OF ASSESSMENT Trauma History Trauma exposure screen Mental Health Symptoms and Behavior Problems Post-traumatic stress Other mental health or behavioral symptoms Environment Safety, support, parent-child relationship System involvement and support for family Characteristics of Trauma Frequency, chronicity, interpersonal, disclosure and response marcela.torres@colorado.edu 25

26 Trauma Exposure Screen Lang & Connell, 2016 Behaviorally-specific items assessing lifetime experience of traumatic events (1 in 4 children are likely to endorse at least one event) Trauma Symptom Assessments Trauma-related thoughts, feelings, and behaviors from the past TWO weeks. marcela.torres@colorado.edu 26

27 Behaviorally-specific items assessing lifetime experience of traumatic events (1 in 4 children are likely to have experienced at least one event). Also a caregiver report version for ages 6+ Trauma-related thoughts, feelings, and behaviors from the past 30 days. Also a caregiver report version for ages 6+ marcela.torres@colorado.edu 27

28 OTHER SCREENING TOOLS General Mental Health Assessment E.g. Strengths and Difficulties Questionnaire Emotional symptoms Conduct problems Hyperactivity/inattention Peer relationship problems Prosocial behavior WHAT CAN YOU DO? Keep the signs of trauma in mind. ALL school personnel can be involved in identifying students in need of support. For identified kids: Maintain normal routines Increase support / encouragement Create a safe place to talk Kid-sized information Pay attention to environmentalcues Breaks Extra time Engage families marcela.torres@colorado.edu 28

29 DEFINITION OF EVIDENCE-B ASED PRACTICES An evidence-based practice is a treatment or intervention with a combination of the following three factors: (1) best research evidence (2) best clinical outcomes (3) consistent with client/family values (Institute of Medicine, 2001; CEBC, 2015) OVER 25 YEARS OF CLINICAL RESEARCH EVIDENCE B ASED INTERVENTIONS: DEVELOPED, TESTED, AND READY FOR IMPLEMENTATION Examples of Trauma-Focused Interventions for Children, Youth and Families: Trauma-Focused Cognitive-Behavioral Therapy TF-CBT Alternatives for Families Cognitive Behavioral Therapy AF- CBT Eye Movement Desensitization Reprocessing - EMDR Child-Parent Psychotherapy CPP Dialectic Behavior Therapy - DBT Multisystemic Therapy - MST marcela.torres@colorado.edu 29

30 TRAUMA-FOCUSED COGNITIVE BEHAVIORAL THERAPY WHAT IS TF-CBT? Components-based treatment protocol Goal is to empower children and families to recover Caregivers are an integral part of treatment Time limited, structured (12-20 sessions) Therapist is directive and active! Treatment settings: clinic, school, residential, home, inpatient 30

31 WHO IS TF-CBT FOR? Children 3-18 years with known trauma history Any type of trauma type single, multiple, complex (abuse, DV, traumatic grief, disaster, accidents, etc.) Prominent trauma symptoms (PTSD, depression, anxiety, with or without behavioral problems) Parent/caregiver involvement is optimal, but not required (non-offending caregiver) WHY TF-CBT? Most rigorously tested treatment for traumatized children (over 20 RCTs!) TF-CBT greater improvement in PTSD, depression, anxiety, behavior problems compared to comparison or control conditions TF-CBT works for complex trauma A good fit for diverse cultural groups marcela.torres@colorado.edu 31

32 TF-CBT: A PPRACTICE Assessment and case conceptualization Psychoeducation Parenting skills Relaxation Affective modulation Cognitive coping Trauma narrative and processing In vivo mastery of trauma reminders Conjoint child-parent sessions Enhancing future safety and development PSYCHOEDUCATION Educate about trauma reminders and common reactions to traumatic experiences Provide information about PTSD or other child problems. Normalize the child s and parent s reactions. Provide hope for recovery. Cohen, 2014 marcela.torres@colorado.edu 32

33 PARENTING COMPONENT Parents receive individual sessions for all PRACTICE components. Parenting skills to enhance child-parent interactions including: Praise, effective attention, warmth, behavior management Help parent connect the child s emotional and behavioral problems to trauma experiences Cohen, 2014 RELAXATION SKILLS Reverse physiological arousal effects of trauma through: Focused breathing, mindfulness Progressive muscle relaxation Exercise Yoga Meditation Songs, dance, blowing bubbles, reading, prayer, other relaxing activities Use relaxation strategies when trauma reminders occur Cohen, 2014 marcela.torres@colorado.edu 33

34 AFFECTIVE MODULATION SKILLS Identify and modulate upsetting affective states including: Body and emotion awareness Emotion regulation Positive distraction activities Developing skills to lessen the intensity of trauma reminders Cohen, 2014 COGNITIVE COPING Recognize connections among thoughts, feelings and behaviors Thought Replace thoughts with more accurate/ more helpful ones Behavior Feeling Child s cognitive processing of personal trauma experiences typically occurs during the next phase (the trauma narrative phase) Cohen, 2014 marcela.torres@colorado.edu 34

35 TRAUMA NARRATIVE AND PROCESSING Gradually develop a detailed narrative of child s personal trauma experiences. Process using cognitive strategies learned earlier (changing inaccurate/unhelpful thoughts about the trauma) Meaning-making, finding themes of resilience and healing Cohen, 2014 IN VIVO MASTERY OF TRAUMA REMINDERS For increasing sense of mastery over fears / trauma triggers (e.g., school, bathroom) and reducing avoidance Develop fear hierarchy, gradually master increasingly feared stimuli Cohen, 2014 marcela.torres@colorado.edu 35

36 CONJOINT PARENT-CHILD SESSIONS Child shares narrative directly with a supportive caregiver Enhance child-parent traumarelated and general communication Cohen, 2014 ENHANCING SAFETY AND FUTURE DEVELOPMENT Safety plans for specific, needed situations Social skills, problem solving, risk reduction Additional skills as individual child/family need Cohen, 2014 marcela.torres@colorado.edu 36

37 COLORADO EVIDENCE-BASED PRACTICES TRAINING INITIATIVE 1,100+ mental health clinicians trained in TF-CBT by our team across Colorado and nationwide THANK YOU! Contact Information: Center for the Study and Prevention of Violence CU Boulder Institute of Behavioral Science 37