Understanding Trauma from a Trauma Systems Therapy perspective. B. Heidi Ellis, Ph.D. Children s Hospital Boston

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1 Understanding Trauma from a Trauma Systems Therapy perspective B. Heidi Ellis, Ph.D. Children s Hospital Boston

2 The Basics

3 Denise

4 What do you do?

5 Bottom line

6 The Trauma System 1. A traumatized child who is unable to regulate emotional states, 2. A social-environment/system-of-care that cannot help contain this dysregulation.

7 Social-Ecological Model Culture Neighborhood Peer Group School Family Individual

8 Denise Why does she act and feel the way she does? What is at stake if we ignore her? What can we do to help?

9 Denise Why does she act and feel the way she does?

10 Traumatic Stress Survival in the moment

11 The Trauma System The amygdala leads a hostile takeover of consciousness by emotion (Joseph LeDoux)

12 Survival Circuits are adaptive

13 Survival Circuits are adaptive unless they are triggered in nonthreatening situations

14 Phases of Dysregulation Regulating Reving Reexperiencing Reconstituting Affect Awareness Action

15 The 3 A s of Emotional Regulation Affect Awareness Action

16 The 4 R s of Regulation Phases Regulating Reving Reexperiencing Reconstituting

17 Survival Circuits Amygdala Broca s area Rauch, S., Van der Kolk, B., Fisler, R., Alpert, N. (1996). A symptom provocation study of Posttraumatic Stress Disorder using positron emission tomography and script-driven imagery. Archives of General Psychiatry, 53(5) pp

18 Situations That Can Be Traumatic Physical or sexual abuse Abandonment, neglect, or betrayal of trust The death, loss or life-threatening illness of a loved one Witnessing domestic violence Automobile or other serious accidents Bullying Life-threatening health situations or medical procedures Witnessing or experiencing community violence (e.g., drive-by shooting, fight at school, robbery) Witnessing police activity or having a relative incarcerated Life-threatening natural disasters Acts or threats of terrorism

19 Denise What is at stake if we ignore her?

20 Understanding Child Trauma One out of every four children attending school has been exposed to a traumatic event that can affect learning and/or behavior. 1 Some of the most common types of trauma are physical abuse, sexual abuse, domestic violence, and community and school violence. By the age of % to 85% of youth have witnessed community violence 66% of youth have been victims of community violence 25% to 43% of youth have been exposed to sexual abuse Trauma can have long-term effects on school performance by 1 : Adversely affecting a child s attention, memory and cognition Reducing a child s ability to focus, organize and solve problems Decreasing reading ability and GPA Increasing rate of school absences Increasing suspensions, expulsions and drop-outs 1. National Child Traumatic Stress Network Schools Committee. (October 2008). Child Trauma Toolkit for Educators. From 2. American Psychological Association (2008). Child and Trauma Update for Mental Health Professionals. From

21 Adverse Childhood Experiences (ACE) Study Death Early Death Whole Life Perspective Disease, Disability, and Social Problems Adoption of Health-risk Behaviors Social, Emotional, & Cognitive Impairment Adverse Childhood Experiences Conception Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., and Marks, J.S. (1998, May). Adverse Childhood Experiences (ACE) Study. (1998). Retrieved from

22 Consequences of Traumatic Stress Social Drug abuse Anti-social behavior Isolation/withdrawal Psychological Posttraumatic Stress Disorder Reexperiencing, Avoidance, Hyperarousal Depression Conduct disorder Emotion Regulation Academic

23 What You Might Observe in Students Who Have Experienced Trauma Anxiety or fear about safety of self and others (more clingy with teachers or parents) Worry about recurrence of violence Increased distress (unusually whiny, irritable, moody) Changes in behavior: Increase in activity level Decreased attention and/or concentration Withdrawal from others or activities Angry outbursts and/or aggression Absenteeism Distrust of others, affecting how children interact with both adults and peers

24 What You Might Observe in Students Who Have Experienced Trauma (Cont.) A change in ability to interpret and respond to social cues Increased somatic complaints (e.g., headaches, stomachaches, overreaction to minor bumps and bruises) Changes in school performance Recreating the event (e.g., repeatedly talking about, playing out, or drawing the event) Over- or under-reaction to physical contact, doors slamming, sirens, lightning or sudden movements Statements and questions about death and dying Difficulty with authority, redirection, or criticism

25 Denise What can we do to help?

26 Trauma and the Social Environment

27 Playing Rats In Panksepp JP (1998): Affective Neuroscience: The Foundation of Human and Animal Emotions, Oxford, New York

28 Where is the cat hair? Amount of Play over 10 days A lot Amount of Play Some A little Cat hair introduced Cat hair removed None Day In Panksepp JP (1998): Affective Neuroscience: The Foundation of Human and Animal Emotions, Oxford, New York

29 Social-Ecological Model Culture Neighborhood Peer Group School Family Individual

30 Where is the cat? How much do you know about the location of the cat hair and the cat in the children you treat? How important is this knowledge for understanding the child s main emotional & behavioral problems? What tools do you use for locating the cat hair and the cat; and doing something about it?

31 What Regulates the Survival Circuit? Kirsch, P., Esslinger, C., Chen, O., Mier, D., Lis, S., Siddhanti, S., et al. (2005). Oxytocin modulates neural circuitry for social cognition and fear in humans. Journal of Neuroscience, 25,

32 A girl, a jump rope, and a ball

33 Why? He bumped me because [I was in his way, he wasn t looking, by accident] He bumped me because he hates me He bumped me because he hates me and he could really hurt me next time

34 Why is that the Why? Signals of Care Subtle interpersonal signals that people send each other, all the time, wittingly or unwittingly These signals can be signals of care or carelessness; signals of safety or danger; signals of love or hate We all have a balance of positive and negative signals in our lives. We base our expectations of the world largely on this balance

35 Lucy s Signals Father frequently drunk, enraged, and violent Mother scared and vulnerable, frequently blames Lucy for triggering father s violence by her cheekiness Teachers see Lucy as trouble-maker Lucy has learned that people generally are hostile, unhelpful to her, and more likely to hurt than help. Her world is saturated with Cat hair

36 Signals of Care: Changing the balance The remedy for Signals-of-Danger are Signals-of-Care These Signals-of-Care usually communicate warmth, empathy, and positive regard Our job is to help build a critical mass of signals-of-care across the system of care. We must help create a social environment filled with Signals-of-Care

37 Moment-by-Moment Assessment Regulating Reving Reexperiencing Reconstituting Description: Child is in calm, continuous emotional state and well engaged with his or her environment Description: Child has been triggered by a provocative stimuli and is engaging coping skills to manage emotion: Description: Child s coping skills have been overwhelmed. He or she has entered into a state of extreme emotion. Description: Child s state of emotion has diminished. Child is using existing coping skills to manage emotion and to reengage with the environment. Clinical Priority: How to minimize triggers to prevent Escalation. Clinical Priority: How to help child to regulate emotion once triggered. Clinical Priority: How to minimize containment interventions from being retraumatizing Clinical Priority: How to help the child continue to manage emotion and to reengage with the environment. Affect Awareness Action

38 Survival in the moment in action Part 1 Video Clip

39 Survival in the moment in action What just happened? What happened with Esmeralda? Was she being deliberately disobedient and disrespectful? What happened with Manuel?

40 Survival in the moment in action What just happened? What state is Esmeralda in now? How might she respond to consequences right now? How might she respond to efforts to reconnect? Did you see any signals of care?

41 Survival in the moment in action How did Esmeralda s history make her vulnerable to dysregulation when Manuel spoke with her? What was the cat hair for Esmeralda?

42 What Can Be Done at School to Help a Traumatized Child? 1. Maintain usual routines to send the message that the child is safe 2. Give children choices to provide a feeling of control 3. Increase support and encouragement for the traumatized child 4. Set clear limits and logical consequences for inappropriate behavior 5. Provide a safe place for the child to talk about what happened 6. Be sensitive to environmental cues that may cause a reaction in the traumatized child (e.g.,the anniversary of a traumatic event) 7. Warn children before doing something out of the ordinary, such as turning off lights or making a sudden loud noise

43 When Should a Referral Be Made for Additional Help for a Traumatized Child? Give referrals for additional help when reactions: Are severe (such as intense hopelessness or fear), or Go on for a long time (more than one month), and Interfere with a child s functioning Severity can be difficult to determine some children may become avoidant or appear to be fine (e.g., a child who performs well academically no matter what) You don t have to be certain before making a referral let a mental health professional evaluate the likelihood that the child could benefit from some type of intervention

44 NCTSN: Resources for School Personnel From NCTSN Resources for School Personnel website:

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