RESPONDING TO THE IMPACT OF EARLY CHILDHOOD TRAUMA THROUGH TRAUMA-INFORMED CARE

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1 RESPONDING TO THE IMPACT OF EARLY CHILDHOOD TRAUMA THROUGH TRAUMA-INFORMED CARE J A N E E C E W A R F I E L D P S Y. D. G O K C E D U R M U S O G L U, P H. D. W R I G H T S T A T E U N I V E R S I T Y S C H O O L O F P R O F E S S I O N A L P S Y C H O L O G Y J O H N K I N S E L, M S, L P C C - S K I N S E L C O N S U L T I N G

2 What happens during the first months and years of life matters a lot; not because this period of life provides an indelible blueprint for adult wellbeing, but because it sets either a sturdy or fragile foundation for what follows. National Research Council and Institute of Medicine (2000) Torres, 2014 YCS Institute for Infant and Preschool Mental Health

3 NATIONAL SURVEY OF CHILDREN EXPOSED TO VIOLENCE 6 out of every 10 children are exposed to violence Almost 1 in 2 children are assaulted (46%) 1 in every 10 children see one person in their family assault another 1 in every 16 children are sexually abused 1 in every 10 kids are maltreated (physically, sexually, emotionally, neglected, and family abducted) Van Tassell, 2012

4 DEFINITION OF TRAUMA A trauma is any injury, whether physically or emotionally inflicted, that occurs as a result of a traumatic event.

5 TRAUMAS THAT IMPACT CHILDREN Accidents Child abuse and neglect Violence Sexual abuse and rape School shootings Parent/caregiver/sibling death Murder Animal attacks Medical illness Natural disasters Terrorism and other manmade disasters Economic constraints War Gurwitch, 2010

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7 TRAUMA AND THE DEVELOPING BRAIN Prefrontal Cortex Midbrain Brain Stem

8 DOMAINS OF IMPAIRMENT DUE TO CHRONIC TRAUMA Biology Attachment Affect Regulation Dissociation Behavioral Control Cognition Self-Concept -National Traumatic Stress Network, Complex Trauma Taskforce 2003 Cook, Blaustein, Spinazzola, & van der Kolk, 2003)

9 DIAGNOSTIC CONSIDERATIONS PTSD AND DSM-5/ICD-10 Separate criteria for children 6 years and younger: (F43.10) A.Exposure to actual or threatened death, serious injury, or sexual violence B.Presence of intrusion symptoms associated with the traumatic event, beginning after the traumatic events occurred C.Persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s) must be present, beginning after the event(s) or worsening after the event(s) D.Alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred E.Duration of the disturbance is more than 1 month F. Disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behavior G.The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition

10 DIAGNOSTIC CONSIDERATIONS REACTIVE ATTACHMENT DISORDER AND DSM-5/ICD (F94.1) A.A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers B.Persistent social and emotional disturbance C.The child had experienced a pattern of extremes of insufficient care D.The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A E.The criteria are not met for ASD F. The disturbance is evident before age 5 years G.The child has a developmental age of at least 9 months Specify if: Persistent: present more than 12 months Specify current severity

11 CONSEQUENCES OF TRAUMA Disturbed Social Relationships Developmental Delays Behavioral Issues Dissociation Increased risk for psychological, medical and economic distress

12 CONSEQUENCES OF TRAUMA

13 CONSEQUENCES OF TRAUMA

14 SYMPTOM EXPRESSION CAN VARY Depend on: Child s developmental level Sources of support Temperament, coping resources Frequency, intensity, duration of traumatic events Relationship to perpetrator, if applicable Current cultural context

15 CULTURE AND COMPLEX Cumulative adversities faced by many persons, communities, ethnocultural, religious, political, and sexual minority groups can also constitute forms of complex trauma (Curtois, 2004). TRAUMA These adversities can include but are not limited to: Poverty and ongoing economic challenge Community violence and the inability to escape/relocate Disenfranchised ethnoracial, religious, and/or sexual minority status and discrimination Displacement, refugee status, and relocation

16 TRAUMA-INFORMED CARE Context in which trauma is addressed or treatments deployed contributes to the outcomes for the trauma survivors, the people receiving services, and the individuals staffing the systems Trauma-informed care/approach is different than trauma-specific services Trauma-informed care is inclusive of trauma-specific interventions, assessment or recovery, but also incorporates key trauma principles into the organizational culture SAMHSA (2014)

17 KEY ASSUMPTIONS IN TRAUMA- INFORMED CARE 1. Realization: all people at all levels of the organization have realization about trauma and understand how trauma can affect individuals 2. Recognition: all people in the system are able to recognize signs of trauma 3. Responding: The organization or system responds by applying principles of a trauma-informed approach to all areas of functioning 4. Resist to re-traumatization: preventing retraumatization of clients and staff SAMHSA (2014)

18 KEY PRINCIPLES OF TRAUMA-INFORMED CARE 1. Safety 2. Trustworthiness and transparency 3. Peer support 4. Collaboration and mutuality 5. Empowerment, voice and choice 6. Cultural, historical and gender issues SAMHSA (2014)

19 GUIDANCE FOR IMPLEMENTING TRAUMA- INFORMED CARE 1. Governance and leadership 2. Policy 3. Physical environment 4. Engagement and involvement 5. Cross sector collaboration 6. Screening, assessment ant treatment services 7. Training and workforce development 8. Progress monitoring and quality insurance 9. Financing 10.Evaluation

20 KEY STEPS FOR CONDUCTING ASSESSMENT OF TRAUMA IN YOUNG CHILDREN 1. Assess for a wide range of traumatic events 2. Assess for a wide range of symptoms, risk behaviors, functional impairments and developmental derailments 3. Gather information using variety of techniques 4. Gather information from a variety of sources 5. Try to make sense of how each traumatic event might have impacted developmental tasks and delayed future development 6. Try to link traumatic events to trauma reminders that may trigger symptoms 7. Assess children over time

21 DOMAINS TO ASSESS Attachment and relationships Physical health Emotional responses Thinking and learning Behavior Dissociation Trauma history/exposure Trauma reminder and triggers PTSD symptoms Family environment Caregiver functioning and response to trauma Strengths, talents, abilities Sources of emotional support Capacity for resilience Cultural/Diversity variables Cook et al (2005)

22 MEASURES TO ASSESS TRAUMA IN YOUNG CHILDREN Trauma Symptom Checklist for Young Children (TSCYC) Behavior Assessment System for Children-2 (BASC-2) Behavior Rating Inventory of Executive Function (BRIEF) Personality Inventory for Children-2 (PIC-2) Child Behavior Checklist (CBCL) Child Sexual Behavior Inventory (CSBI) Traumatic Events Screening Inventory-Parent Report Revised (TESI-CRF-R) Family Environment Scale (FES) Parenting Stress Index (PSI) Violence Exposure Scale for Children-Preschool Version (VEX-RPR) Posttraumatic Symptom Inventory for Children (PT-SIC)

23 Child Measures Child PTSD Reaction Index*(CPTS-RI) Child PTSD Symptom Scale (CPSS) LIST OF PTSD MEASURES: CHILD/ADOLESCENT Target Age Group Format # of items Time to Admin. (min.) 6-17 Interview Self-Report Childhood PTSD Interview n.s. Interview 93/ Children's Impact of Traumatic Events Scale-Revised (CITES-2) 6-18 Interview Children's Posttraumatic Stress Disorder Inventory (CPTSDI) Clinician-Administered PTSD Scale for Children & Adolescents (CAPS-CA) CPTS-RI Revision 2 (aka PTSD Index for DSM-IV) 7-18 Interview 43/ Interview 33/ Interview

24 LIST OF PTSD MEASURES: CHILD/ADOLESCENT CONTINUED Child Measures Target Age Group Format # of items Time to Admin. (min.) My Worst Experiences Survey 9-18 Self-Report Parent Report of Child's Reaction to Stress Trauma Symptom Checklist for Children (TSCC) n.s. Parent Report Interview 54/ Trauma Symptom Checklist for Young Children (TSCYC) 3-12 Caregiverreport 54/ Traumatic Events Screening Inventory*(TESI) UCLA PTSD Index for DSM-IV When Bad Things Happen Scale (WBTH) 4 and up Interview 18/varies child, 13+ adol Self-Report Self-Report 95/

25 MOST TRAUMA-FOCUSED TREATMENTS AGREE IN THESE CORE CONCEPTS BUT DIFFER IN DELIVERY (NCTSN) Screening and triage Systematic assessment, case conceptualization, and treatment planning Psycho-education Addressing children and families' traumatic stress reactions and experiences Trauma narration/organization Enhancing emotional regulation and anxiety management skills Facilitating adaptive coping and maintaining adaptive routines Parenting skills and behavior management Promoting adaptive developmental progression Addressing grief and loss Promoting safety skills Relapse prevention Evaluation of treatment response and effectiveness Engagement/addressing barriers to service-seeking

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27 PLAY-BASED TECHNIQUES TO ADDRESS TRAUMA Creating safe place Feeling map Expressive therapies(play, art, and sand therapy) CBT interventions Trauma-Focused Play Therapy (TF-PT)

28 AROUSAL REDUCTION AND AFFECT REGULATION Feeling Identification: -Charades -Playing Concentration, or Go Fish - Bingo or *Tic-Tac-Toe -Making collages or a dictionary -*Feeling without words -Drawing the anger/pain -Boat in a storm Coping/Impulse control/: -Deep breathing -Progressive Muscle Relaxation -Shield of Faith -Games which involve either release or impulse control: -Simon Says -Red Light Green Light -Little Sally Walker

29 FEELING DICTIONARY HAPPY DISAPPOINTED ANGRY WORRIED

30 YOGA PRETZELS (GUBER,KALISH, & FATUS)

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32 RELATIONSHIP-BASED INTERVENTIONS

33 ATTACHMENT Child Parent Psychotherapy Theraplay activities Filial Therapy Story telling: mutual story telling technique, bibliotherapy, narrative, and social stories Sandtray Build a world

34 SAMPLE SOCIAL STORY I get angry when I am told no at school. When I get angry I feel like a volcano ready to explode. It is okay to feel angry. But it is not okay to hit or kick things when I am told no. Hitting or kicking things can hurt people or get me in trouble. When I get angry because I am told no, I can use my cool down techniques: I can get a drink of cold water. I can ask When might I be able to do something? If I feel like hitting I can beat a drum. I will try to not act out my anger when I m told no and use my cool down techniques. My teachers and classmates like it when I remember not to act out my anger.

35 VISUAL EXAMPLE OF THE SOCIAL STORY I get angry when I am told no at school. When I get angry I feel like a volcano ready to explode It is okay to feel angry. But it is not okay to hit or kick things when I am told no.

36 WHAT ALL CHILDREN NEED:5 R S Relationships that are safe, secure, and loving these help the child feel cared for and worthy of love. Responsive interactions that allow the child to initiate a sound, a task, a game and get a positive response from an adult. These help children learn that what they do has an impact on the world around them. Respect for the child, and for the child s family and culture. Treating the child as an individual with rights and feelings goes a long way toward establishing feelings of self-esteem. Routines provide comfort for the child, allowing him to predict what will come next during the day. They also encourage memory and the development of early organizational skills. Repetition of activities actually strengthens the connections between brain cells. While adults usually tire of repetition, children are drawn to repeat activities and tasks over and over again in an attempt to master them. Source: Adapted from Seibel, Britt, Gillespie, and Parlakian (2006). Torres, 2014 YCS Institute for Infant and Preschool Mental Health

37 INTEGRATION OF TRAUMA INFORMED CARE What will you do differently?

38 QUESTIONS

39 RESOURCES Cohen, J.A., Mannarino, A.P., & Deblinger, E. (2012). Trauma-focused CBT for children and adolescents: Treatment approaches New York, NY: The Guilford Press. Gil, E., (2011). Extended play-based developmental assessment. Royal Oak, MI: Self Esteem Shop. Goodyear-Brown, P. (2010). Play therapy with traumatized children: A prescriptive approach. Hoboken, NJ: John Wiley & Sons. Hall, T.M., Schaefer, C.E., Kaduson H.G.( 2002). FIfteen effective play therapy techniques. Professional Psychology Research & Press. 33, t, pp Homeyer. L.E., & Sweeney, D. (2011). Sand tray therapy: A practical manual. New York: NY: Routledge. James, B., (1994). Handbook for treatment of attachment trauma problems in children NY: Lexington Books. Jernberg, A., & Booth, P (2001)/ Theraplay. San Francisco, CA: Jpssey-Bass Publications. Kaduson, Heidi Gerard & Schaefer (Eds.) (2004) 101 Favorite Play Therapy Techniques. Lanham, MD, Rowman & Littlefield Publishers, Inc.

40 RESOURCES Lowenstein, L.E.(2011). Favorite therapeutic activities for children adolescents,& families: Practitioners share their most effective interventions.- free e-book: Malchiodi, C.A. (2008) (Ed.). Creative interventions with traumatized children. New York, NY: The Guilford Press. National Child Traumatic Stress Network. (2011). Retrieved from Ohio CanDo4kids-has a variety of test resources: Poolle, N. (3023) Trauma-informed practice. Pacific Aids Network. Shelby, J.S.,& Felix, E.D> (2005). Posttraumatic play therapy. The need for an integrated model of directive and nondirective approaches. In L. Reddy, T.M., Files-Hall & C.E. Schaefer (Eds.). Empirically based play intervention for children ( pp Washington DC: American Psychological Association.. Steele, W., & Malchiodi, C.A. (2012). Trauma-informed practices with children and adolescents: TF-CBT online training through Medical University of South Carolina (MUSC)- http//tfcbt.musc.edu