Trauma Informed Hands-On Tools: Building Youth s Core Competencies for a Healthy Future Presented by KVC KVC Health Systems, headquartered in the greater Kansas City area, is a private, nonprofit 501(c)3 organization committed to enriching and enhancing the lives of children and families by providing medical and behavioral healthcare, social services, and education. KVC touches the lives of tens of thousands of children and families each year. Its services include foster care, adoption, in-home family therapy and behavioral healthcare. In Kansas, KVC has 15 offices and two children s psychiatric hospitals. KVC Prairie Ridge Hospital and KVC Wheatland Hospital offer both inpatient and psychiatric residential treatment and use innovative, evidence-based treatment approaches to ensure each child s safety and wellbeing. KVC is accredited by The Joint Commission and endorsed by the Annie E. Casey Foundation. 4300 Brenner Dr. Kansas City, KS 66104 (913) 334-0294 205 E. 7 th St. Hays, KS 67601 (785) 624-6000 2 Our Goals 1. Enhance services for children exposed to trauma and maltreatment 2. Provide tools for employees to help respond to crisis and behavioral disruptions 3. Enhance cultural aspects of the environment to improve consumer and employee experience 1
Our Objectives 1. Enhance our understanding of the impact of trauma on child development, behavior and functioning 2. Learn principles and practical applications of Trauma Informed Care 3. Learn new practical Trauma Informed Care and Strengthening my Brain Tools Trauma Informed Services Trauma Sensitive Schools Trauma Informed Services Trauma Informed Community Trauma Focused Services What is Trauma? Trauma occurs when an individual experiences an event that results in a stress response the individual is unable to cope with or manage. 2
Traumatic Experiences Witnessing violence (community, domestic, at school, neighborhood, residential/foster homes) Death of a loved one Physical/sexual/emotional abuse Physical/emotional neglect Removal from the home Parent discord/separation/divorce Unstable home environments Lack of emotional nurturing Torture/rape/attempted murder/infanticide Exposure to drugs/alcohol in utero about two-thirds of children will experience a traumatic event before the age of 16 (NCTSN) Prevalence of Trauma A report of child abuse is made every 10 seconds (National Children s Alliance). As many as one in three girls and one in seven boys will be sexually abused at some point in their childhood (Stop It Now). Child sexual abuse happens in all racial, religious, ethnic and age groups, and at all socio-economic levels (Stop It Now). Nearly five children die every day in American from abuse and neglect. (National Children s Alliance) Types of Trauma Acute Chronic 3
Complex Trauma Dual problem of exposure and adaptation Traumatic (Toxic) Stress Traumatic (toxic) stress is the body s response to adverse and overwhelming experiences Traumatic stress impacts development of: Sensorimotor Physical Emotional Cognitive (learning) Neurological When bad things happen early in childhood, the brain and other parts of the body don t forget. (Shonkoff & Phillips, 2000) Balancing Stress Risk Factors Duration and intensity Developmental age Relationship to perpetrator Level of violence, unpredictability and risk of death Protective Factors Reliable supports/resources Coping strategies Hope Executive Functioning 4
Opening our Eyes about Youth Trauma significantly disrupts attachment, the understanding of healthy relationships and the ability to align with safe people Traumatized children are unlikely to understand how their current emotions, thoughts and behaviors are influenced by their trauma histories Trauma has a cumulative impact on development and functioning (Adapted from: Abramovitz & Bloom, 2003) Opening our Eyes about Ourselves Providers: May have little understanding of youths experiences and may minimize their trauma Overlook the impact of trauma and how adaptive behaviors are related to mental health symptoms Struggle when traditional treatments are ineffective due to trauma related barriers Lack the ability to maintain a strength based, recovery focused and person centered approach Don t understand their own trauma; the impact of secondary and vicarious trauma; and how one person s trauma can impact the whole system (Adapted from: Abramovitz & Bloom, 2003) 5
Adverse Childhood Experiences ACE s Questions: 1. Did a parent or adult in the household swear at you, put you down, or humiliate you? or Act in a way that made you afraid you might be physically hurt? 2. Did a parent or other adult in the household push, grab, slap, or throw something at you? Ever hit you so hard that you had marks or were injured? 3. Did an adult or person at least 5 years older ever touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you? (Felitti, et. al., 1998) Adverse Childhood Experiences 4. Did you often or very often feel that no one in your family loved you or thought you were important or special? or Your family didn t look out for each other, feel close to each other, or support each other? 5. Did you often or very often feel that You didn t have enough to eat, had to wear dirty clothes and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? 6. Was a biological parent ever lost to you through divorce, abandonment or other reason? (Felitti, et. al., 1998) Adverse Childhood Experiences 7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threated with a gun or knife? 8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? 9. Was a household member depressed or mentally ill, or did a household member attempt suicide? 10. Did a household member go to prison? (Felitti, et. al., 1998) 6
Adverse Childhood Experiences (Felitti, et. al., 1998) Adverse Childhood Experiences (Felitti, et. al., 1998) Adverse Childhood Experiences (Felitti, et. al., 1998) 7
Adverse Childhood Experiences (Felitti, et. al., 1998) 4+ Adverse Childhood Experiences 2x more likely to smoke 6x more likely to have had sex before the age of 15 7x more likely to be alcoholics 10x more likely to have injected street drugs 12x more likely to attempt suicide 2x more likely to have been diagnosed with cancer 2x more likely to have heart disease 4x more likely to suffer from emphysema or chronic bronchitis (Felitti, et al., 1998) Adverse Childhood Experiences (Felitti, et al., 1998) 8
Life Span Development Regulating Regions of the Brain Frontal/Pre-frontal Cortex Problem solving Learning Focusing Limbic System Hippocampus: Long term memory Amygdala: Emotions Brain Stem Biological response Instincts Survival Regulating Regions of the Brain Frontal Lobe Limbic System Brain Stem 9
Regulating Regions of the Brain Frontal Lobe Limbic System Brain Stem Regulating Regions of the Brain Relaxed Optimistic Comfort Frontal Lobe Limbic System Happiness Brain Stem Stress Fear Sadness Anger Regulating Regions in Context Service System Community School Family/Caregiver 10
Moments in Time Triggers Stimuli in the environment that causes a neurophysiological reaction Signals the brain a threat is present Can be from all the senses May be perceived as non-threatening by others Signals of Threat: Danger, Loss, Abandonment, Victimization, Lack of Nurturing, Vulnerability, Alienation, Rejection, Neglect, Lack of Control, Others Dysregulation The inability modulate: Emotions Thoughts Behaviors Irritability Frustration Anger Rage Dissociation Hyper-arousal Defiance Avoidance Shutting down Frozen Nervous Anxious Fearful Terrified Sad Depressed Hopeless Hyper-vigilance Intrusive thoughts Flashbacks Distorted thinking Arguing Threatening Aggression High risk behavior Self-harm Suicidal behavior 11
The Capacity to Cope Capacity to Cope Ability to withstand future stressors Current Stressor Level Ability to withstand future stressors Capacity to Cope Current Stressor Level Bringing it Together Trauma Exposure Trigger Dysregulation Disruption A New Landscape What s wrong with you? vs. What happened to you? (Abramovitz & Bloom, 2003) 12
A New Landscape Trauma Informed Framework Protect children Recognize impact of trauma Build capacity to cope Consumer input Empower children Trauma Informed Care Focus on relationships Build on strengths Focus on recovery Cultural competence Allow expression (adapted from Fallot & Harris, 2001) 13
Emotion Regulation Why Emotion Regulation? Interventions focusing on early brain development, the brainstem and selfregulation are required prior to treatment involving higher level brain functioning (Perry, 2009) Why Emotion Regulation? 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. 380-387. 14
Emotion Regulation Building Capacity Capacity to Cope Emotion Focused Problem Solving Safety Planning Emotion Regulation Building Capacity ER Capacity Building Emotion Focused Problem Solving Safety Planning Emotion Regulation Building Capacity Emotion Focused Problem Solving Safety Planning Parental Support Child s Capacity 15
Emotion Regulation Building Capacity ER Problem Solving Emotion Focused Problem Solving Safety Planning Emotion Regulation Building Capacity ER Problem Solving Emotion Focused Problem Solving Safety Planning Emotion Regulation Building Capacity ER Problem Solving Emotion Focused Problem Solving Safety Planning 16
Emotion Regulation Building Capacity ER Problem Solving Emotion Focused Problem Solving Safety Planning Emotion Regulation Building Capacity ER Problem Solving Emotion Focused Problem Solving Safety Planning Emotion Regulation Building Capacity ER Problem Solving Emotion Focused Problem Solving Safety Planning 17
Building Capacity Emotion Focused Problem Solving My family is disappointed with me When people yell at me Missing my family Shame,, Hopelessness, Worry Scared, angry Disappointed, shame Safety Planning Mom Sara Patrick 555-5555 555-5555 555-5555 Home Outside Brother s House Exercise Go for a walk Play catch Brain Education http://dev.thebrainarchitecturegame.com/media-resources/ 18
Science Aligned Practice We must accept that: As a community, we are allowing our children to be abused, neglected, mistreated and harmed. Thus it is our responsibility to protect traumatized children and provide opportunities for the development of emotional, cognitive and behavioral abilities; necessary to break the cycle of trauma. References Abramovitz, R., & Bloom, S. L., (2003). Creating sanctuary in residential treatment for youth: from the well ordered asylum to a living-learning environment. Psychiatric Quarterly, 74, 2 American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th Ed.). Washington, DC: Author. Barton, S., Gonzalez, R. & Tomlinson P. (2011). Therapuetic residential care for children and young people: An attachment and trauma-informed model. Philidephia, PA: Jessica Kingsley Publishing. Children s Alliance of Kansas (n.d.) Prevalence of trauma. Retrieved from http://www.childally.org. Cloitre, M., Stolbach, B.C., Herman, J.L., van der Kolk, B., Pynoos, R., Wang, L. & Petkova, E. (2009). A developmental approach to complex PTSD: childhood and adult cumulative trauma as predictors of symptom complexity. Journal of Traumatic Stress, 22(5), 399-408. Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., et al. (2005). Complex trauma in children and adolescents. Psychiatric Annals, 35, 390 398. Fallot, R. D., & Harris, M. (2001). Trauma Recovery and Empowerment Model Groups: A Report of Pilot Outcomes. Washington, DC: Community Connections. 19
References Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., Marks, J.S., (1998). The relationship of childhood abuse and household dysfunction and many leading causes of death in adults. American Journal of Preventative Medicine. 14(4). Pages 245-258. Golman, D. (2005). Emotional Intelligence. Bantam Dell, New York, NY. Ledoux, J. E., (1996). The Emotional Brain. Simon & Schuster. New York, New York. Maschi, T., & Bradley, C. (2008). Exploring the moderating influence of delinquent peers on the link between trauma, anger, and violence among male youth: implications for social work practice. Child and Adolescent Social Work Journal, 25, 125-138. The National Child Traumatic Stress Network. (n.d.). Facts and Figures. Retrieved from http://www.nctsn.org/resources/topics/facts-and-figures. Saxe, G., Ellis, H., & Kaplow,. (2009). Collaborative Treatment of Traumatized Children and Teens: A Trauma Systems Therapy Approach. Gulford Press. New York. Spinazzola, J., Ford, J., Zucker, M., van der Kolk, B., Silva, S., Smith, S., et al. (2005). National survey of complex trauma exposure, outcome and intervention for children and adolescents. Psychiatric Annals, 35, 433 439. Stop It Now (n.d.) Prevalence of trauma. Retrieved from http://www.stopitnow.org/prevalence References Perry, B.D., Pollard, R.A., Blakley, T.L., Baker, W.L. & Vigilante, D. (1995). Childhood Trauma, the Neurobiology of Adaptation, and Use-dependent Development of the Brain: How States become Traits. Infant Mental Health Journal, 16 (4), 272-291. Rivard, J.C., et. al.(2004). Implementing a trauma recovery framework for youth in residential treatment. Child and Adolescent Social Work Journal, 21 (5), 529-550. Shonkoff, Jack P. (Editor); Phillips, Deborah A. (Editor); Committee on Integrating the Science of Early Childhood Development. From Neurons to Neighborhoods : The Science of Early Childhood Development. Washington, DC, USA: National Academies Press, 2000. p 39. van der Kolk, B. (2003). The neurobiology of childhood trauma and abuse. Child Adolescent Psychiatric Clinics, 12. 20