Trauma Informed Care, Part 1: Trauma and the Adolescent

1. Trauma Informed Care, Part 1:Trauma and the Adolescent The National Council for Behavioral Health May 12, 2015

2. Karen Johnson, LCSW Director of Trauma-Informed Services National Council for Behavioral Health 19 years working in child welfare and community-based mental health Certified in the ChildTrauma Academy’s Neurosequential Model of Therapeutics Parent of an adult child with severe and chronic mental illness

3. The National Council 8 2147 Behavioral Health Organizations 750,000 staff serving 8 million adults, children, and familieswith mental illnessand substance use disorders…

4. Overview • What is trauma? • Understanding ACES • Neuro/Bio/Psycho/Social impact of trauma • Trauma-informed care

5. Paradigm Shift We begin to ask, “What happened to you?” rather than “What is wrong with you?” We have to ask, “What’s strong?” rather than “What’s wrong?”

6. Understanding Trauma Trauma is • Pervasive • Impactful • Life shaping • Self-perpetuating

7. What is Trauma? Definition (SAMHSA Experts 2012) includes three key elements event experienced effects Individual trauma results from an , series of events, or set of circumstances that is by an individual as overwhelming or life-changing and that has profound on the individual’s psychological development or well-being, often involving a physiological, social, and/or spiritual impact.

8. Types of Trauma • Child maltreatment and complex trauma • Serious accident or illness • Victim/witness to domestic, community and school violence • Natural disaster, war, terrorism, political violence • Traumatic grief/separation, significant loss • Historical and generational trauma

9. What Does Trauma Do?Shapes our Beliefs Spirituality Worldview Identity

10. What Does Trauma Do? Symptoms are adaptations • Drinking = self medication • Cutting = release of pressure • Isolating = avoidance of fear • Aggression = protecting oneself

11. Results in Vicious Loop

12. Prevalence • In the general population, 61% of men and 51% of women reported exposure to at least one lifetime traumatic event, but majority reporting more than one traumatic event (Kessler, et al, 1995) • 2012 numbers show that 59% of the general population has experience adverse childhood events

13. Prevalence of Trauma in Students 13 of every 30 students in a classroom will have toxic stress from 3 or more Adverse Childhood Experiences (ACEs) Source: Washington State Family Policy Council

14. What Does The Prevalence Data Tell Us? The majority of adults and children in psychiatric treatment settings have trauma histories A sizable percentage of people with substance use disorders have traumatic stress symptoms that interfere with achieving or maintaining sobriety A sizable percentage of adults and children in the prison or juvenile justice system have trauma histories (Hodas, 2004, Cusack et al., Mueser et al., 1998, Lipschitz et al., 1999, NASMHPD, 1998)

15. Polling Question Adverse Childhood Experiences Study How much training have you had on the ACE Study? None Some I know this work quite well

16. Therefore, we need to exercise…

17. Adverse Childhood Experiences (ACE) Study • Center for Disease Control and Kaiser Permanente (an HMO) Collaboration • Over a ten year study involving 17,000 people • Looked at effects of adverse childhood experiences (trauma)over the lifespan • Largest study ever done on this subject

18. Adverse Childhood Experiences • Child physical abuse • Child sexual abuse • Child emotional abuse • Physical Neglect • Emotional Neglect • Mentally ill, depressed or suicidal person in the home • Drug addicted or alcoholic family member • Witnessing domestic violence against the mother • Loss of a parent to death or abandonment, including abandonment by divorce • Incarceration of any family member

19. Dose-Response Relationship: More ACEs = More Disease Response gets bigger Dose gets bigger

20. Higher ACE Score Increases Smoking 6 of 100 people with 0 ACEs smoke 11 of 100 people with 3 ACEs smoke 17 of 100 people with 7 ACEs smoke

21. ACE Score Increases Suicide Attempt 1 of 100 people with 0 ACEs attempt suicide 10 of 100 people with 3 ACEs attempt suicide 20 of 100 people with 7 ACEs attempt suicide

22. Childhood Experiences and Adult Alcoholism 4+ 3 2 1 0

23. Life-Long Physical, Mental & Behavioral Health Outcomes Linked to ACEs • Alcohol, tobacco & other drug addiction • Auto-immune disease • Chronic obstructive pulmonary disease & ischemic heart disease • Depression, anxiety & other mental illness • Diabetes • Multiple divorces • Fetal death • High risk sexual activity, STDs & unintended pregnancy • Intimate partner violence—perpetration & victimization • Liver disease • Lung cancer • Obesity • Self-regulation & anger management problems • Skeletal fractures • Suicide attempts • Work problems—including absenteeism, productivity & on-the-job injury

24. Impact of Trauma Over the Lifespan Are neurological, biological, psychological and social in nature. They include: • Changes in brain neurobiology; • Social, emotional & cognitive impairment; • Adoption of health risk behaviors as coping mechanisms (eating disorders, smoking, substance abuse, self harm, sexual promiscuity, violence); and • Severe and persistent behavioral health, health and social problems, early death. (Felitti et al, 1998)

25. Adverse Childhood Experiences The #1 Chronic Health Epidemic in the United States “The impact of ACEs can now only be ignored as a matter of conscious choice.  With this information comes the responsibility to use it” (Anda and Brown, CDC) ACE Study DVD from Academy on Violence and Abuse

26. Neuro/Bio/Psycho/Social Impact of Trauma

27. The Amazing Brain

28. Neuroscience & Trauma • Prior to 1980’s – little attention paid to the impact of trauma on the brain • 1980 – PTSD first introduced • 1990s – the Decade of the Brain • April 2014 – $100,000 million BRAIN • Study of the teenage brain has been neglected until past decade

29. Brain Development Cognition (Abstract & Reflective) Cognition (Concrete) Affiliation Attachment Reward Sexual Behavior Emotional Reactivity Motor Regulation Arousal Appetite/Satiety Sleep Blood Pressure Heart Rate Body Temperature

30. Plasticity of the Human Brain Complexity Plasticity

31. Myths about the Teenage Brain • Brain growth is complete by kindergarten • Teens are impulsive and emotional because of surging hormones • Teens are rebellious and oppositional because they want to be difficult and different • Teen brains are the same as adult brains

32. Adolescent Brain is a Work in Progress • Functioning, wiring and capacity are all different in adolescents than in the adult brain • Teens don’t have the same tolerance for stress • New connections between brain areas are being built • Teenage brain has lot of gray matter and less white matter • Connectivity to and from the frontal lobes is the most complex and is the last to fully mature Jensen, F. E. & Nutt, A. E. (2015). The teenage brain: a neuroscientist’s survival guide to raising adolescents and young adults.

33. Adolescent Brain • Flexibility, growth, and exuberance of the teenage brain allow for tremendous learning • “Open” and excitable brain also can be adversely affected by stress, drugs, chemical substances, and any number of changes in the environment • Influences can result in problems that are dramatically more serious for teens than adults • Dopamine, or reward neurotransmitter, is increased during adolescence

34. Survival Mode Response • Inability to • Respond • Learn • Process

35. At Risk Youth • Brain is impacted by trauma insults • Mistrustful of adults or most relationships • Often cannot access post high school education, which can serve as buffer to taking on adult tasks • Defined as an adult at 18 when the average age of financial independence is 26 • Ill equipped to navigate complex transition to adulthood

36. What to do? • Encourage positive social connections • Intervene early to address alcohol and drug abuse • Ask the question: What happened to you? • Focus on what’s strong in you • Promote resilience

37. Ability to adapt well to stress, adversity, trauma or tragedy

38. Promoting Resilience Involves Teaching

39. Working with Youth Involves

40. Trauma-Informed Approaches Systems of care need to be trauma-informed. This includes all systems and organizations, their work force, regulatory bodies and funders.

41. Principles of a Trauma-Informed Approach (Fallot 2008, SAMHSA, 2012)

42. Safety Physical Psychological Social Moral If you have never felt safe or remembered safety, how will you know it when it is present?

43. Trustworthiness and Transparency

44. Collaboration and Mutuality

45. Empowerment

46. Voice and Choice

47. Trauma Informed Services “Takes into account an understanding of trauma in all aspects of service delivery and places priority on the person’s safety, choice and control” Harris and Fallot 47

48. We all matter! Every contact with a client and with each other will affect us in one of two ways: 1. Contribute to a safe and trusting healing environment OR 2. Detract from a safe and trusting environment We all play a role in assisting our clients to make progress in their lives We all matter when it comes to creating a safe, trusting and healing environment

49. The stresses of our own work and lives make trauma a personal concern None of us are immune to traumatic experiences in our own lives. All of us work in human services where people are struggling with many challenges that are often overwhelming. It’s important to be aware of how these experiences may challenge our own emotional resources.

50. “Ultimately, what determines how children survive trauma, physically, emotionally or psychologically, is whether the people around them – particularly the adults they should be able to trust and rely upon, stand by them with love, support and encouragement. “ Dr. Bruce Perry, “The Boy Who Was Raised as a Dog” The same applies to adults!