Screening & Assessment of Trauma for IEP's

1. Screening & Assessment of Trauma for IEP's Chris Dunning, Ph.D. Professor Emerita University of Wisconsin-Milwaukee cdunning@uwm.edu

2. Workshop Objectives • Increase ability to identify effects of child traumatic experience presenting at school • Connect trauma-based barriers to learning to student performance • Improve ability to use screening and assessment tools to inform consultation with teaching staff • Develop strategies to include trauma assessment in the development of IEPs.

3. Why are we doing this? Trauma & Academics • Impact of trauma on school readiness • Impact of trauma on school performance • Impact of trauma on cognitive functioning that may result in behavioral difficulties • Increased likelihood of dropping out of school

4. What affects learning associated with traumatic experience?

5. Academic tasks that are difficult when experiencing trauma related conditions Processing Oral Information (When experiencing stress reaction) Sitting Still Concentrating Talking (When experiencing stress reaction) Controlling Impulses and Behavior Organizing Setting Priorities Making Decisions Memory Remembering Contextualizing (associating concepts appropriately)

6. Nickerson, Amanda, Stephen Brock, et al (eds.) (2008) Identifying, Assessing, and Treating PTSD at School Springer Pub. Reference

7. What needs to be Assessed? Not PTSD!Acute and Chronic Traumatic Stress • Traumatic Experience • Objective & subjective features • Appraisal/Response to Threat • Scope of danger • Reaction & regulation • Protective responses • Positive/negative adjustment • Proximal & Distal Reminders • Internal & external cues • Proximal & Distal Secondary Stress • Family functioning, social support, service system demands • Acute Reactions • Symptoms, developmental failure, learning impairments

8. Intrinsic Factors • Genetics, anxiety sensitivity, developmental status, trauma history • Social Ecology • Parent/Family functioning & psychopathology, school, peers • Proximal & Distal Development & Psychopathology • Biological maturation, cognitive & emotional development, impulse control, personality features • Repeated Exposure & Adversity • Subsequent trauma, chronic life adversity • Psychopathology • Premorbid & comorbid disorders, emergent vulnerability, treatment response

9. What We’re Looking For LONG-TERM STRESS REACTIONS HEALTHY (Common) • LEVEL 1: Initial Crisis Reactions • LEVEL 2: Acute Stress Disorder • LEVEL 3: Post-Traumatic Stress Reactions • LEVEL 4: Post-Traumatic Stress Disorder UNHEALTHY (Uncommon)Stephen Brock 2008

10. Utilize comprehensive assessment. • Trauma-specific standardized assessments can identify potential risk behaviors (i.e. danger to self, danger to others) and help determine interventions that will reduce risk. • Thorough assessment can identify a student’s reactions and how his or her behaviors are connected to the traumatic experience. • Assessment results provide valuable information for developing treatment goals with measurable objectives designed to reduce the negative effects of trauma. • Assessment results also can be used to determine the need for referral to trauma-specific mental health care or more detailed trauma assessment.

11. Issues which might require referral Acute Stress Disorder Post Traumatic Stress Disorder Dissociative Disorders Attachment Disorders Adjustment Disorders

12. Where do you start? • Review existing school records for trauma-related markers • Enrollment pattern • Attendance • Health • Behavior/discipline • Outside agency connections • School performance

13. Let’s Start with Health FirstImpact of Trauma over the Life Span Effects of ACEs* • neurological • biological • psychological • Social *Adverse Childhood Experiences

14. Smoking COPD Heart disease Fractures due to re-enactment Diabetes Severe obesity/bulimia Compulsive overeating Alcoholism Other substance abuse IV drug use Early intercourse Teen pregnancy – including paternity Promiscuity Dysphagia-difficulty swallowing Pseudo-epilepsy Health Issues Related To Adverse Experiences In Childhood

16. An ACE—adverse childhood experience—is exposure to any of the following before the age of 18: • Recurrent physical abuse • Recurrent emotional abuse • Sexual abuse • An alcohol or other drug abuser in the household • An incarcerated family member • A household member who was chronically depressed, mentally ill, institutionalized or suicidal • Violence between adults in the home • Parental separation or divorce 16

17. Emotional Abuse Substance Abuse In Household Separation/divorce Physical Abuse Violence Between Adults Mental Illness In Household Sexual Abuse Incarcerated Household Member 29% 27% 21% 17% 16% 16% 11% 6% Figure ES2. Prevalence of Individual ACEs in Wisconsin

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20. ACE Study Key finding 1: Expanding definition of childhood stress, trauma and “maltreatment” had real life significance beyond the event. Key Finding 2: Adverse childhood experiences can have an astonishingly broad based, harmful influence on adult health. (And the beginnings of a health impact are evident while in childhood.) Key finding 3: The health effects of adverse childhood experiences may not appear for decades.

21. Key Finding 4: The more kinds of adverse childhood experiences a participant reported the greater the risk for a given health problem (trauma-dose relationship). Key Finding 5: The more kinds of adverse childhood experiences a participant reported the greater the risk for more health problems (co-morbidity). ACE Study

22. Adverse Childhood Experiences in Wisconsin: Findings from the 2010 Behavioral Risk Factor Survey. http://wctf.state.wi.us/index.php?section=adverse-childhood or http://wichildrenstrustfund.org/index.php?section=adverse-childhood

23. The Child’s BrainDifferences due to Trauma

24. Hippocampal Volume Reduction in Childhood Abuse-related PTSD * *p<.05 12% reduction in left hippocampal volume in abuse-related PTSD

25. Brain Circuits in Trauma Spectrum Disorders: Brain Volumes

26. Hippocampal Volume Reduction in PTSD NORMAL PTSD Bremner et al., Am. J. Psychiatry 1995; 152:973-981. Bremner et al., Biol. Psychiatry 1997; 41:23-32. Gurvits et al., Biol Psychiatry 1996;40:192-199.Stein et al., Psychol Med 1997;27:951-959. DeBellis 1999-no change in children with PTSD J Douglas Bremner, MD, Emory University

27. Child’s BrainHealthy Neglected/Abused

28. Lateral Ventricles Measures in an 11 Year Old Maltreated Male with Chronic PTSD, Compared with a Healthy, Non-Maltreated Matched Control (De Bellis et al., 1999)

29. Depression from Child Trauma5-HTTLPR polymorphismHealthy Child Depressed Child

30. Sensory integration Dysfunction DSI is a neurologically based disorder, like ADHD and learning disabilities. A child with DSI has an inability to organize sensory input for use in daily living, which includes school, play, and family life. The child has either a hyposensitivity or a hypersensitivity to sensory input, such as an overreaction to the feel of clothing or to the texture of food. DSI is similar to ADHD in that it impacts learning, but is not a learning disability. DSI overlaps with ADHD in symptoms of inattention and restlessness Nonverbal Learning Disorder (NVLD) is a type of learning disability where the child has deficiencies in nonverbal reasoning. NVLD overlaps with both ADHD and DSI: the child with NVLD can have the sensory sensitivity of a child with DSI and the impulsiveness, disorganization, and hyperactivity of a child with ADHD or with DSI. Examples of Exclusions/OverlapSo what is it? DSI, NVLD, ADHD, PTSD?

31. Auditory Distortions • Auditory Perceptual Problem: Trouble taking information in through the sense of hearing and/or processing that information. • Auditory discrimination problem - hearing an angry rather than a joking tone of voice. • Auditory figure-ground problem - Trouble hearing a sound over background noise: for example, being unable to hear the telephone ring when one is listening to the radio.

32. Stimuli Distortions • Catastrophic response - An involuntary reaction to too may sights, sounds, extreme emotions or other strong stimuli.This may result in losing one's temper, becoming dazed or unaware of one's surroundings, or "freezing" for a short time. • Cognitive Disorganization: Difficulty thinking in an orderly, logical way, People with this problem often jump to conclusions and have difficulty planning tasks.

33. Body Distortions • Crossing the Midline : Trouble with moving one's limbs across the center of the body. This could include: Difficulty writing across a page, sweeping a floor or controlling a steering wheel. • Unaware of body parts, such as not being aware of self below waist.

34. Sense Of Touch Tactile Perceptual Problem: Trouble taking information in through the sense of touch. Some tactile handicaps are: • Immature Tactile System- People with this problem dislike being touched lightly, but crave pressure touch, such as being hugged hard or huddling with knees to their chest. Until the immaturity is overcome, tactical discrimination cannot develop. • Tactile Defensiveness- Tendency to avoid being touched because of an immature tactile system.

35. Sensory integration dysfunction (DSI or SI) • …can look like a learning disability, but it isn’t. • DSI is a neurologically based disorder, like ADHD and learning disabilities. • A child with DSI has an inability to organize sensory input for use in daily living, which includes school, play, and family life. • The child has either a hyposensitivity or a hypersensitivity to sensory input, such as an overreaction to the feel of clothing or to the texture of food. • DSI is similar to ADHD in that it impacts learning, but is not a learning disability. DSI overlaps with ADHD in symptoms of inattention and restlessness.

36. Memory Problems • Memory Problem - Short term,, Trouble remembering; names, numbers, specific facts, what happened a few minutes ago. A poor memory makes academic success difficult. • Perceptual Problems: Trouble taking information in through one's senses and/or processing that information.

37. Neurological Signs Soft Neurological Signs: Signs of central nervous system dysfunction that can be observed; • staring, • turning the head instead of moving the eyes, • inability to look people in the eye, • not holding the head straight, • being easily startled.

38. Impact of Recurrent ACE on Development Chronic exposure to trauma may result in deficits in the ability to identify internal emotional experience difficultieswith safe expressionof emotions impaired capacity to modulateemotional experience regression in behavior and physical control needs

39. Behavioral Presentations • Where do you start? • With school performance? • With Behavior?

40. Emotional and behavioral consequences occurring across age groups: 1. Regression to childish/dependent behavior 2. Fears/anxieties 3. Changes in eating patterns 4. Changes in sleeping patterns 5. Gender differences 6. School problems 7. Disciplinary Referrals 8. Freezing 9. Dissociation

41. Conditions Co-morbid with Child PTSD • AD/HD • Depression • Obsessive/Compulsive Disorder • Oppositional/Defiant Disorder • Anxiety Disorder • Conduct Disorder • Intermittent Explosive Disorder • Impulse Control Disorders

42. Consequences of PTSD/Developmental Trauma Disorder Academic 1. Cognitive 2. Academic achievement 3. Academic performance 4. Grade retention 5. Adult outcome 6. School behavior

43. Impact on Learning Organizing narrative material Cause & effect Taking another's perspective Attentiveness Regulating emotions Executive functioning Engaging in curriculum

44. Impact on Learning (continued) • Single exposure may cause • Jumpiness, intrusive thoughts, interrupted sleep and nightmares • Anger and moodiness, and/or, social withdraw any of which can interfere with concentration and memory

45. Impact on Learning (continued) • Chronic exposure, especially during child’s early years (complex/developmental trauma) can adversely affect: • Attention, Memory, and Cognition • Reduce a child’s ability to focus, organize and process information • Interfere with effective problem solving and/or planning • Result in overwhelming of feelings of frustration and anxiety

46. Impact on Classroom Behavior Reactivity & impulsivity Aggression Defiance Withdrawal Perfectionism

47. Academic Childhood trauma creates difficulty with: •Focus •Social functioning •Decline in academic performance •Outbursts of anger, hyperactivity, impulsivity All are symptoms often associated with LD

48. Consequences of PTSD effects on cognitive functioning 1. Motivation and persistence in academic tasks 2. Development of short-and long-term goals 3. Sequential memory 4. Ordinal positioning 5. Procedural memory 6. Attention/Working memory

49. Consequences of PTSD executive functioning All cognitions have an emotional context. •Educators must emotionally engage students •Learning does not occur without positive emotional engagement. •When in an acute emotional state, frontal lobes are “off-line.” •You have input and output. •Between input and output, organization needs to take place. •Have to have organization of input to get output. •Executive functioning is the conductor

50. Differences Between Traumatized Student And Those Who Were Resilient Or With LD • Sense of fatalism, • Corrupt or evil self-esteem, • Inconsistent cognitive abilities, • Self-destructiveness, • Impaired hope and fantasy, • Hyperaroused behavior patterns • Inability to use external support.