Treating Complex Childhood Trauma in Primary Schools: Targeting the Building Blocks of Resilience

1. Treating Complex Childhood Trauma in Primary Schools: Targeting the Building Blocks of Resilience Presentation by Helen Aspland and Siobhan Foley, Islington CAMHS in Schools, TIPPP project January 2018 Day 2 ARC Developed By: Margaret E. Blaustein, Ph.D. Kristine M. Kinniburgh, LICSW The Trauma Center at JRI

2. Ground rules: Kindness Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

3. To Recap…ARC – a framework for intervention Core principles Trauma derails healthy development Trauma happens in a context, and service provision has to address the context 3 Core Domains to address: A safe caregiving system (Attachment) The ability to regulate and tolerate experience (Self-Regulation) Support in the mastery of an array of tasks crucial to resilient outcome (Competency)

4. What are we Targeting? • Caregiver Affect Management • Caregiver Attunement • Caregiver Consistent Response • Self Awareness/affect identification • Emotional Modulation Skills • Children’s Relational Engagement/emotional expression • Improve Problem Solving • Enhance Self and Identity

5. 2 Integrating Strategies • Routines • Psychoeducation Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

6. 3 Primary Domains • Attachment • Regulation • Competency Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

7. Executive Functions Expression Modulation Identificat. Attunement ConsistentBehavioural Response Caregiver Affect Mgmt. 8 Primary Skills: Building Blocks and Skills Self Dev’t & Identity Competency Routines Regulation Psychoed Attachment Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

8. Attunement Is the Foundation for helping children learn to regulate themselves. Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

10. Attunement skills support youth regulation OBSERVE: yourself (caregiver): notice your own cues of distress, support needs, or loss of control Modulate:yourself: if you can only stay in control of one thing, make it you. Use your in-the-pocket strategies. Observe: your pupil: pick up on those “clues” of need / distress as early as possible. Increasingly, try to anticipate (get in front of) these by observing and anticipating patterns. Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

11. Attunement skills support youth regulation (CO-)MODULATE: your pupil: mirror what you see (simply), and cue, support, and reinforce use of regulation strategies. Pay attention to opportunities to give them a sense of control. Do: after everyone is calm: reflect, process, limit-set, problem-solve. Don’t waste the “do” on the limbic system (yours or the child’s). Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

12. Consistent Response CONSISTENT Response The Main Idea: Building predictable, safe, and appropriate responses to children’s behaviors, in a manner that acknowledges and is sensitive to the role of past experiences in current behaviors. Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

13. Consistent Response: Key Concepts An important part of building a safe environment is building predictability in both caregiver and systemic response Traumatized children’s lives are often marked by chaos. In an effort to re-gain (or gain) some safety, these children may attempt to control their environment and others around them.

14. What doesn’t work…. Shaming them (they already feel bad about themselves and think they are toxic). What discipline strategies do you think evoke shame? Raised voices (can echo abuse) Dismissing distress/telling them it doesn’t matter. It does to them. Telling them to ‘act their age’ – they are – developmentally Negative labelling Long verbal instructions Getting into battles over eye contact (they may have had terrifying experiences of being looked at by another) ‘One size fits all’ or ‘zero tolerance’ (need for differentiation due to lag) Try to imagine the interaction through a trauma lense– what might it trigger?

15. Some Needs Challenging Behavior may be trying to meet • Control • Children and adolescents engage in behaviors that give them a sense of control sometimes seen as being “opposition”; “defiance”; “manipulative”. • Attempt to cope • Behaviors are sometimes used to provide immediate relief for overwhelming internal distress (sensory – running/rocking; self harm and aggression) • Communication of wants, needs and overwhelming discomfort through behaviour • Often (always?) more effective to respond to the need rather than the behaviour All of this leads to significant behavioral challenges for our children/youth and their caregivers.

17. There are (at least) two in the equation: • Children’s responses to limit-setting may be affected by: • Heightened arousal and difficulty responding to in-the-moment cues • Prioritization of needs (i.e., Survival need trumps cooperation) • Caregiver becoming dysregulated Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

18. Sequence for managing behaviour • 1. Be proactive and practice ‘in the pocket’ self care strategies. • 2. Use attunement to try to identify the need(s) • 3. Use your ’fundamentals’ • Meet needs • Support regulation and address safety • 4. Make use of opportunity to help them develop, with support, in areas of developmental lag • Praise and reinforcement • Problem-solving • Appropriate limits Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

19. 1.Be Proactive • Trauma-impacted youth are complex: • Many different challenging behaviours • Many different states • Changing response in relationships • The most effective strategies are those that are proactive, or get in front of the behaviours • Identify a limited number (no more than 3) of behaviours to focus on • Pay attention to behaviours you want to see more of, not just ones you want to reduce • Use a ‘skills development’ frame and recognise challenge as learning opportunities • Notice and praise any attempts to express or manage themselves appropriately Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

20. 2. Identify the needs • Use your detective skills: remember to read the clues that tell you what your child’s needs, feelings, and experience might be. • Remember – what are the primary functions of youth trauma-based behaviors? • Survival (fight, flight, freeze, submit) • Need fulfillment (emotional, relational, physiological) Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

21. 3. Use Your fundamentals “Go-To’s” • Meet needs • Once laid down by trauma, needs are experienced on a deep level and may need to be met many times, in many ways, for the need to decrease • Meeting needs does not mean you can not address behaviours in other ways, and does not reinforce the negative behaviours. • Spotting and responding to the need e,g. to feel in control, can help get in front of the behaviour, and through experimenting with may to meet the need you can hopefully reduce the behaviors from occurring • Exercise – think of an example of when a pupil has got into battles for control with you? How could/did you get ahead of the behaviour and respond to their need to control (to manage their own stress response) in an appropriate way? Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

22. 3.Use Your Fundamenals/“Go-To’s” • Support regulation • Sometimes, the first clue that a need is not being met is dysregulation – a signal that the child’s brain has begun to shift into “survival mode” • At this point, the primary goal is to support regulation, and shift the child (and the caregiver, if necessary!) Out of survival mode and into a more regulated state (off of the express road and back to the main road) • A “regulation break” may be enough to shift negative behaviours before they have a chance to start Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

23. 4. Target Strategies Purposefully Consider what strategies are in your behavioural toolbox, and use them purposefully according to the moment (child state, adult state, situational context, historical experience). Make a plan – mentally walk through a “typical” scenario, and consider which strategies might work when Consider strategies to be “experiments”; no one strategy will work for all children all the time Multiple strategies can be used to address the same behavioural goal, at different times Don’t try to change everything at once Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

24. Engage Children in the Process Actively engage children in setting / defining / understanding rules, as appropriate Be explicit with pupils about the values underlying rules, and find common ground Solicit child’s input on ways adults can support them in following established structures; anticipate / collaborate on building success Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

25. Use of Praise and Reinforcement Praise and reinforcement: Help build desirable behaviours as well as a sense of efficacy and self-esteem Don’t praise everything Start small Choose behaviours that are salient and desired Re-define success Go beyond “being good” Use concrete reinforcers and incentive systems to build positive behaviours Give especially clear/unambiguous facial cues of being pleased Be aware for some pupils praise can be a trigger

26. https://youtu.be/bFJHbCMV7kc

27. Domain 2:REGULATION Affect Identification Modulation

28. Regulation Overarching goal: Support children to safely and effectively (at age- and stage-appropriate levels) manage experience on many levels: emotional, physiological, cognitive, and behavioral; this includes the capacity to identify, access, modulate, and share various aspects of experience Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

29. What is the need? • Traumatic stress overwhelms the limited coping skills available to a developing child, often forcing them to either disconnect from their feelings or to use other unhealthy coping skills. • Persistent trauma may mean children are disconnected from or unaware of their own emotional experiences and haven’t learnt how to identify and regulate their emotions and may have difficulty reading the cues of others. These skills will only develop with support.

30. What is the need? (cont) • Trauma reminders may trigger the child, causing them to dysregulate in a fight/flight/freeze response, and in that moment may need others to ‘lend them their pre-frontal cortex or thinking brain’. Triggers may be beyond the child’s conscious awareness. • A child’s attempts to self-regulate may have become part of the problem; try to understand the function behind the behavior, and support the development of alternative strategies to get the need met (e.g. giving limited choices to enable a sense of control)

32. Developmental lag caused by developmental trauma means…. • Firstly – may need extra help to learn how to identify emotions in themselves and then, later, in others • Secondly – may need to learn to regulate/modulate these emotions initially through co-regulation by another (who is themselves regulated(caregiver affect management))and then move on to develop skills in self-regulation • Punishment systems work on the assumption that children are not employing skills that they already have –traumatised children may not have developed these skills

33. Affect Identification: The Role of Carers (teachers) in Self-Regulation Reflection: The lens through which the child learns to interpret experience. Modelling: Learning how people “do emotions” Stimulation and soothing: regulating a child

35. Name it to tame it -Siegel • https://youtu.be/ZcDLzppD4Jc • Stating the emotions we are having helps to re-engage the prefrontal cortex and we begin to think more clearly • Naming emotions helps to build new neural pathways of understanding for how to use our emotions to our advantage (respond rather than react) • This is best learnt through repetition and so much better support by the everyday adults in a child’s life

36. Remember this? Observe Modulate Do ………and repeat Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

37. The Main Idea: Work with children to build an awareness of what is going on emotionally for them, the ability to recognize and name emotional states, and an understanding of where these states come from. Identification: Affect Identification

38. Things to teach to kids first. • Everyone has feelings • Feelings come from somewhere • It is not always easy to know what we feel • There are cues that can tell us what we might be feeling • Knowing about feelings helps us understand ourselves, the situation we are in, and whether we need to do something to manage the feeling.

39. Primary Targets 1. Help children to accurately identify, at an age-appropriate level internal experience (emotions, energy/arousal) • Language for emotions energy/arousal • Connection among feelings, body sensations, thoughts and behaviours: understanding the links and using these as “clues” to understand experience • Context in which experiences bring which emotions or increase arousal 2. Help children and youth to identify (age appropriately) emotions in others.

40. It starts with developing an awareness… • Talk to the class about emotions in everyday classroom life, make it part of the fabric of what you do in every topic.. • Check in’s at the start and end of the day etc. • Ask about feelings – how did you feel when you got that right? In this story/event etc, how do you think X felt about Y happening? • Model talking about your own feelings and energy levles and what you do to modulate these • Do activities/look at resources to raise awareness or and stimulate discussion about emotions – keep it alive afterwards! • Encourage children to tune it to the clues in their bodies through mindfulness, body maps, discussion, feelings posters ( opportunity to widen vocab)

41. Helping children learn to ‘control the switch’ when they are triggered • Feelings come in all sizes • Help pupils learn subtle shifts in emotions are difficult for us all but that there are things we can do things to make feelings bigger or smaller or our ‘energy’ higher or lower. • Activities to help pupils understand the idea of ‘degrees of feeling’ including • Draw a control know with marks 0-10 • Use the richter scale as an anology e.g. how upset are you • Use a thermometre ‘you seemed red hot just then. How hot would that be on this thermometre?’ • Can also use ideas in terms of physical movements too.

42. +10 +9 +8 +7 +6 +5 +4 +3 +2 +1 0 -1 The POWER zone – living in hyperarousal THE ROLLER-COASTER – Comfort zone? What comfort zone? The KEEP-IT-COOL zone – any arousal is scary Individual Differences:The Comfort Zone Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

43. Strategies For Building Basic Identification Skills 1. Invite the child to share daily emotional experience; incorporate check-ins into appropriate routines: i.e., How are you feeling today?

44. 2. Name or invite reflection on emotions in the context of specific experiences • “How did it feel when you got that test back?”

45. 3. Reflect on what you can see: describe what you see: “ It looks like you might be feeling worried.”

46. 4. Normalise and validate emotions; pay attention to mixed emotion: “ other children would probably feel this way too, if it had happened to them.”

47. Further developing the skills • Once pupils are showing an understanding about different emotions move on to understanding the connection of emotions to other aspects of experience (“ I know I’m feeling happy because…..”) • Understanding the context of emotion ( the reason I’m feeling happy is……)

48. Connection of Emotions • Support child in becoming “feelings detectives” about self and others.. • Build an understanding of the way in which people express emotions ( how does a teacher show she is angry vs how a child might) • Recognise we may show the same emotion in different ways at different times (sometimes when I am sad I … other times I….)

49. Contextualisation of emotions • Looking at environmental and internal factors as well as precipitating events… • Basic “ I was sad when my teacher was cross with me” • Advanced “ I was sad when my teacher was cross with me, because it reminded me of when my mum was cross with me”.

50. Teaching children about brains • Story bots video, sesame street, upstairs brain, monkey brain • What does your brain need right now to feel okay? • Idea of ‘over active alarm systems’ and ‘false alarms’ • Books and resources