Children Can Heal from Trauma and Abuse and You Can Make the Difference!

1. Children Can Heal from Trauma and Abuse and You Can Make the Difference! Lisa Cowart, LPC-S, RPT-S, NCC

2. Trauma is more than an experience that took place • Trauma impacts our body, our minds, our relationships • Trauma becomes part of who we are and our life story

3. Power of Trauma and Adverse Experiences • ACES Study • Corporal Punishment study • Long Term health effects • Example of Bruce Perry’s two boys from same genetics raised with different nurturing

4. Long term or complex trauma symptoms- (National Center for PTSD and U.S. Department of Veterans Affairs) • Emotional Regulation Issues • Self-concept and Perception Issues • Concentration Issues • World Belief- despair, hopelessness, sense of impending doom, loss of faith • Relationships with Others- lack of trust, isolation

5. Brain Development • Neurons and growth • Synapses • Use it or lose it • Continue throughout life • Stimulation

6. Goal of Play Therapy in Treating Trauma • Neurogenesis – new growth of neurons (stimulating interventions) • Neuroplasticity- occurs during learning and practice (repetition for rebuilding)

7. Healthy Brain Development Bruce Perry Cortex Cortex Limbic Midbrain Brainstem • Cortex- decision making, intellectual brain, abstract thought, insight (cognitive) • Limbic- emotions, affect regulation, reactivity, attachment (social/emotional) • Midbrain-appetite, sleep, arousal (regulation) • Brainstem-body temp, heartrate, blood pressure (survival)

8. Unhealthy Brain Development due to Repeated Trauma Bruce Perry Cortex Limbic Midbrain Brainstem • Cortex- decision making, intellectual brain, abstract thought, insight (cognitive) • Limbic- emotions, affect regulation, reactivity, attachment (social/emotional) • Midbrain-appetite, sleep, arousal (regulation) • Brainstem-body temp, heartrate, blood pressure (survival)

9. Brain and Trauma • Develops differently when exposed to repeated trauma • Brain and body with repeated exposure to trauma are programmed to perceive world as dangerous place • Reacting from survival states, fight flight freeze, and not from thoughtful responding • Architecture = world is not safe (core belief/ perception and make up) • Conditioned to respond in a reactive manner not from a choice

10. What can this look like • Children who do not focus in school (probably more attuned to searching for danger to survive) • Children who lie (trying to avoid being harshly punished) • Children who steal (living in survival mode trying to make sure needs are met) • Children who hide food (survival mode, not sure where next meal coming from) • If in survival mode not in mode of making thoughtful choices or learning, just reacting to world • Consequences – juvenile, loss of support, friends, family placement, issues at school • Even if these children are now in safe environments they may be reacting from the way their brains have been wired due to early adverse trauma experiences

11. Where to begin • First interaction with caregivers- Trauma informed intakes and hx gathering and interviewing • First interaction with child- we review limit setting for safety • Creating therapeutic safe environment • Observing and assessing- regulation • Building synapses too create safety and control • Bottom up approaches • Caregivers • Top down approaches

12. Trauma is Unique • No one size fits all approach • Important to listen to caregivers perspective and children’s perspectives (normalize, validate) (sense of control) (treating their perspective not investigating) • Perspectives may differ (ambivalence and grief and SA) • Symptoms (mind, body, reactions) • Impact on life (financial, relationships, stability, functioning, losses) • Rapport is large portion of treatment (studies show that use of different treatment modalities do not impact outcome as much as the actual relationship) • Caregiver involvement is associated with more positive outcomes

13. How can we help • Meet the child where they are (help them regulate) • Help them learn safety and containment • Assess what are their strengths and needs (ACES Study and focusing on negative and need to also build strengths) what have they overcome, what are their positive qualities, what are their dreams • Relationships- including attachment • Coping (what works and does not work, self efficacy) • Support (stable, healthy, available, listens, does, nurtures, calms) • Trauma integration- Play Therapy • Create activities that stimulate enough to remember and use a variety of activities to achieve the same goal week after week in order to rebuild synapses. (3 goals regulation, containment, attachment)

14. First Contact with Caregiver and Child, Creating Safety

15. Safety starts from the very first contact • Phone Intake • Intake in Office • Safe environment (outside office and inside) • Consistency • Their level • No promises • Boundaries • Limit Setting

16. Limit Setting for Safety

17. Limit Setting and Gary Landreth • Reflect feeling • State Limit • Provide Alternative • Communicate consequence

18. Theoretical Orientation Limits in Play Non-directive • ACT model (Garry Landreth)-ACT model Acknowledge feeling, needs, wants wishes, Communicate limit, Target acceptable alternatives • Facilitate expression rather than limit action, socially acceptable manner (Landreth 220) • Landreth-if you are continuing to do __________ you are choosing not to _____ (responsibility on child to modify their behavior) • Freedom and choices allow for a sense of control and responsibility (Landreth 209) • Natural consequences that pertain to the event occurring

19. ACT Model • You want to hurt something, the doll is not for cutting, the paper is for cutting • You would like to pour sand on the floor, the sand is not for the floor, you can pour sand in the sand box • You want to hurt the couch with scissors, the scissors are not for stabbing, you can use the foam sword for stabbing • You want to color on the floor, the floor is not for coloring, the paper is for coloring • You want to shoot me with the gun, I am not for shooting, the stuffed bear is for shooting • You want to give me a check up with the stethoscope, I am not for checking, the doll is for giving a check up • You want to take that toy with you, the toy is not for taking out of the room, the toy is for you to play with here next time • You want to throw marbles, the marbles are not for throwing, the foam ball is for throwing

20. After three times of ACT implement consequence • If you continue to pour sand on the floor, the sand is not for playing • If you continue to cut the couch, the scissors are not for playing today • If you choose not to shoot me anymore, you can continue shooting • If you continue to hit me, you are choosing to end the session

21. Be positive • Try to refrain form the word don’t, you can’t, no, or why • Try to refrain from being passive like I’d rather you not throw that or I wish you wouldn’t do that • Be clear and reflective and articulate- I know you are angry the time is up, the wall is not for punching, you can punch the pillow (O’conner, Schaefer, Braveman)

22. Limits in Play Therapy • Provides safety • Self-control and empowerment • Allows to learn emotional regulation

23. Sexualized Children in Play Therapy • Masturbation • Rubbing against you with genitals • Looking down shirt • Do not shame • If continues, consider sessions with another professional present

24. Limit choices with touching (O’Conner, Schaefer, Braveman ) • Ignore- do nothing, like a child playing with therapist hair • Redirect- my hair is not for playing with, the dolls hair is for playing with, or you seems to want a hug, the blanket is for holding • Interpret- you feel sad so you are wanting a hug, you need more attention so you are trying to sit in my lap • Confront- doctor’s kit

25. Limit choices with touching (O’Conner, Schaefer, Braveman • Model – Johnny tried to hug therapist, therapist redirected and modeled a fist bump or side hug • Teachable moment- boundaries twizzlers, circles, hula hoops • Don’t encourage • Always inform the caregiver and document how you handled • In some circumstance include another professional in your sessions

26. Regulation is Key

27. Build up • Bottom up approaches • Remember triangles • Let’s review

28. Healthy Brain Development Bruce Perry Cortex Cortex Limbic Midbrain Brainstem • Cortex- decision making, intellectual brain, abstract thought, insight (cognitive) • Limbic- emotions, affect regulation, reactivity, attachment (social/emotional) • Midbrain-appetite, sleep, arousal (regulation) • Brainstem-body temp, heartrate, blood pressure (survival)

29. Unhealthy Brain Development due to Repeated Trauma Bruce Perry Cortex Limbic Midbrain Brainstem • Cortex- decision making, intellectual brain, abstract thought, insight (cognitive) • Limbic- emotions, affect regulation, reactivity, attachment (social/emotional) • Midbrain-appetite, sleep, arousal (regulation) • Brainstem-body temp, heartrate, blood pressure (survival)

30. Goal in Play Therapy • Help rewire the brain and build new pathways from the bottom up • Start with self regulation (bottom up approaches to build that area of the brain) • This allows people to feel they have choices and are in control of their world and bodies

31. Goal in Play Therapy • Biggest goal creating safety in the therapeutic environment so that the child can open up their minds to let in new experiences to learn and grow from (hand, fist)

32. Using our regulating to regulate them • Oxygen Mask • Mirror Neurons (works both ways, we can attune to them or they can attune to our regulatory system) • Regulate ourselves if had a difficult meeting before session

33. Our goal as play therapist is to help them learn to regulate to have control of their worlds and have more positive life experiences by having choice to make thoughtful decisions

34. Observe • What pattern are they expressing in therapy • Are they regulated? • S pattern of regulating (Autonomic Nervous System, two branches Sympathetic Nervous System Gas pedal activator and Parasympathetic brake, calmer) • Outside the norm – just reacting • When inside the zone- there is access to conscious decisions and information and using the cortex, problem solving and ability to choose to engage in prosocial behaviors • When children experience repetitive negative childhood experiences they can be wired to have a dysregulated system and live outside the norm

35. Regulating • Fight, flight- Hyper • Freeze- Hypo state • Homeostasis – in the middle, natural rhythm • Cues- environmental, body language, tone of voice, smell • Look for the Pattern

36. What state are they in • Hypo Are they shut down Do they feel distant Do they seem distracted and not paying attention or listening Do they feel withdrawn Not engaging or dissociating Zoned out or tired Slower Sand example • Hyper • Do they seem overstimulated • Are they unable to focus • Are they bouncing from one thing to the next or hyper • Anxious or agitated • Disruptive or escalated • Do they feel defiant • Fast • Laughing example

37. Homeostasis • Calm • Thoughtful • Able to make decisions • Relaxed • Able to learn • Able to make changes • Able to reflect back • Able to gain insight

38. Goal is Homeostasis • We want to get them online and experience rhythm to regulate and learn how to regulate • Fist will open up so learning can begin and change can occur

39. If hypo aroused • Move toward hyper with more active rhythmed activities • Think of using all 5 senses • Drumming • Dancing • Breathing • Tactile sensations

40. If hyper aroused • Move toward slower paced activities • Calm voice • Drumming • Breathing • Yoga

41. Interventions • Need to be repeated during each session • Make a plan to target teaching regulation • New interventions slightly different to be stimulating enough to build new synapses • Help the child get on line in the safe resilient zone • Elicit help from caregivers, teachers, other professionals in their life to use similar activities, the more repetition the quicker can build and rewire

42. Regulation • Learning to regulate creates safety • Practice self efficacy inside office • Practice self efficacy outside office

43. Remember the Pattern • Goal is to meet in the middle homeostasis • Hand flexed verses balled up • Receive info verses reacting • Primitive responses verses Decision making • Dictated by world verses feeling in control

44. Bottom up approaches • Safety • Emotional Regulation • Repeated exposure and building • Stimulating interventions- to create learning

45. Scenario 1 • A child enters office and they are bouncing around the room, moving from one item to the next, has rapid thoughts and speech, spilling and throwing things • Therapist feels vulnerable, defensive, stressed

46. Move them out of Hyper arousal and toward Hypo. Goal is homeostasis in the middle. • Talk slower • Slow drumming • Slow breathing out breaths (brake)- feather activities scarf, across floor, bubbles, pinwheels, star breathing, bee breathing • Stretch ball • Yoga animal poses or like tree, flower, bee breathing • Use of a lamp instead of bright overhead light • Room with less toys and distractions

47. Scenario 2 • Child enters the room, plops down, stares off, does not respond • Therapist feels like they are not engaging, shutdown, inadequate, lack of connection

48. Move from Hypo toward Hyper arousal toward goal of homeostasis • Faster activities • Faster drumming- touch, sound • Faster speech or music or movements • Fast breathing – gas pedal in breaths(feather activities scarf-eye contact, Basketball hoop with arms and paper eye contact, bubbles). • Tactile activities- touching rough surfaces like sand paper or a brush or use of warm and cold surfaces • Wave a wand with streamers- sight • Brighten the lights in the room

49. Structure/ Regulation • Three big step to enter the room • Hop on the lily pads when I say flower • Food crunch- baby bites, crunch 3 times

50. Start and Stop Games • Basket ball –shoot after listening for favorite color • Red light green light • Simon says