Trauma Informed Services Engaging Families April 21, 2016 Suzanne Taggart, MSW, LCSW

1. Trauma Informed Services Engaging Families April 21, 2016 Suzanne Taggart, MSW, LCSW Pathways Community Health/Family Counseling Center Compass Health Network Inspire Hope. Promote Wellness

2. Child Trauma Children face many traumas. Each year, young people are injured physically and emotionally. They see others harmed by violence. They suffer physical, emotional and sexual abuse. They lose loved ones. They lack food or medicine. Or, they witness other tragic events.

3. Child Trauma Children are very sensitive. They struggle to make sense of trauma. They also respond differently to traumas. They often have emotional reactions. They may hurt deeply. They may find it hard to recover from frightening experiences. They may act out and threaten others. They may hurt themselves.

4. Child Trauma Educators, counselors, principals and staff are often the first adults to learn of a child’s trauma. Trauma experiences are complex and difficult to sort out, one trauma may compound and result in new trauma or issues.

5. What is trauma? • ACE Study Findings • What is trauma’s impact on individuals, family members, and the community at large? • How can parents, caregivers, caring adults can offer support to someone who has experienced trauma. • What evidence based clinical treatments are being offered to traumatized youth and families? • Why Trauma Informed Care?

6. Definition of Trauma • exposure to extreme stressor • threatened death or serious injury directly • witnessing event (involving death, injury or threat) • learning about event experienced by a loved one • response to the event • intense fear, helplessness or horror • various way it is re-experienced • e.g.. nightmares, intrusive thoughts of the event, feeling detached from others, dissociation, sleep trouble, startle response, etc.

7. What kinds of events are traumatic? • sexual abuse • severe neglect • physical abuse • domestic violence • witnessed violence and cruelty to others • deprivation caused by extreme poverty • serious emotional and psychological abuse • gang and drug related violence • repeated abandonment or sudden loss • rape (sexual assault)

8. Adverse Childhood Experiences (ACES) Study Findings (1998 and 2010) • Adverse childhood experiences are common (verified by both CDC studies) • Childhood experiences powerfully influence who we become as adults (verified by CDC/Kaiser study)

9. Trauma in Child’s Household Alcohol or drug use, 2% Depressed, emotionally disturbed, or suicidal household member, 17% Mother treated violently, 13% Imprisoned household member, 6% Loss of parent, 23% Types of Adverse Childhood Experiences (Birth to 18) • Abuse of Child • Emotional abuse, 11% • Physical abuse, 28% • Contact sexual abuse, 22% • Neglect of Child • Emotional neglect, 19% • Physical neglect, 15%

10. Health Risks Smoking Severe obesity Physical inactivity Suicide attempts Alcohol and/or drug abuse 50+ sex partners Repetition of trauma Self injury Eating disorders Violent, aggressive behavior Impacts of Childhood Trauma and Adoption of Health Risks to Ease Pain • Neurobiological Impacts • Disrupted development • Anger–rage • Hallucinations • Depression/other mental health challenges • Panic reactions • Anxiety • Somatic problems • Impaired memory • Flashbacks • Dissociation

11. Long-Term Consequences of Unaddressed Childhood Trauma • Social Problems • Homelessness • Prostitution • Delinquency, criminal behavior • Inability to sustain employment • Re-victimization • Less ability to parent • Teen and unwanted pregnancy • Negative self- and other perception and loss of meaning • Intergenerational abuse • Involvement in MANY services • HIV/AIDS • Disease and Disability • Ischemic heart disease • Autoimmune diseases • Lung cancer • Chronic obstructive pulmonary disease • Asthma • Liver disease • Skeletal fractures • Poor self-rated health • Sexually transmitted infections

12. ACEsInfluence Health and Well-BeingThroughoutthe Lifespan

13. ACE Scores and Impact • Adverse childhoodexperiences are underlyingfactorsfor: • Chronicdepression • Suicide attempts • Serious and persistent MH challenges • Addictions • Being a victim rape and domesticviolence

14. INDIVIDUAL IMPACT

15. Trauma Impact • Severe distress almost universal • Unresolved childhood trauma may lead to adult mental health problems • Trauma impact may be long lasting • Trauma impact varies; most children recover over time

16. Child Trauma Indicators Children Cutting on Themselves Lack of Food Parental Drug Use Domestic Violence in the Home Educational Neglect Medical Neglect Sexual Abuse Non-Caretaker Reports Child makes threat of harm to self Child threatens others Sad about friend who died Acting out in class Lack of supervision Suicidal ideations Acting weird Missing school Physical abuse Child drew a threatening picture Child brought weapon to school Child assaulted another Observed suspicious bruising Child has stated he will kill himself if has to go home Says his mother won’t give him his meds

17. Effects of Traumatic Abuse • Every person’s response to a traumatic event is unique. • Previous experiences and current beliefs shape a survivor’s reactions to abuse and traumatic stress. • The trauma that happens in childhood at the hands of caregivers is doubly destructive — because it destroys the attachment relationship that the child would normally depend on to manage the trauma of abuse.

18. Violence impacts learning • Lower HS graduates • Increased expulsions • Increased suspensions • Increased aggression • Increased substance use • Lower IQ • Lower reading ability • Lower grade point average • Increased absences • Increased depression

19. What makes the difference? • Resiliency • Temperament • Trauma history • Age • Coping skills

20. Emotional Response • Anger • Depression • Anxiety • Hopelessness • Difficulty with affect regulation • Low self esteem

21. FAMILY IMPACT

22. Families • Roles and responsibilities change • Impacts each person differently • Communication issues • Trust issues • Caregivers traumatized and their capacity to support and protect may be reduced • Financial impact • Housing

23. COMMUNITY IMPACT

24. Community • Direct cost of $4.5 billion federal expenditure to Child Welfare system • Indirect cost of $658 million of future productivity lost for severely abused and neglected children • Juvenile delinquency cost of $14.9 million • Increased health care cost

25. CALL TO ACTION WE ALL ARE RESPONSIBLE FOR RESPONDING

26. What can Parents/Caregivers do? • Let children know you are there to help and keep them safe • Understand their emotional reactions and don’t take it personally • Seek professional help when needed • Learn about trauma and its impact • Encourage your child to talk • Listen and understand without being critical • Be patient and tolerant

27. When to Seek Professional Help • Withdraw from friends and family • School refusal for long periods, weeks or month • Focused on fear, guilt or grief • New fears • Regression in behaviors

28. Effective Treatments • Medication • Cognitive Behavioral Intervention for Trauma in Schools • PCIT Parent Child Interaction Therapy • Abuse Focused Cognitive Behavioral Therapy • TF-CBT Trauma Focused Cognitive Behavioral Therapy • CPT Cognitive Processing Therapy (for adults)

29. Medication Because stress is also a biological response as well as a psychological response, medications may be useful. Medications could help with some of the symptoms a child may have such as anxiety, depression, and difficulty sleeping. Discuss with your doctor.

30. Cognitive Behavioral Intervention for Trauma in Schools • Cognitive-behavioral approach – learn coping skills • Group approach • Some individual child sessions • Parent/Caregiver involvement • Skill Building

31. 3 Approaches to Build Skills • 1. Psycho-education • 2. Relaxation Techniques • 3. Safety Planning

32. Skill Building Areas • Self-Awareness • The childs ability to read her bodily, emotional, and motivational states accurately and to articulate that awareness to others in a clear manner. • Self-Protection • The childs ability to recognize, avoid and/or manage potentially harmful situations and relationships and to establish safe and manageable boundaries. • Self-Soothing • The childs ability to manage and diminish feelings of distress, pain and hurt.

33. Skill Building Areas (2) • Emotional Regulation • The childs ability to control the intensity and the expression of affective states. • Relational Mutuality • The childs ability to engage in a reciprocal relationship that results in meeting interpersonal needs. • Accurate Labeling of Self and Others • The childs ability to use accurate words to label her behavior and the behavior of others.

34. Skill Building Areas (3) • Sense of Initiative Taking • The childs ability to see herself as the primary source of action and initiative in her life. • Consistent Problem Solving • The childs ability to combine cognitive, affective and social skills in resolving personal and interpersonal situations. • Reliable Parenting • The caregivers ability to respond to the needs of dependent children and/or grandchildren in a reliable and consistent way.

35. Skill Building Areas (4) • Possessing a Sense of Purpose and Meaning • The youths’ ability to actively seek and meet her own needs in an appropriate manner and to view her actions in a larger context of meaning. • Judgment and Decision Making • The youths’ ability to form reliable judgments based on her thoughts, feelings, and perceptions and to use those judgments to make beneficial decisions.

36. CHANGES IN UNDERSTANDING: Why Trauma-Informed Services? • Trauma is pervasive • Trauma’s impact is broad and diverse • Trauma’s impact is deep and life shaping • Trauma, especially interpersonal violence, is often self-perpetuating • Trauma differentially affects the more vulnerable • Trauma affects how people approach services • The service system has often been re-traumatizing • Caregivers can be deeply affected by systemic stressors

37. Core Elements of a Trauma Philosophy 1.Experiences of childhood sexual and physical abuse betray a child’s core assumptions about themselves, their family, and the world. 2. Abuse severs fundamental connections to oneself, one’s family, and one’s community.

38. Core Elements of a Trauma Philosophy cont. 3. Experiences of abuse and the responses of others to that abuse can serve to invalidate one’s judgment, one’s perceptions, one’s sense of reality, and one’s sense of self-worth. 4.Working from a trauma framework and understanding consumers and their symptoms in the context of their life experiences, their cultures, and their society is the most helpful, respectful, and empowering clinical model for helping individuals with histories of abuse.

39. A Culture Shift: The Core Principles of a Trauma-Informed System of Care • Safety: Ensuring physical and emotional safety • Trustworthiness: Maximizing trustworthiness, making tasks clear, and maintaining appropriate boundaries • Choice: Prioritizing consumer choice and control • Collaboration: Maximizing collaboration and sharing of power with consumers • Empowerment: Prioritizing consumer empowerment and skill-building

40. A Culture Shift: Scope of Change in a DistressedSystem • Involves all aspects of program activities, setting, and atmosphere (more than implementing new services) • Involves all groups: supervisors, caregivers, consumers, families, administrators. • Involves making change into a new routine, a new way of thinking and acting (more than new information)

41. Caregiver Support and Well-Being Understanding trauma-informed change as a “cultural” and “systemic” process means: • Support and care for all caregivers is essential, not an option and not a luxury • Caregiver support is an organizational obligation as well as a “personal” or “professional” concern • In stressed systems, trauma is a literal and a figurative reality for many caregivers and administrators • In such settings, we can apply much of what we know about trauma and recovery to the agency or program as a whole

42. The Basic Lesson Staff and caregivers —all staff and caregivers—can create a setting of, and offer relationships characterized by, safety, trustworthiness, choice, collaboration, and empowerment only when they experience these same factors in the program as a whole. It is unrealistic to expect it to be otherwise.

43. Your Community Mental Health Center • Sindy Armstrong, Dir Community Services-Eastern Region • Pathways Community Health • Camdenton: 573-317-9100 • Lebanon: 417-532-7102 • Waynesville: 573-774-3121 • Rolla: 573-364-7551