RECOGNIZING CHILDHOOD TRAUMA, AND PROVIDING TRAUMA INFORMED CARE

1. RECOGNIZING CHILDHOOD TRAUMA, AND PROVIDING TRAUMA INFORMED CARE FDR Middle School Bristol, Bucks County GORDON R. HODAS M.D. August 23, 2007

2. INTRODUCTION IMPORTANT STARTING POINTS • Schools repeatedly identified as a core protective factor for children and adolescents: • If child attends regularly, feels safe, is engaged. • If educational program is individualized, flexible, and committed to wellbeing of students. • Most effective way to achieve above = “trauma informed care.”

3. INTRODUCTION TRAUMA INFORMED CARE • Ultimately, TIC is an attitude & set of beliefs: • The youth’s development & choices have been limited by traumatic life experiences. • Youth’s negative behaviors largely an outcome of trauma & not intentional. • Given the opportunity & support, the youth can and will do better. • TIC not stand alone: “value added” to effective treatment, care, and education.

4. INTRODUCTION THE CHALLENGE OF EFFECTIVE TEACHING “Being a teacher, that’s an awful hard thing to learn....A good teacher has got to be able to know what a person can be taught…a teacher is most interested in teaching the normal way, the way the average person learns. And there’s some people, they’re lacking in knowing how to do things the average way. It don’t make no sense to them....what counts (is) having a way that is your own…all the way to you from inside your own self.”

5. INTRODUCTION THE BEST TEACHER, THE BEST METHOD “The best teacher will be he who has at his tongue’s end the explanation of what it is that is bothering the pupil. These explanations give the teacher the knowledge of the greatest possible number of methods, the ability of inventing new methods, and, above all…the conviction that the best method would be the one which would answer best all of the possible difficulties incurred by a pupil – that is, not a method but an art and talent.” Leo Tolstoy

6. INTRODUCTION “REFLECTING ON TEACHING” – IMPORTANCE OF BEING “A REFLECTIVE PRACTITIONER” Reflection-in-action involves thinking about what one is doing, in order to “cope with…troublesome ‘divergent’ situations of practice,” and come up with new ways to address the problem. “When someone reflects-in-action, he…constructs a new theory of the unique case.” Don Schon, The Reflective Practitioner

7. INTRODUCTION OUR FOCUS: CHILDHOOD TRAUMA AND ITS IMPACT ON STUDENT LEARNING & BEHAVIOR • PART I: Trauma – basic considerations & role of culture • PART II: Impact and neurobiology • PART III: Direct effects of trauma on student learning and behavior • PART IV: Maintaining trauma informed care, and trauma informed educational settings

8. PART I: TRAUMA – BASIC CONSIDERATIONS • Prevalence • Definition • Types • Determinants of child’s response • Cultural considerations

9. PART I: TRAUMA – BASIC CONSIDERATIONS CHILDHOOD TRAUMA AS A “HIDDEN EPIDEMIC” • Actual prevalence high. • Disclosure of maltreatment to professionals uncommon. • Screening by professionals inconsistent. • Poorly understood by many. • Responses by professionals can be counter-productive and re-traumatizing. • Distinction: trauma informed care vs. trauma-specific treatment.

10. PART I: TRAUMA – BASIC CONSIDERATIONS CHILDHOOD TRAUMA PREVALENCE • Adolescent Inpatients: 93% with history of trauma, 32% met PTSD criteria. • Up to 67% males and females seeking substance abuse Rx have PTSD – complete or partial. • Youth in JJ: 93% of males, and 84% of females, with one or more traumatic events. • Youth in JJ: witnessing – violence or death: • 59% males. • 47% females.

11. PART I: TRAUMA – BASIC CONSIDERATIONS TRAUMA AS PRECURSOR TO ARREST & VIOLENCE • Arrest, as consequence of childhood abuse or neglect: • As juvenile, 53% more likely. • As young adult, 38% more likely. • Violent crime leading to arrest: 38% more likely.

12. PART I: TRAUMA – BASIC CONSIDERATIONS CHARACTERISTICS OF TRAUMA • Traumatic event (per DSM IV) involves experiencing, witnessing, or being confronted by event or events that involved “actual or threatened death or serious injury, or a threat to the integrity of self or others.” • The individual’s response involved “intense fear, helplessness, or horror” (with children, may have disorganized or agitated behavior). • Only 2 trauma-related diagnoses: Acute Stress Disorder, and Posttraumatic Stress Disorder (re-experiencing, avoidance/numbering, hyperarousal).

13. PART I: TRAUMA – BASIC CONSIDERATIONS TYPES OF TRAUMA INCLUDE • Neglect, and abuse – physical, sexual, emotional. • Witnessing domestic abuse or community violence. • Bullying. • Traumatic loss. • Medical trauma. • Natural disasters. • War and terrorism. • Refugee trauma.

14. PART I: TRAUMA – BASIC CONSIDERATIONS DETERMINANTS OF CHILD’S RESPONSE TO TRAUMA – RESULT OF 3 SETS OF VARIABLES: • Characteristics of the traumatic event(s) • Characteristics of the environment • Characteristics of the individual child

15. PART I: TRAUMA – BASIC CONSIDERATIONS CHARACTERISTICS OF THE TRAUMATIC EVENT(S) • Frequency, severity, & duration of event(s) • Degree of physical violence and bodily violation • Level of terror and humiliation experienced • Persistence of threat • Physical and psychological proximity to event and perpetrator

16. PART I: TRAUMA – BASIC CONSIDERATIONS CHARACTERISTICS OF THE ENVIRONMENT • Immediate reaction of caregivers or those close to child • Type, quality of, and access to, constructive supports • Attitudes and behaviors of first responders and caregivers • Degree of safety for victim following the event • Prevailing community attitudes and values • Cultural and political considerations

17. PART I: TRAUMA – BASIC CONSIDERATIONS CHARACTERISTICS OF THE INDIVIDUAL CHILD • Age and stage of development • Prior trauma history • Intelligence • Strengths, coping, and resiliency skills • Vulnerabilities • Child’s culturally based understanding of the trauma

18. PART I: TRAUMA – CULTURAL CONSIDERATIONS SIGNIFICANCE OF CULTURE IN UNDERSTANDING IMPACT OF TRAUMA ON CHILDREN • Traumatic event – influenced by cultural beliefs and parenting practices. • Environment – may or may not recognize event as traumatic, such that trauma not acknowledged and support not offered. • Child – may or may not cognitively experience event as traumatic, but body responds anyway.

19. PART I: TRAUMA – CULTURAL CONSIDERATIONS THE REFUGEE EXPERIENCE: 3 PHASES (NCTSN) • Preflight – Time prior to escape from country of origin; disruption, violence, danger. • Flight – Time of transitional placement (refugee camps) following displacement from one’s home; uncertainty; basic needs unmet; possible separation of family and/or physical/sexual trauma to children. • Resettlement – Family settlement in new, host country; clash between traditional and new cultures, social disruption, and task of acculturation.

20. PART I: TRAUMA – CULTURAL CONSIDERATIONS TYPES OF PREFLIGHT STRESS FOR CHILDREN • Witnessing atrocities. • Possible direct victimization. • Insufficient food & other necessities. • Forced labor. • Forced combat. • Separation from family. • Segregated camps.

21. PART I: TRAUMA – CULTURAL CONSIDERATIONS TYPES OF FLIGHT STRESS FOR CHILDREN • Uncertainty and instability. • Basic needs unmet – malnutrition and medical care. • Separation from family and familiar cues. • Refugee camps. • Depersonalization. • Witnessing violence or suicide. • Victimization in camp.

22. PART I: TRAUMA – CULTURAL CONSIDERATIONS TYPES OF RESETTLEMENT STRESS FOR CHILDREN • Loss of culture and social network of homeland (“cultural bereavement”). • Reconciling traditional beliefs and practices with those of prevailing culture. • Language barriers. • Stigma based on nationality, race, religion.

23. PART I: TRAUMA – CULTURAL CONSIDERATIONS TYPES OF RESETTLEMENT STRESS FOR CHILDREN (2) • Victimization through bullying. • Lack of familiarity with laws & social service systems • Differential rates of acculturation between parents and child. • Possible inversion of family hierarchy. • Possible secrecy/denial re past family trauma.

24. PART I: TRAUMA – CULTURAL CONSIDERATIONS SYMPTOMS RESULTING FROM REFUGEE STRESS • Each phase of refugee process associated with Sxs. • Younger children more vulnerable. • Stress exposures cumulative. • Internalizing behaviors common – anxiety, PTSD, depression, withdrawal, somatic complaints. • Externalizing behaviors – impulsivity, inattention/ hyperactivity, aggression, delinquency.

25. PART I: TRAUMA – CULTURAL CONSIDERATIONS SOURCES OF POTENTIAL COPING & RESILIENCE • Parental wellbeing, parental support to child. • Esprit de corps among war-exposed children. • Devotion to a cause. • Abilify to recognize and avoid danger. • Abilify to appeal to adults for caretaking. • Abilify to manage anxiety and calm self.

26. PART I: TRAUMA – CULTURAL CONSIDERATIONS SOURCES OF COPING AND RESILIENCE (2) • Use of play. • Use of imagination – wishing things were different. • Sense of humor. • Acculturation to new country. • Use of social support network in community. • Maintaining connection to culture of origin.

27. PART I: TRAUMA – CULTURAL CONSIDERATIONS BACKGROUND ON LIBERIA • Located on Africa’s western coastline. • Founded as a republic in 1847 by freed American slaves. English spoken in much of Liberia. • Civil war began in 1989 and continued intermittently, disrupting prior prosperity and creating strife among indigenous groups. • Resettlement of Liberians in America began in 1992, under the U.S Refugee Program (USRP).

28. PART I: TRAUMA – CULTURAL CONSIDERATIONS BACKGROUND ON LIBERIA (2) • Resettlement increased in 1998 due to continued instability. • Between 2003-2005, more than 8,000 refugees emigrated to US. Bucks County as one site. • Most wealthy Liberians in US came earlier. • Recent & current immigrants more rural, & greater exposure to war, flight, and refugee camp life. • Some on the run for a decade or more.

29. PART I: TRAUMA – CULTURAL CONSIDERATIONS BACKGROUND ON LIBERIA (3) • “Dual flight” for some: forced to flee 2x or more. • Many adults with limited exposure to formal education. Children with refugee camp education. • One parent families common, due to flight, death. • Recent settlement of extended families in US, some with limited previous time living together. • Informal guardianships common. Not all children biological.

30. PART I: TRAUMA – CULTURAL CONSIDERATIONS CONSEQUENCES OF PRIOR REFUGEE STATUS • Poor primary health care – concept not embedded. • High blood levels possible. • Lack of trust toward outsiders. • Education limited, disrupted in past, low skill levels. • Education may not be a parental priority for child. • Lack of understanding of expected school behavior, and limited readiness.

31. PART I: TRAUMA – CULTURAL CONSIDERATIONS PARENTAL RESPONSE TO PRIOR TRAUMA • Shame and humiliation. • Secrecy. • Denial. • Unwillingness to discuss. • Impact often greater on 2nd generation, the children of parents subject to trauma in homeland.

32. PART I: TRAUMA – CULTURAL CONSIDERATIONS PARENTING PRACTICES • Extended family, not nuclear family, the typical family structure in earlier village life and in US. • Large, multi-generational families, many in house. • Membership in family fluid and informal. • Communal network of support helps raise children. • Any adult in network seen as empowered to monitor child and intervene.

33. PART I: TRAUMA – CULTURAL CONSIDERATIONS PARENTING PRACTICES (2) • Traditional values: adults primary, children respect elders. Older children help with younger siblings. • Children allowed considerable independence in play. • Corporal punishment seen as necessary to prepare child to be good citizen, and sign of good parent. • Harsh tone and verbal reprimands also common. • Ancient custom – punishing child with ground hot peppers.

34. PART I: TRAUMA – CULTURAL CONSIDERATIONS PARENTING – POTENTIAL CULTURAL CONFLICTS • Unapproved family member picks up child at school. • Examples of possible “neglect”: • Ten year old child left alone to care for infant. • Child running around without apparent supervision. • Examples of possible “abuse”: • Giving child a “beating.” • Use of switch or belt, leaving a mark. • Verbal abuse. • Use of ground hot peppers.

35. PART II: TRAUMA –IMPACT AND NEUROBIOLOGY • Impact global, encompassing development, physical health, behavior, beliefs, and values • Neurobiological processes influence, and are influenced by, above elements

36. PART II: TRAUMA –IMPACT CHILDHOOD TRAUMA OVERVIEW • Multiple variables determine impact, as discussed. • Single events disrupt the life of child and family, but often resolve without serious long-term damage. • Severe, chronic, and/or recurring trauma can have serious, long-term consequences. • These consequences can affect every aspect of a child’s functioning, including mental & physical health, values & beliefs, learning, and behavior.

37. PART II: TRAUMA –IMPACT CHILDHOOD TRAUMA OVERVIEW (2) • Childhood maltreatment – neglect, physical abuse, emotional abuse, and sexual abuse – can have severe consequences. Secretive, stigmatizing, family betrayal, threats to prevent disclosure. • Refugees may have prior exposure to war, displacement & loss, trauma in refugee camp, family separation, and stress of immigration & resettlement.

38. PART II: TRAUMA – IMPACT CHILDHOOD TRAUMA OVERVIEW (3) • Immigrant children may be subjected to other forms of trauma in US: • Witnessing – community violence or domestic abuse • Bullying. • Victimization by other community violence (drugs, guns, etc.). • Possible traumatic loss.

39. PART II: TRAUMA – IMPACT CONSEQUENCES OF SEVERE, CHRONIC TRAUMA • Neurobiological abnormalities. • Effect on brain size and activity. • Disruption of normal developmental process. • Likelihood of additional victimization. • Likelihood of aggression & violence.

40. PART II: TRAUMA – IMPACT SEVERE, CHRONIC TRAUMA: CONSEQUENCES (2) • Likelihood of negative lifestyle & unhealthy habits. • Physical health problems, during childhood and throughout the life cycle, and shorter life expectancy. • Increased risk of psychiatric disorders. • Increased risk of substance abuse.

41. PART II: TRAUMA – IMPACT SEVERE, CHRONIC TRAUMA: CONSEQUENCES (3) • Effect on behavior – What do we see? • Effect on relationships – What do we see? • Effect on beliefs – What are typical beliefs re others? • Effect on values – What are typical values? • Effect on learning and school-related behavior.

42. PART II: TRAUMA – IMPACT VICTIMS AND VICTIMIZERS: SAD REALITY: • Many juvenile offenders were victimized earlier. • Childhood and youth victims are, as result of their victimization, at higher risk of becoming victimizers. • Dramatic example, per Philadelphia police: 90% of city’s murderers, and also 90% of city’s homicide victims, have prison records. • Trauma increases likelihood of arrest – 53% more for juveniles, and 38% more for young adults.

43. PART II: TRAUMA – IMPACT TRAUMA AS PRECURSOR TO VIOLENCE • Violent crime leading to arrest: 38% more likely. • Adjudicated females (2 separate studies): • Over 75% of adjudicated females had been sexually abused. • Over 90% of incarcerated females reported some form of childhood maltreatment (2 separate studies).

44. PART II: TRAUMA – NEUROBIOLOGY THE BOTTOM LINE: LONG-TERM EFFECTS OF TRAUMA ON THE BRAIN • Severe, prolonged childhood abuse damages the developing brain via hormonal and structural changes. • Potentially irreversible, although the brain is dynamic and continues to grow into mid-20’s. • Childhood violence a significant causal factor in 10-25% of all developmental disabilities.

45. PART II: TRAUMA – NEUROBIOLOGY BASIC SURVIVAL RESPONSES TO DANGER AND THREAT (NORMAL PROCESSES): • Hyperarousal responses: “fight” or “flight”, in support of active mastery and/or • Dissociation responses: passive, surrender response, to escape/avoid situation. • Both responses are normal and of adaptive benefit, increasing the likelihood of survival.

46. PART II: TRAUMA– NEUROBIOLOGY THE HYPERAROUSAL RESPONSE: • Either “fight” or “flight,” enabling individual to take emergency action in response to fear, terror, and danger. • “Fight” = self-defense. • “Flight” = removing self from danger. • Mediating neurobiology: Catecholamines – adrenaline and noradrenalin – and hypothalamic pituitary axis.

47. PART II: TRAUMA – NEUROBIOLOGY THE HYPERAROUSAL RESPONSE (2): • Physiological responses associated with hyperarousal: • Increased heart rate. • Increased blood pressure. • Increased energy availability in skeletal muscles. • Observable manifestations of hyperarousal: • Highly focused attention • Sweating • Erect posture

48. PART II: TRAUMA – NEUROBIOLOGY THE DISSOCIATION RESPONSE • Dissociation = “disengaging from stimuli in the external world and attending to an internal world” (Perry et al, 1995), in order to “camouflage” oneself and child and buy time. • Dissociation involves emotional numbing and withdrawal. • A dissociation continuum, depending on trauma severity and circumstances. • Mediating neurobiology: Increase in vagal tone.

49. PART II: TRAUMA – NEUROBIOLOGY THE DISSOCIATION RESPONSE (2) • Physiological responses associated with dissociation: • Decrease in heart rate. • Decrease in blood pressure. • Observable manifestations of dissociation: • Decreased movement • Compliance • Avoidance • Restrictive affect

50. PART II: TRAUMA – NEUROBIOLOGY TRAUMA DISRUPTS AROUSAL SYSTEM • Hyperarousal the primary problem. • Catecholamine release, and over-activation of hypothalamic-pituitary axis. • A previously adaptive, emergency response becomes maladaptive. • Adaptive emergency “state” becomes maladaptive “trait.”