Karleen Jakowski LMFT Adolescent Services Manager Behavioral Health

+ Karleen Jakowski, LMFT Adolescent Services Manager Behavioral Health Programs Adverse Childhood Experiences (ACEs) & Trauma Informed Care for Educators

+ Definition of Trauma

+ What is Child Traumatic Stress? Child traumatic stress is when children and adolescents are exposed to traumatic events or traumatic situations, and when this exposure overwhelms their ability to cope. http: //nctsn. org

+ Situations that can be traumatic: o. Physical or sexual abuse o. Abandonment, betrayal of trust (such as abuse by a caregiver) o. Neglect o. The death or loss of a loved one o. Life-threatening illness in a caregiver o. Witnessing domestic violence o. Automobile accidents or other serious accidents o. Bullying o. Life-threatening health situations and/or painful medical procedures o. Witnessing or experiencing community violence (e. g. shootings, stabbings, robbery, or fighting at home, fights at school, in the neighborhood, or at school) o. Witnessing police activity or having a close relative incarcerated o. Life-threatening natural disasters o. Acts or threats of terrorism (viewed in person or on television) o. Living in chronically chaotic environments in which housing and financial resources are not consistently available www. nctsn. org

+ Acute, Chronic and Complex Trauma Acute Trauma n n Single Incident Crime Victim Serious Accident Chronic Trauma n Repeated n Prolonged Trauma n Domestic Violence n Abuse (Physical or Sexual) n War Natural Disaster Complex Trauma Chronic, Interpersonal Trauma, Varied and Multiple Traumas, Early Onset, Often by Trusted Caregivers

+ Prevalence

+ Trauma Facts for Educators n FACT: One out of every 4 children attending school has been exposed to a traumatic event that can affect learning and/or behavior. n FACT: Trauma can impair learning. n n n Single exposure to traumatic events may cause jumpiness, intrusive thoughts, interrupted sleep and nightmares, anger and moodiness, and/or social withdrawalany of which can interfere with concentration and memory. Chronic exposure to traumatic events, especially in a child’s early years, can: n Adversely affect attention, memory and cognition n Reduce a child’s ability to focus, organize, and process information n Interfere with effective problem solving and/or planning n Result in overwhelming feelings of frustration and anxiety FACT: Trauma can impact school performance. n n n Lower GPA Higher rate of school absences Increased drop-out More suspensions and expulsions Decreased reading ability

+ General Statistics n 60% of adults report experiencing abuse or other difficult family circumstances during childhood. n 26% of children in the United States will witness or experience a traumatic event before they turn four. n Four of every 10 children in American say they experienced a physical assault during the past year, with one in 10 receiving an assault-related injury. n Nearly 14% of children repeatedly experienced maltreatment by a caregiver, including nearly 4% who experienced physical abuse. n More than 13% of children reported being physically bullied, while more than 1 in 3 said they had been emotionally bullied. n 1 in 5 children witnessed violence in their family or the neighborhood during the previous year. n In one year, 39% of children between the ages of 12 and 17 reported witnessing violence, 17%reported being a victim of physical assault and 8% reported being the victim of sexual assault. n 1 in 3 girls and 1 in 6 boys are victims of sexual abuse

+ Adverse Childhood Experiences (ACEs) Study Kaiser Permanente and Center for Disease Control, 1998 The Study: • 17, 000, mostly white, college-educated, employed adults were screened for 10 prominent childhood traumatic experiences as a part of their routine health care at Kaiser. Participants received one point for each type of trauma. The Results: • 70% of the 17, 000 people experienced at least one type of trauma resulting in an “ACE score” of one; 87% of those had more than one. • ACE scores of 4 or more resulted in four times the likelihood of depression, 12 times the risk of suicide. • ACE scores were also directly correlated with early initiation of smoking and sexual activity, adolescent pregnancy, and risk for intimate partner violence. • Eighteen States have since conducted ACE surveys with similar results. • A person with an ACE score of 4 is 260% more likely to have COPD, 240% more likely to have Hepatitis, and 250% more likely to have a sexually transmitted disease than a person with an ACE score of 0. • A male child with an ACE score of 6 has a 4600% increase in the likelihood of becoming an IV drug user when compared to a child with an ACE score of 0.

+ ACEs Conceptual Framework Early Death Retaliation and Imprisonment Diabetes Weapon Possession and Self-Medication Overeating Hospitalization and Discharge to the Street Early Death Depression Physical Assault (Shot/Stabbed) Disease, Disability and Social Problems Sexual Abuse Adoption of Health-Risk Behaviors Social, Emotional and Cognitive Impairment Disrupted Neurodevelopment Adverse Childhood Experiences

+ Toxic Stress

+ ACES Questionnaire for Youth

+ Impact of Adverse Childhood Experiences (ACEs)

+ Adverse Childhood Experiences…. …. are very common. . occur together -- if you have one ACE, there’s an 87% chance you have more. . the more you have, the higher your risk of physical, mental and social problems.

+ Important Things to Remember n Not “what’s wrong with you” but “what happened to you” n Symptoms are adaptations n Violence causes trauma and… trauma causes violence. SAMHSA, 2013

There are students in your school + who have experienced trauma What you might observe in students: n Anxiety, fear and worry about safety of self and others (Elementary aged students may be more clingy with teacher or parent) n Worry about the recurrence of violence n Increased distress (unusually whiny, irritable, moody) n Changes in behavior: n Increase in activity level n Decreased attention and/or concentration n Change in academic/school performance n Withdrawal from others or activities n Irritability with friends, teachers, events (Middle School students) n Angry outbursts and/or aggression n Absenteeism n Increase in impulsivity, risk-taking behavior (High School students) www. nctsn. org

+ n Distrust of others, affecting how children interact with both adults and peers (Elementary School students) n A change in ability to interpret and respond appropriately to social cues (Elementary School students) n Increased somatic complaints n n headaches, stomachaches, chest pains overreaction to minor bumps and bruises (Elementary School students) n Discomfort with feelings (such as troubling thoughts of revenge)-Middle School students n Increased risk for substance abuse (High School students) n Recreating the even (e. g. repeatedly talking about, “playing” out, or drawing the event) n Over- or under-reacting to bells, physical contact, doors slamming, sirens, lighting, sudden movements www. nctsn. org

+ n Statements and questions about death and dying n In High School students- repetitive thoughts and comments about death and dying (including suicidal thoughts, writing, art, or notebook covers about violent or morbid topics, internet searches) n Difficulty with authority, redirection or criticism n Re-experiencing the trauma (e. g. nightmares, or disturbing memories during the day) n Hyperarousal (e. g. sleep disturbances, tendency to be easily startled) n Avoidance behaviors (e. g. resisting going to places that remind them of the event) n Emotional numbing (e. g. seeming to have no feeling about the event) www. nctsn. org

+ Protective Factors for Post Trauma Adjustment n A reliable support system (family, friends) n Access to safe and stable housing n Timely and appropriate care from first responders n Self care practices (sleeping, nutrition) n Using positive coping mechanisms verses negative coping mechanisms n Parental resilience n Knowledge of parenting and child development n Nurturing and attachment

+ Trauma Informed Care

+ What is “Trauma Informed”? A program, organization or system that is trauma informed realizes the widespread impact of trauma and understands the potential paths for healing; recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings. SAMHSA, 2013

+ Goals of Trauma Informed Care n Provide the foundation for a basic understanding of the psychological, neurological, biological and social impact that trauma and violence have on many of the individuals we serve by: Avoiding unintentional re-traumatization through agency policies, practices and staff interactions with youth and their families n Recognizing the impact of trauma on your students, your staff and YOU n Incorporating Trauma Informed Practices in policies and procedures n Educating and empowering staff and youth n Encouraging self care practices and identifying vicarious trauma n

+ Trauma Informed System of Care Trauma Informed Non-Trauma Informed Recognition of high prevalence of trauma Lack of education on trauma prevalence and “universal” precautions Recognition of primary and co-occurring Over diagnosis of Schizophrenia, trauma diagnoses Bipolar Disorder, Conduct Disorder, and singular addictions Assess for traumatic histories and symptoms Cursory or no trauma assessment Recognition of culture and practices that are re-traumatizing “Tradition of Toughness” valued as best care approach Power/control minimized- constant attention to culture Keys, security uniforms, staff demeanor, tone of voice

+ Trauma Informed System of Care Trauma Informed Non-Trauma Informed Caregivers/supporters-collaboration Rule enforcers-compliance Address training needs of staff to improve knowledge and sensitivity “Youth blaming” as fallback position without training Staff understand function of behavior (rage, repetition-compulsion, self-injury) Behavior is seen as intentionally provocative Objective, neutral language Labeling language: “manipulative”, “needy”, “attention-seeking” Transparent systems open to outside parties Closed system- advocates discouraged

+ Utilizing a Trauma Informed Approach to Teach Students n Teaching and learning play an important role in diminishing trauma symptoms and enabling traumatized children to reach their potential despite their difficult circumstances. n Helping children regulate emotions in order to master social and academic skills. n Maintaining high academic standards. n Helping children feel safe. n Managing behavior and setting limits. n Reducing bullying and harassment. n Helping children have a sense of agency. n Building on strengths. n Understanding the connection between behavior and emotion. n Avoiding labels.

Lincoln High School, Walla, WA

+ UCSF HEARTS Program: Healthy Environments and Response to Trauma in Schools n A comprehensive, multilevel school-based prevention and intervention program for children who have experienced trauma n Their goal is to create school environments that are more trauma-sensitive and supportive of the needs of traumatized children. n A main objective is to work collaboratively with the school district to promote school success by decreasing trauma-related difficulties and increasing healthy functioning in students who have experienced complex trauma. n Trauma-sensitive school environments will likely benefit not only traumatized children, but also those who are affected by these children, including child peers and school personnel.

+ UCSF HEARTS Program: What does UCSF Hearts do? n First Area: school-based intervention and prevention work with children and adolescents directly and indirectly affected by trauma » Tertiary interventions, e. g. , trauma-informed therapeutic interventions for youth who are having post-trauma difficulties » Secondary interventions, e. g. , skill-building groups for at-risk youth » Primary prevention, e. g. , classroom presentations on coping with trauma and violence n Second Area: training, consultation and support for adult members of the caregiving system (school personnel and parents/guardians) » Interventions such as psychoeducational and skill-building workshops for parents/caregivers » Training and consultation in complex trauma and trauma-sensitive practices for teachers, administrators, paraprofessionals, and school mental health staff » Aimed at building capacity in SFUSD personnel around more effectively working with traumatized students » Support for school staff around stress, burnout, and vicarious traumatization n Third Area: working with SFUSD at the school-level and the districtlevel to help improve school- and district-wide policies and procedures » Trauma-informed consultation around positive behavioral support systems, discipline policies, and alternatives to suspension from school for students with behavioral challenges

+ Supporting student’s resilience n Encourage social connectedness – developing community n Provide concrete support in times of need n Demonstrate social and emotional competence n Support the use of restorative practices in managing conflict

Supporting our children’s resilience + through CONNECTION Caring Adults at School (Student Reported), by Gender and Grade Level: 2011 -2013 Definition: Percentage of public school students in grades 7, 9, 11, and non-traditional students reporting each level of agreement (high, medium, and low) that teachers or other adults at school care about them, by gender (e. g. , in 2011 -13, 35. 6% of female students in grades 7, 9, 11, and non-traditional classes in California public schools expressed a high level of agreement that teachers or other adults at school care about them). Data Source: As cited on kidsdata. org, California Department of Education, California Healthy Kids Survey and California Student Survey (West. Ed).

Supporting our children’s resilience + through CONNECTION School Connectedness (Student Reported), by Gender and Grade Level: 2011 -2013 Definition: Percentage of public school students in grades 7, 9, 11, and non-traditional students by level of connectedness to school and gender (e. g. , in 2011 -13, 45. 6% of female students in grades 7, 9, 11, and non-traditional classes in California public schools had a high level of connectedness to school). Data Source: As cited on kidsdata. org, California Department of Education, California Healthy Kids Survey and California Student Survey (West. Ed).

Supporting our children’s resilience + through CONNECTION Depression-Related Feelings (Student Reported), by Gender and Grade Level: 2011 -2013 Definition: Percentage of public school students in grades 7, 9, 11, and non-traditional students reporting whether in the past 12 months they had felt so sad or hopeless almost every day for two weeks or more that they stopped doing some usual activities, by gender. Data Source: As cited on kidsdata. org, California Department of Education, California Healthy Kids Survey and California Student Survey (West. Ed).

+ Relationship is the Evidence-Based Practice n Trauma results primarily from disrupted relationships n Relationship is the vehicle for life success n Attachment key to well-being n Critical role of core caregiver-infant relationships n Early learning creates persistent but potentially modifiable responses n Progressive role of extended caregivers and intimate relationships Copyright WSU AHEC CLEAR Center 2013

+ Supporting Resilient Communities • Safe, stable, and nurturing relationships and environments are essential to prevent child maltreatment and to assure children reach their full potential. • Adopt the vision Raise awareness Partner with others • • Join the Yolo County ACES Connection Group at acesconnection. com

+ Resources

+ TF-CBT Providers in Yolo County n Communi. Care Health Centers n n Yolo County Alcohol, Drug and Mental Health n n n 500 B Jefferson Blvd West Sacramento, CA 95605 (916)403 -2970 804 Court Street Woodland, CA 95695 (530)668 -2400 www. communicarehc. org 137 N Cottonwood St Woodland, CA 95695 (530) 666 -8650 http: //www. yolocounty. org/index. aspx? page=59 Yolo Family Service Agency n n 455 1 st St · Woodland (530) 662 -2211 http: //yolofamily. org

+ Aces. Too. High. com

+ ACEs. Connection. com

+ Helping Traumatized Children Learn: http: //traumasensitiveschools. org

+ National Child Traumatic Stress Network: http: //nctsn. org

+ Self Care for Educators “There is a cost to caring”-Charles Figley n Be aware of the signs n n n Increased irritability or impatience with students Difficulty planning classroom activities and lessons Decreased concentration Denying that traumatic events impact students or feeling numb or detached Intense feelings and intrusive thoughts, that don’t lessen over time, about a student’s trauma Dreams about students’ traumas n Don’t go it alone n Recognize compassion fatigue as an occupational hazard n Seek help with your own traumas n If you see signs in yourself, talk to a professional n Attend to self care

+ Resources n www. nctsn. org n www. tfcbt. musc. edu n www. samhsa. org n www. recognizetrauma. org/statistics. php n http: //freedomnetworkusa. org/wpcontent/uploads/2012/05/Trauma_Informed_Care_Powerpoint. pdf n http: //www. ohsu. edu/xd/outreach/occyshn/trainingeducation/upload/Trauma. Powerpoint-Dr. Burr. Harris 2012. pdf n http: //rodriguezgsarah. files. wordpress. com/2013/05/traumaresbookletweb. pdf n http: //acestudy. org/ n http: //acestoohigh. com n http: //acesconnection. com

+ Resources www. ACEs. Too. High. com - news site Link to story about Lincoln High: http: //acestoohigh. com/2012/04/23/lincoln-high-school-in-walla-wa-tries -new-approach-to-school-discipline-expulsions-drop-85/ www. ACEs. Connections. com - professional networking site CDC Synopsis: http: //www. cdc. gov/violenceprevention/acestudy/index. html CDC’s Essentials for Childhood Framework: http: //www. cdc. gov/violenceprevention/childmaltreatment/essentials. html National Child Traumatic Stress Network http: //nctsn. org Substance Abuse and Mental Health Services Administration http: //samhsa. org