Trauma Informed Care in Early Childhood Understanding trauma
- Slides: 70
Trauma Informed Care in Early Childhood Understanding trauma informed care and responding to trauma’s impact on behavior
Trauma Informed Care in EC • Brought to you by: Early Childhood Mental Health Initiatives Valerie Alloy, Ph. D. , Lead Whole Child Matters Grant • Created by: Ø Erin Lucas, LISW-S Early Childhood Programs Director Hopewell Health Centers, Inc. erin. lucas@hopewellhealth. org Ø Nicole Kennedy, LISW Early Childhood Programs Coordinator Hopewell Health Centers, Inc. Nicole. kennedy@hopewellhealth. org Early Childhood Programs Stress
Objectives 1. Understand trauma & toxic stress 2. Learn effects on social and emotional development 3. Learn strategies to respond to trauma’s effect on behavior
Objective 1: Understand trauma & toxic stress
Defining Trauma: SAMHSA “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. ” (SAMHSA, 2014)
The Three E’s in Trauma Events Circumstances cause trauma Experience Effects
Traumatic Events: (1) render victims helpless by overwhelming force; (2) involve threats to life or bodily integrity, or close personal encounter with violence and death; (3) disrupt a sense of control, connection and meaning; (4) confront human beings with the extremities of helplessness and terror; and (5) evoke the responses of catastrophe. (Judith Herman, Trauma and Recovery, (1992)
Potential Traumatic Events Abuse Emotional Sexual Physical Domestic violence Witnessing violence Bullying Cyberbullying Institutional
Potential Traumatic Events Loss Abandonment Neglect Separation Natural Disaster Accidents Terrorism War Death
Potential Traumatic Events Chronic Stressors Poverty Racism Invasive medical procedures Community Trauma Historical Trauma Family member with substance abuse disorder Family member with a mental illness Bullying
ACE Study Early Death Disease, Disability and Social Problems Adoption of Health-Risk Behaviors Social, Emotional and Cognitive Impairment Disrupted Neurodevelopment Adverse Childhood Experiences The Adverse Childhood Experiences Study (ACE Study) is a research study conducted by Kaiser Permanente health maintenance organization and the Centers for Disease Control and Prevention (CDC). Participants were recruited to the study between 1995 and 1997 and have been in long-term follow up for health outcomes.
ACES: CDC. GOV
Adverse Childhood Experiences are Common! § Of the 17, 000 Participants… § 1 in 4 was exposed to 2 categories of ACEs § 1 in 16 was exposed to 4 categories § 22% were sexually abused as children § 66% of the women experienced abuse, violence or family strife in childhood
Ace Score and Health Risk As the ACE score increases, risk for these health problems increases in a strong and graded fashion:
The Three E’s in Trauma Events Experience Circumstances and dosage matter Effects
Circumstances and dosage matter: Experience of trauma affected by: How? When? Where? How Often?
Circumstances that Increase Impact Context, expectations, and meaning Practices, policies, procedures Threat to life, bodily integrity, or sanity Humiliation, betrayal, or silencing Subconscious or unrecognized
Why are traumatic events different for individuals? How can the same event be traumatic for one person and not for another?
Objective 2: Learn effects on social and emotional development
Healthy Development
The Three E’s in Trauma Events Experience Effects Normal response to an abnormal situation
Signs and Symptoms of Trauma: Infant and Toddlers • Eating & Sleeping disturbance • Reacting to reminders/trauma triggers • Clingy/separation anxiety • Difficulty engaging in social interactions through gestures, • Repetitive/post-traumatic play smiling, cooing • Developmental regression • Persistent self-soothing • Language delay behaviors, for example, head • General fearfulness/new fears, banging • Aggression (toddlers) • Easily startled • Irritable/difficult to soothe
Signs and Symptoms of Trauma: Preschoolers • Avoidant, anxious, clingy • Sadness • General fearfulness/new fears • Repetitive/ post-traumatic play • Talking about the traumatic • Restless, impulsive, hyperactive event and reacting to trauma triggers • Physical symptoms (headache, etc. ) • Developmental regression • Inattention, difficulty problem • Poor peer relationships and solving social problems (controlling/over • Irritability permissive) • Helplessness, passive • Aggressive and/or sexualized behavior
Activity 1: Think of a child you have known that displayed signs of trauma and/or toxic stress. 1. Turn to an elbow partner and share what that looked like, signs and symptoms you’ve observed. 2. What events might have contributed to these signs/symptoms? 3. How does this knowledge increase your empathy for the child/family you serve?
r e r ca t fo r te en s Fo cem ths pla on 6 m Expelled from 2 previous preschoo ls Meltdowns Witness ed violence domestic Transitions Fidgeting Hitt Hi ing din “No” Grandpa died 3 months ago at r pa ty e S xie an nce a t s y sub il Fam e abus on nti tte R ing n un ssi ng Ina Kicked o ut babysitt of er’s house ion Cu g 3 adults 4 kids 2 bedroom h ome 6 different caregivers in last 3 months
Compounding Effects Early occurrence Being silenced or not believed Blaming or shaming Perpetrator is trusted caregiver
Effect: Strengths vs. Risks Protective Factors Risk Factors • Attachment • Initiative/Curiosity • Self- Regulation • Trauma history • Poverty • Stressful events
Trauma and Development A child's ability to adapt, use internal coping resources, and employ defense mechanisms in the face of trauma are determined by: Ø Development (brain development, self-regulation, psychosocial development, cognitive functioning and communication) Ø Attachment relationships (an attuned and responsive caregiver, social environment) Ø Resilience (ability to bounce back from life's adversity based on protective factors such as good health, easy going temperament, close relationships, consistent parenting, etc. ) • (Cook et al, 2003; Blumenfeld et al, 2010)
Meltdowns r e r ca t fo r te en s Fo cem ths pla on 6 m Expelled from 2 previous preschoo ls Witnessed do mestic violence Transitions Fidgeting Hitt Hi ing din “No” Grandpa died 3 months ago at r pa ty e S xie an nce a t s y sub il Fam e abus on nti tte R ing n un ssi ng Ina Kicked o ut babysitt of er’s house ion Cu g 3 adults 4 kids 2 bedroom h ome 6 different caregivers in last 3 months
How Trauma Impacts the Brain Early Death Disease, Disability and Social Problems Adoption of Health. Risk Behaviors Social, Emotional and Cognitive Impairment Disrupted Neurodevelopment Adverse Childhood Experiences
State Dependent Functioning Used with permission by Dr. Bruce D Perry, www. childtrauma. org
Activity 2: Recognizing signs of emotional distress Calm Alert Alarm Fear Terror
Shift in Thinking: Through the trauma lens… Instead of… How about? What is your diagnosis? What is your story? What has brought you here? What are your symptoms? How have you coped and adapted? How can I best help or treat you? How can we work together to figure out what helps?
Shift in Thinking: Coping mechanisms Mislabeled “Normal” Responses Survival Responses Fight Coping Behaviors Labeled by Systems Struggling to regain or hold on to power, especially when feeling coerced “Non-compliant” “In denial” “Combative” “Challenges authority” “Treatment resistant” Giving in to whoever/whatever is in a position of power Disengaging completely: keeping to oneself, leaving services, abandoning housing, etc. Flight Freeze “Passive” “Can’t be helped” “Using the system” “Chronic” “Unmotivated” When coping behaviors are labeled as “symptoms” or problems, they can easily become the focus of relationships. This is NOT how people heal!
Objective 3: Strategies to respond to trauma’s impact on behavior
Strategies to Respond: Understanding opportunity
r e r ca t fo r te en s Fo cem ths pla on 6 m Expelled from 2 previous preschoo ls Meltdowns Witnessed do mestic violence Transitions Hitting Hi din Fidgeting “No” Grandpa died 3 months ago at r pa ty e S xie an ce tan s b u s on nti tte R ing n un ssi ng Ina Kicked o ut babysitt of er’s house ion Cu g 3 adults 4 kids 2 bedroom h ome ily Fam e abus 6 different caregivers in last 3 months
Strategies to Respond: Action planning cycle Assess Plan Evaluate Implement
Action Planning Cycle: Assessment Phase Asses s ØComponents: § Parent & Early Learning Professional (ELP) Interview o. Parent & ELP Questionnaire § Observation of Child In each component, how might you use a trauma informed perspective in gathering information?
Assessment Phase: Interview and Questionnaire Trauma Informed Purpose Understand Experience • Gather information and history to guide planning Understand Environment • Obtain feedback between settings and caregivers Understand Protective Factors • Identify routines, strengths, and potential areas for growth
Parent & ELP Interview: Suggested Tools DECA Preschool Program • Discussion Questions and Family Questionnaire • Team Meeting Preparation Questions Georgetown Model • Family Routines and Activities Questionnaire • Functional Behavior Assessment Help Me Grow Early Intervention • Routines Based Interview Trauma Treatment and Training Center • Childhood Trust Events Survey: Caregiver Form
Parent & ELP Questionnaire: Suggested Tools Devereux Early Childhood Assessment (DECA) • DECA-I/T • DECA-P 2 Ages and Stages Questionnaires • ASQ-3 • ASQ: SE-2 Help Me Grow Early Intervention • Bayley-III and Batelle • Social Emotional Parent Questionnaire • Batelle Others: • ODE • ODJFS
Action Planning Cycle: Observation of Child Trauma Informed Purpose Observe Behavior • Observe behavior in context of routines and interactions Observe Impact • Assess overlapping developmental domains Observe Meaning • Identify potential themes, trends, or cycles of behavior
Observation of Child: Suggested Tools DECA Preschool Program • Child Observation Form (I/T and Preschool) Georgetown Model • Observation Toolkit for Mental Health Consultants Help Me Grow Early Intervention • Bayley-III • Batelle Others: • ODE • ODJFS
Activity 3: Taking your “child” through the assessment phase Assess
Identifying Strengths: 1. What are this child’s existing strengths? 2. How could these strengths be used in our setting? 3. When can these strengths be used within our routine?
Identifying Areas for Growth: 1. What are they? 2. How could trauma or toxic stress be impacting this behavior? 3. What state is this child functioning in when this behavior occurs? 4. Where are opportunities in the daily routine to build these skills?
Adjusting Our Lens: How is my “lens” impacting my perception of this child? Their behavior? Their caregivers? Other professionals?
Action Planning Cycle: Developing a Plan ØComponents: § SNAP: Strengths, Needs, Abilities, Preferences § Goal(s) § Strategies § Evaluation and Follow up
Developing a Plan: Suggested Planning Tools DECA Planning Model • Child Strengths, Goals, and Strategies Plan • Positive Guidance Plan Georgetown Planning Model • Facilitating Individualized Interventions to Address Challenging Behavior Toolkit Help Me Grow Early Intervention Model • Individualized Family Service Plan (IFSP) Others: • ODE • ODJFS
Action Planning Cycle: Developing a Plan Trauma Informed Purpose Plan for Events Create new Experience Change Effects • Use assessment information to outline future responses • Change expectations using strategies that promote protective factors • Support behavior congruent to new events, stressors, and experiences
Resources: Building Emotional Intelligence
Resources: Sesame Street Topic specific videos with printable resources and tools for educators and families: • • • Divorce Grief Incarceration Military Families Resilience Support After An Emergency
Resources: Trauma and Loss The National Institute for Trauma and Loss in Children Resources for professionals and families Ø One Minute Interventions for Traumatized Children and Adolescents § Brief intervention strategies for ages 3 -18 § Themes: safety, worry, hurt, fear, anger, relaxation, and survivor § Crisis Intervention Tips
Resources: Devereux Center for Resilient Children Centerforresilientchildren. org
Resources: Georgetown • Teaching Tools for Young Children • Taking Care of Ourselves: Stress Reduction and Relaxation Ecmhc. org
Strategies: ECMH Consultant See Sample Handout: • • • • Morning Rituals Circle Time Songs for Transitions End of Day Rituals Clearly Defined Learning Space Visual Routines Alone Time Helper Duties Labeled Praise Music Movement Social Stories Zones of Emotional Regulation Non-Verbal/Visual Cues
Toxic Stress to Safe Zone: Preventing Escalation Calm • Play • Teach • Learn Alert • Sing • Prep • Voice • Sing • Less Alarm words • Step away Fear • Step Away • Calm self • Space • Stay Away Terror • Stay Calm • Safety
Creating a Safe Zone: Responding to Toxicity • Regulation § Children are co-regulators § If the adult is not regulated, the child will not be able to regulate • Step Back • Give Space • Process after the child has calmed down
Activity 4: Using resources to practice planning Plan
You’ve created a classroom!
With your group, answer the following and document your plan using the sample form: 1. Identify overlapping strengths and areas for growth amongst the children in your “classroom” 2. Select a strategy or resource from your kit that could be used to prevent or respond to challenging behavior in this “classroom” 3. How could this strategy be used in a daily routine? 4. Share out with the larger group when finished
Action Planning Cycle: Implementation Implement Ø Techniques for Implementation § Teaming Approach: Regular contact for consultation between providers and caregivers § Support or coach adults for implementation in the natural environment § Continue to share strategies and resources with caregivers
Action Planning Cycle: Evaluation Evaluate ØComponents § Repeat assessment phase interviews, questionnaires, and observations § Analyze pre/post data § Review and revise plan, as needed
Reviewing Our Objectives… üUnderstand trauma & toxic stress. üLearn effects on social and emotional development. üLearn strategies to respond to trauma’s effect on behavior.
Reflections, Questions, and Takeaways…
Closing: Thank you for your time and attention! • Please complete evaluations Special thanks to Dr. Alloy and the Whole Child Matters grant for making this training possible.
Trauma Informed Care in EC: • • • References Blumenfeld, S. , Groves, B. M. , Rice, K. F. , & Weinreb, M. (2010). Children and trauma: A curriculum for mental health clinicians. Chicago: The Domestic Violence & Mental Health Policy Initiative. Chadwick Center for Children and Families (2009). Assessment-Based Treatment for Traumatized Children: A Trauma Assessment Pathway (TAP). San Diego, CA: Author. Retrieved August 17, 2010 from http: //www. TAPtraining. net/ Center on the Developing Child (ND) Toxic Stress Response: Questions & Answers. Boston: Harvard University. Available at http: //developingchild. harvard. edu/topics/science_of_early_childhood/toxic_stress_response/ Cohen, E. & Walthall, B. (2003) Silent Realities: Supporting Young Children and Their Families Who Experienced Violence. Washington DC: The National Child Welfare Resource Center for Family-Centered Practice. Cook, A. , Blaustein, M. , Spinazzola, J. , & van der Kolk, B. Eds. , (2003). Complex trauma in children and adolescents: White paper. National Child Traumatic Stress Network. Retrieved July 2005 from http: //www. NCTSN. org/ Cooper, J. L. , Masi, R. , Dababnah, S. , Aratani, Y. , & Knitzer, J. (2007). Strengthening policies to support children, youth, and families who experience trauma: Unclaimed Children Revisited, Working Paper No. 2. Retrieved August 5, 2010 from http: //www. nccp. org/publications/pub_737. html Early Promotion and Prevention Research Consortium (2008). Research to Practice: Lessons learned from interventions to address Infant Mental Health in Early Head Start. Administration for Children & Families, Health and Human Services, Office of Planning, Research, and Evaluation. Retrieved August 14, 2010 http: //www. acf. hhs. gov/programs/opre/ehs/epirc/ Early Trauma Treatment Network, (ND) Trauma definition. University of San Francisco. Groves, B. M. (2002) Children Who See Too Much: Lessons from the Child Witness to Violence Project. Beacon Press. Groves, B. M. (2007). Early intervention as prevention: Addressing trauma in young children in Traumatic Stress/Child Welfare. Focal Point: Research, policy, & practice in children's mental health. Winter 2007, Research and Training Center, Portland OR: Portland State University, policy & Practice. Available at http: //www. rtc. pdx. edu/PDF/fp. W 07. pdf
Trauma Informed Care in EC : References • • • • Lieberman, A. F. , Padron, E. , Van Horn, P, & Harris, W. W. (2005). Angels in the Nursery: The intergenerational transmission of benevolent parental influences. Infant Mental Health Journal, 26, 504 -520. Masten, A. S. (2001). Ordinary magic: Resilience Processes in Development. American Psychologist, 56(3), 227 -238. National Center for Child Traumatic Stress (2010) Current and Affiliated NCTSN Organizational Members. Retrieved on August 10, 2010 from http: //www. nctsnet. org/about-us/network-members National Center for Child Traumatic Stress, Zero To Six Collaborative Group (2010) Early Childhood Trauma. Retrieved on August 23 from http: //www. nctsnet. org/sites/default/files/assets/pdfs/nctsn_earlychildhoodtrauma_08 -2010 final. pdf National Research Council and Institute of Medicine (2000). From Neurons to Neighborhoods: the Science of Early Childhood Development. Committee on Integrating the Science of Early Childhood Development. Jack P. Shonkoff and Deborah A. Phillips. Ed. s Board on Children, Youth, and Families, Commission on Behavioral and Social Sciences and Education. Washington, DC: National Academy Press. National Scientific Council on the Developing Child (2010). Persistent Fear and Anxiety Can Affect Young Children's Learning and Development: Working Paper #9. Boston: Center on the Developing Child at Harvard University. Available at http: //www. developingchild. net/ National Scientific Council on the Developing Child (2005). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper #3. Boston: Center on the Developing Child at Harvard University. Available at http: //www. developingchild. net/ National Scientific Council on the Developing Child (ND). In Brief: The Impact of Early Adversity on Children's Development. Boston: Center on the Developing Child at Harvard University. Available at http: //developingchild. harvard. edu/library/multimedia/inbrief_series/ National Scientific Council on the Developing Child (ND). In Brief: The Science of Early Childhood Development. Boston: Center on the Developing Child at Harvard University. Available at http: //developingchild. harvard. edu/library/multimedia/inbrief_series/ National Scientific Council on the Developing Child (2007). The Timing and quality of Early Experiences combine to Shape Brain Architecture: Working paper #5. Boston: Center on the Developing Child at Harvard University. Available at http: //www. developingchild. net/ National Child Traumatic Stress Network (2008). Child Welfare Trauma Training Toolkit. Retrieved on August 20, 2010 from http: //www. nctsnet. org/nccts/nav. do? pid=ctr_cwtool Osofsky, J. D. (1996). When the helper is hurting. In J. Osofsky and E. Fenichel (Eds. ), Islands of Safety Washington, DC: Zero to Three. Office of Planning, Research, and Evaluation, Administration for Children and Families (2000, 2006) The Family and Child Experiences Survey (FACES). Washington DC: U. S. Department of Health and Human Services. Reports available at http: //www. acf. hhs. gov/programs/opre/hs/faces/ Rice, K. F. & Groves B. M. (2005). Hope & healing: A caregiver's guide to helping young children affected by trauma. Washington DC: ZERO TO THREE Press.
Trauma Informed Care in EC : • • • References Saakvitne, K. , Gamble, S, Pearlman L, & Tabor Lev, B (2000). Risking Connection: A Training Curriculum for Working with Survivors of Childhood Abuse. Baltimore, MD: Sidran Press. Scheeringa, M. Personal communication on August 10, 2010 co-author of Preschool PTSD Treatment (PPT) Scheeringa, M. S. & Zeanah, C. H. (2001). A relational perspective on PTSD in early childhood. Journal of Traumatic Stress, 14(4), 799 -815+ van der Kolk, B. , Pynoos, R. , Cicchetti, D. , Cloitre, M. , D'Andrea, W. , Ford, J. , Liebermann, A. , Putnam, F. , Saxe, G. , Spinazolla, J. , Stolbach, B. , & Teicher, M. (2009). Proposal to include a developmental trauma disorder diagnosis for children and adolescents in DSM-V. Retrieved September 24, 2010 from http: //www. traumacenter. org/ van der Kolk, B. (2005). Developmental trauma disorder: Towards a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35, 401 -408. Van Horn, P. (2008). Children Exposed to Domestic Violence: A Curriculum for DV Advocates. Chicago: Domestic Violence & Mental Health Policy Initiative. ZERO TO THREE (2005). Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, Revised (DC: 0 -3 R) Washington DC: ZERO TO THREE Press ZERO TO THREE (ND). FAQ's On the Brain. Washington DC: Author Retrieved on August 13, 2010 from http: //www. zerotothree. org/child-development/brain-development/faqs-on-the-brain. html Zindler, P. Hogan, A. & Graham, M. (2010). Addressing the unique trauma-related needs of young children. Tallahassee: Florida State University Center for Prevention & Early Intervention Policy. Retrieved August 25, 2010 from http: //cpeip. fsu. edu/resourcefiles/Trauma. Related_needs_children. pdf? CFID=135049&CFTOKEN=4 4089600 http: //itstartsintheheart. weebly. com/printables. html
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