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Using Trauma Informed Care Approaches with Students who are Deaf or Hard of Hearing Michelle Niehaus, LCSW Program Administrator Deaf and Hard of Hearing Services KY Division of Behavioral Health Angela Simpson School Social Worker Kentucky School for the Deaf
Imagine for a Moment… You have a six year old boy in your classroom. He has difficulty sitting down in class and occasionally erupts in anger when asked to do something he doesn’t want to do. He is African-American and currently lives with a white foster family. He experienced physical abuse in his family of origin. He is very behind academically and struggles with both written English and sign. He has hearing aids but rarely brings them to school. …Later…you see him in middle school. He is aggressive towards others and some say he is sexually acting out with other boys in his dorm. He can communicate his wants and needs in concrete terms yet doesn’t seem to connect his actions and consequences. Sometimes he “tunes out” for long periods of time which frustrates school staff and his peers. His behaviors are putting him at risk of expulsion.
What is it with this kid? We’ve tried everything!. . . Or Have We? Explore with us today… v What “trauma” is – what can be labeled trauma in general and with Deaf or Hard of Hearing children in particular v Behaviors that may be trauma-related and how to reframe them v Coping Skills for Children who have Experienced Trauma v Resources for addressing trauma and for helping your students
Trauma Psychological Trauma occurs when… Trauma �Often leaves the individual feeling helpless and/or powerless ordinary selfcare that provides the individual with a sense of control, connection, and meaning in life � The person experiences a threat to life, bodily integrity, or sanity; � The circumstances of the event include abuse of power, betrayal of trust, entrapment, helplessness, pain, confusion, and/or loss � The ability to cope (integrate emotional experience) is overwhelmed �Overwhelms Pearlman& Saakvitne, 1995; Giller, 2003)
What do we mean by “trauma? ” It is the individual’s personal experience of an event that determines whether it is or is not traumatic The meaning The feelings The severity The loss of control The unexpectedness
Thinking of these definitions, what are some of the traumas your students have experienced? q Which are experiences that any child may have? q Which are unique to being Deaf or Hard of Hearing?
Types of Traumas all Children May Experiences Physical Abuse** Sexual Abuse** Neglect Witnessing Domestic Violence Natural Disasters Death of a Loved One Divorce Abandonment / Separation Traumas Unique to Children who are Deaf or Hard of Hearing Language Deprivation Educational Deprivation Information Deprivation Trauma (IDT) Multiple Medical Procedures
Statistics on Trauma among Children who are Deaf or Hard of Hearing A 2010 Study at Rochester Institute of Technology (RIT) found that 77% of Deaf or Hard of Hearing respondents vs 49% of hearing respondents had experienced maltreatment (http: //www. handsandvoices. org/resources/OUR/2014/study. html) Increased severity of hearing loss was correlated with increased rate and severity of maltreatment Having a deaf parent or a family member who signs, or being part of the deaf community, did not reduce the risk of childhood maltreatment The rate of depression and post-traumatic stress was also higher among all deaf and hard-of-hearing respondents regardless of maltreatment
Kentucky School for the Deaf (information up to date as of 10/31/2017) District: Kentucky School For The Deaf (part state agency, part school) Founded: Apr 10, 1823 Current Enrollment: 28 elementary, 16 Middle, 56 High School type: Public K-12 Takes children from all across the state of Kentucky. Offers a residential/student life program Awarded the AWARE grant in 2016.
Our Students at KSD *Currently we have students in therapy dealing with loss of loved ones, witnessing domestic violence, being a victim of child abuse/neglect, and other issues involving trauma, as well as other mental health issues. *Approximately 20% of our students received school based mental health services to address this, and several also receive case management services. This will continue to grow as new children are identified and referred on a regular basis, and as our network of mental health providers grow. *Some of the trauma has manifested in acting out behavior, self harm, and threats of suicide. It may also manifest as difficulty with interpersonal relationships or learning difficulties/difficulty focusing in the classroom. A lot of this acting out behavior is not seen during the day in the classroom but in the dorms. This is why the Mental Health First Aid was so important for all of our staff, not just teachers, to have. *Some of the students we have are refugees and had experienced trauma prior to coming to the US. These children deal with a double issue of having trauma and often language deprivation resulting in the inability to express what they have experienced.
Trauma and “The ACEs” http: //theprojectbond. com/wp-content/uploads/2015/03/Behavior-is-an-Iceberg-Project-Bond. png
Past Trauma Can Add Layers and Affect Interpretation
For Many Deaf Individuals, System Experiences were Traumatizing
Re-Traumatizing Environments: A Lesson from Jan De. Vinney “No energy. Battles to do. No accessible tty. Closed captioning on the tv? I doubt it. Educating them. Last night the nurse told me I would learn this weekend to accept help…wrong! I have to care for myself as usual…I’m getting more and more isolated with less and less energy to help myself, as well as less desire to try. ” p. Xxv in Glickman’s Mental Health Care of Deaf People
Language Deprivation Syndrome Overview of Language Deprivation Syndrome Indicators of Language Deprivation Syndrome Ø Language dysfluency Ø Fund of knowledge deficits Ø Disruptions in thinking, mood, and/or behavior. See Full Article: Hall, W. C. , Levin, L. L. & Anderson, M. L. Soc Psychiatry Psychiatr Epidemiol (2017) 52: 761. https: //doi. org/10. 1007/s 00127017 -1351 -7 For more in depth information, see Dr. Gupta’s lecture at Brown University: https: //www. youtube. com/watch? v=8 yy_K 6 Vt. HJw
Behaviors Sometimes Seen in Trauma Survivors…. and Why…
What Could the Trauma Look Like? � People who have endured trauma often experience fear, depression, anxiety, lack of trust, and difficulty feeling safe � An individual’s affect may not reflect the level of emotions experienced � A range of emotions can be experienced and expressed in different ways – seeing the individual is critical � A person may have difficulty staying in the “here and now” � Memories are typically fragmented, non-sequential, and filled with gaps Timelines may be distorted Gaps could be filled in with that seems logical (vs. accurate)
Think About… How may a trauma reaction mirror language dysfluency? Could it be misunderstood as a cognitive issue? Could the survivor have a different way of describing his or her experience? Do those involved understand the “typical” ways of expression in the deaf community? Is the interpreter equipped to handle the information? Do those investigating understand Deaf culture, ASL, and how to work with Deaf children?
Did You Know? Developmental Trauma Can Be Framed as a Type of Brain Injury
Trauma Affects the Brain: Lateral Ventricles Measures in an 11 Year Old Maltreated Male with Chronic PTSD, Compared with a Healthy, Non-Maltreated Matched Control (De Bellis et al. , 1999)
How the brain is affected…possibly for life… Dr. Michael De. Bellis (pronounced: Bayless with a long ‘a’) and his colleagues published a study in Biological Psychiatry in 1999. Dr. De. Bellis studied the brains of children who were abused and compared them to the brains of children who were not abused. Dr. De. Bellis found that the brains of children who had been abused were different. The thick white band or cerebral cortex has atrophied or shrunk The hippocampus and the amygdala. These structures also decrease in size. The lateral ventricles, on the other hand, increase in size in people who are traumatized. See this black triangle shapes on left image and how much larger they are in the MRI image of the child with trauma on the right? Trauma physically effects the brain and how it functions. Karestan Koenen, a researcher from Boston, published a groundbreaking twin study in 2003. She looked at twins who were discordant for trauma, meaning one had a history of trauma and one did not. What she found was that the twin who had a trauma history, had on average, an 8 -point reduction in IQ scores – the only distinguishing variable was the trauma. Lowered IQ is a significant risk factor for other negative outcomes, like school failure and juvenile delinquency. What this means is that people with trauma histories, can also have brains that have been adversely effected by that experience. So, trauma can directly effect learning and day-to-day functioning of the people we serve, for the rest of their lives.
Review of Brain Structure and its Functions… From www. easysciencefor kids. com.
Behaviors Sometimes Seen in Children Looks like…. ADHD Anger / Outbursts “He just knows how to push my buttons!” BIG emotions! Or…. no emotions shown (Over- or Under-Reacting to events, people, and environment) Anxiety, Fear, Worry Discussing or drawing death or dying Changes in behavior including grades Difficulty with authority As you develop your “trauma lens, ” think about what behaviors may be telling you…. . http: //theprojectbond. com/wp-content/uploads/2015/03/Behavior-is-an-Iceberg-Project-Bond. png
Taking a “Bottom Up” Approach to Developmental Trauma https: //www. youtube. com/watch? v=FOCTxca. NHeg
Strategies to Help Children who have Experienced Trauma We Have to Start Somewhere…
Creating a Compassionate Holding Environment Establish a solid communication foundation Respect individual language needs Value the individual in all aspects of care Use neutral, objective and supportive language How could sign choice affect a person’s perception? Individually flexible plans and approaches If a Deaf child is the only one in a school, how could that add to the trauma? What strategies could mediate that isolation? Avoid shaming or humiliation at all times 1. Recognize when a child is going into survival mode and respond in a kind and compassionate way. 2. Create calm, predictable transitions. 3. Praise publicly and criticize privately. 4. Adopt or Adapt mindfulness practices. 5. Take care of yourself! http: //greatergood. berkeley. edu/article/ite m/the_silent_epidemic_in_our_classrooms
Building Resiliency…Changing the Contents of the “Invisible Backpack” What messages do your students bring with them to school… …due to their hearing loss and/or other disabilities? …due to their race or ethnicity? …due to their Socioeconiomic Status? …due to their home environment? What messages do you want to send them home with? How can / do you partner with parents to make those messages consistent at home and school?
Skills Educators Can Use to Address Trauma in Children 1. Establish Safety 2. Use Clear, Consistent, Specific Behavior Management Techniques 3. Teach Stress Management / Self Regulation / Relaxation Skills 4. Teach Emotional Vocabulary / Model Expression of Emotions and Coping Skills 5. Identify and Connect with Social Supports Including Role Models 6. Enhance Future Safety by Working with Team around the Child 7. Practice Patience…. and Don’t Take Behavior Personally! 8. Manage Your Own Personal and Professional Stress http: //nyspbis. org/RF 1617/Powerpoints/Applying%20 Trauma%20 Informed%20 Strategies%20 to%20 Classrooms%20 a nd%20 Student%20 Interactions. pdf
In Trauma-Informed Work… Educators Can Help By… Clinicians are Trying To… Maintain Calm/Continuous/ Engaged State Prevent Discontinuous States Build Cognitive Structures that allow choices � Validating the individual by recognizing when a flashback may be occurring � Checking with the Survivor for clarity as needed � Helping to ground the student in the “here and now. ” Using repetitive phrases or a touchstone. � Discussing with parents and the school counselor or team how to handle dissociative states at home and school � Using visuals if needed to establish timelines � Showing patience and allow the survivor to set the pace � Realizing that confusion is probably not about resistance or unwillingness to “cooperate”
Trauma Informed Care…Going from “What’s wrong with you? ” to “What happened to you? ” Emotional and Physical Pain Victim Blaming Many of us walk around with hidden wounds. Trauma informed work is like using universal precautions for emotions.
Considerations for Trauma-Informed Work � � � A Dysregulated Nervous System Fight or Flight Mechanisms “The Reptile Brain” Info Dumping Cognitive vs. Sensory Based or Safety Based Interventions The Effects of the Environment Current and Past Validating or Invalidating And For Deaf Victims… Effectiveness and Accuracy of the Interpreting Cross-Cultural Understanding Fund of Information regarding Abuse Issues
Be Aware of Potential Triggers �A trigger is something that sets off an action, process, or series of events (such as fear, panic, upset, agitation): Situations that mirror when or where abuse or incident happened What examples can you think of? �How would you sign “trigger? ” What is one sign choice that could re-traumatize?
Protective Factors: Building Resilience and Connection Families Must be Supported and Equipped: Kentucky’s Strengthening Families Initiative Protective Factors Nurturing and Attachment Knowledge of Child Development Concrete Support in Times of Need Social and Emotional Competence of Children Social Connections Parental Resilience Parent Cafes as a Means to Grow Connection Research has shown a correlation between connection with the Deaf community and reduced PTSD and symptoms of trauma (file: ///H: /Child%20 Maltreatment%20 and%20 Trauma%20 Exposure%20 in%20 Deaf%20 Children%20 a nd%20 Youth. pdf) Being part of the Deaf community Having access to others who are Deaf How can we connect children who use listening and spoken language more effectively? How can we be more inclusive of ALL children and families?
COMMUNICATION as Essential: A Vital Protective Factor Children MUST be able to communicate basic safety concerns at home and school Consider incorporating safety and self advocacy goals into IFSPs and IEPS. For resources on this… http: //deafed-childabuse-neglectcol. wiki. educ. msu. edu/Silence+is+NOT+an+Option KSD Outreach Consultants offer local sign language dinners and other socials where parents can strengthen their sign communication skills RESPECT the communication choices of families and support them to get what they need for effective communication in the home (ex. Telehealth for speech therapy)
Considering Mediated Treatment: The Impact of An Interpreter in Trauma Work Not all ASL interpreters are equipped for working with people who have experienced trauma Interpreters are at risk for vicarious trauma as well Conflicts of interest / Dual relationships will be common in educational settings and rural areas Promising work is being done out of Boise, Idaho on “The Equitable Triad” and Healing Encounters at their Center on Refugees
Resources for Helping Children who are at Risk for or Who have Experienced Trauma
Observe, Understand & Respond: the O. U. R. Children's Safety Project A wealth of information on abuse prevention specifically for children who are Deaf or Hard of Hearing developed through a Hands & Voices network: http: //www. handsandvoices. org/resources/OUR/index. htm Hotline Specifically for D/HH Population One of the accomplishments of this project is partnering with Child. Help. org and the creation of a toll-free number specifically for support for children who are dhh. This number can be called by anyone anonymously who needs information/support about a particular situation. The number is 1 -800 -222 -4453.
Kentucky’s Specialists in Deaf Mental Health Care Community Mental Health Centers Other Providers Therapists § Laura Burg, LCSW – Bluegrass § § Erin Schilling, LCSW – Centerstone Holly Bean – Family Works Therapy Services, Bowling Green area § Julie Dalbom, LPCC - Centerstone § Dennis Wagner – Forensic Evaluations, Louisville area Targeted Case Managers § Rhonda Mc. Query – Bluegrass § Dodie Karr – Cumberland River
CMHC Point People for Deaf and Hard of Hearing Services [email protected] rbh. org Four Rivers David Hedrich Pennyroyal Kelly Robertson [email protected] org River Valley Mary Kay Lamb [email protected] com Lifeskills Renee Hudson [email protected] com Communicare Calvin Jackson [email protected] org Centerstone Erin Schilling Erin. [email protected] org North. Key Larry Lindeman [email protected] org Comprehend Steve Lowder [email protected] org Pathways Elizabeth Fitzer Elizabeth. [email protected] org Mountain Heather Greene heather. [email protected] org Kentucky River Kathy Gilliam kgilliam [email protected] com CRCC Greta Baker Greta. [email protected] org Adanta Angelia Bryant Adanta Kathrina Riley [email protected] org Bluegrass Laura Burg [email protected] org DDID [email protected] org
KY Managed Care Organizations (MCO) Behavioral Health Hotlines Aetna Better Health of Kentucky Anthem Blue Cross Blue Shield Medicaid 1 -877 -380 -9729 Passport Health Plan 1 -855 -690 -7784 Humana Care. Source 1 -888 -604 -6106 1 -855 -834 -5651 Wellcare of Kentucky 1 -855 -661 -6973 Behavioral Health Hotlines are available 24 hours.
KSD Approaches to Trauma Informed Care in the School KSD had been awarded the AWARE (Advancing Wellness and Resilience Education) grant. Trauma Training through CTAC had already been initiated and trainings had taken place. There was a mental health team up and running. They discussed the needs of the students and what actions/interventions were needed. They also discussed the lack of services available at the time and how to address those. ABRI was working with KSD and PBIS was being discussed. Mental Health First Aid trainings were in the process of being initiated.
What the AWARE Grant DID for KSD…. . Educated our teachers and staff about mental health *All staff received Mental Health First Aid training. *Some staff attended the ADARA Conference which focuses on Mental Health in Deaf Services. Even more staff attended various other mental health conferences. The information was brought back and shared with other staff and community partners. Increased Awareness/decreased the stigma *Mental Health Awareness Days have been used to educate both students and staff about mental heath issues. We focus on fun activities that teach coping skills, executive functioning, help students set goals, and try to normalize Mental Health by addressing as being no different then having a physical health condition. We have also used these days to bring in numerous community partners such as law enforcement, mental health agencies, the health department, and others to help promote community partnerships. Gave better access to equal mental health treatment *Without the AWARE grant our children who are on Passport insurance, have straight Medicaid, or need to see their therapist for an emergency session would not have access to an interpreter. The AWARE grant currently pays for interpreters for these children on an ongoing basis.
For Additional Study… Clinicians, DCBS Workers, Medical Providers, School Counselors, Families, and YOU may benefit from. . Addressing the Trauma Treatment Needs of Deaf Children and the Hearing Children of Deaf Parents. Available in pdf format at http: //www. nctsnet. org/nctsn_assets/pdfs/edu_materials/Trauma_Deaf_Hard-of. Hearing_Children. pdf DMH Facts: Trauma and the Deaf Community. Available in pdf format at https: //dmh. mo. gov/deafsvcs/docs/dmhfacts-traumaandthedeafcommunity. pdf Tate, Candice. (2012). Trauma in the Deaf Population: Definition, Experience, and Services. Alexandria, VA: National Association of State Mental Health Program Directions (NASMHPD). Hegge and Goffman. Childhood Trauma: Identification, Treatment, and Hope. Available online at http: //www. handsandvoices. org/resources/OUR/2014/childhood-trauma. html. Live Trainings and Networking Opportunities This workshop can be adapted and presented in your community! O. U. R. Children Project offers monthly calls #DEAFED Twitter Chats held monthly System of Care Academy DHHS Track – June 19 -21 st in Lexington
References / Special Thanks to. . Fran Belvin, Sally Mason, and Lynn Posze for their slides and input on this presentation originally given for interpreters http: //www. samhsa. gov/nctic/ Joseph Batiano and Morag Mac. Donald for their ongoing advice and perspective as well as their May 2016 trainings in Kentucky
Remember the little boy we started discussing? We hope this workshop has helped you to see him through a different lens and to consider how you may approach him differently when next you meet
Please Stay in Touch! Michelle Niehaus, LCSW Angela Simpson Program Administrator School Social Worker Deaf and Hard of Hearing Services KY Division of Behavioral Health Michelle. [email protected] gov (502) 782 -6181 (V) (502) 385 -0460 (VP) Kentucky School for the Deaf Angela. [email protected] kyschools. us (859) 239 -7017