Impact of Trauma on Children Kimberly McGrath, Psy.D.

Impact of Trauma on Children Kimberly McGrath, Psy.D.

Impact of Trauma on Children Kimberly McGrath, Psy.D. Putting Trauma into Perspective What is trauma? What is it like to be a person suffering from trauma? How does traumatic experiences change a person? Why is it important to understand trauma? How can understanding the impact of trauma improve services? What can I do? 2014 Citrus Health Network, Inc., all rights reserved.

2 Types of Traumatic Events Neglect

Physical abuse/assault Sexual abuse/assault Natural disaster Exposure to violence Traumatic grief Serious accident Military combat Terror attack 2014 Citrus Health Network, Inc., all rights reserved. 3 Trauma

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 individuals functioning and mental, physical, social, emotional, or spiritual well-being (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012, p. 7). DSM-5 expands the definition of trauma to include vicarious exposure: Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: directly experiencing the traumatic event(s); witnessing, in person, the traumatic event(s) as it occurred to others; learning that the traumatic event(s) occurred to a close family member or close friend (in case of threatened death of a family member or friend, the event(s) must have been violent or accidental); or experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (p. 271). 2014 Citrus Health Network, Inc., all

rights reserved. 4 THE THREE ES OF TRAUMA: EVENT(S), EXPERIENCE OF EVENT(S), AND EFFECT Events-The actual or extreme threat of physical or psychological harm. May occur as a single event or over time. Experience-How the individual experiences the event. How the event is experienced may be linked to a range of factors including the individuals cultural development.

Effects-The critical component of trauma. Can be immediate or long term effects. The duration of the effects can be short to long term. Trauma By The Numbers Approximately 7.7 million American adults age 18 and older, or about 3.5 percent of people in this age group in a given year, have PTSD 51% of the general population have experienced trauma in childhood 98% of people served by behavioral health have experienced trauma ACEs emerged from an effort of researchers to identify trauma experienced in childhood that correlated with health problems in adulthood (Felitti et al, 1998)

10-item scale: emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, family violence, parental substance use, parental mental illness, parental divorce/separation or abandonment, and parental incarceration Adverse Childhood Experience (ACE) Questionnaire Finding your ACE Score While you were growing up, during your first 18 years of life: Did a parent or other adult in the household often Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?

Yes No If yes enter 1 ________ Did a parent or other adult in the household often Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? Yes No If yes enter 1 ________

2014 Citrus Health Network, Inc., all rights reserved. 8 Adverse Childhood Experiences Did an adult or person at least 5 years older than you ever Touch or fondle you or have you touch their body in a sexual way? or Try to or actually have oral, anal, or vaginal sex with you?

Yes No If yes enter 1 ________ Did you often feel that No one in your family loved you or thought you were important or special? or Your family didnt look out for each other, feel close to each other, or support each other? Yes No If yes enter 1 ________

Did you often feel that You didnt have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? Yes No If yes enter 1 ________ The Adverse Childhood Experiences (ACE) Study

ACE Study includes over 17,000 participants-ages 19 to 90 64% of participants experienced at least one exposure, and of those, 69% reported two or more incidents of childhood trauma. Results demonstrated connection between childhood trauma exposure, high-risk behaviors & chronic illness such as heart disease and cancer, and early death Adverse Childhood Experiences ACE Study Findings 1 in 6 men have experienced emotional trauma 80% of people in psychiatric hospitals have experienced physical or sexual abuse 66% of people in substance abuse treatment report childhood abuse or neglect 90% of women with alcoholism have experienced trauma

Adverse Childhood Experiences ACE Study Findings 67% of all suicide attempts 64% of adult suicide attempts 80% of child/adolescent suicide attempts Are Attributable to Childhood Adverse Experiences High cumulative ACE scores (4+) increased risk of suicide , increase risk of engaging in risky behaviors (Hillis, Anda, Felitti, & Marchbanks, 2001), depressive disorders (Kerker et al., 2015), alcoholism and drug use (Anda et al., 2002), physical health problems (Anda et al., 2008)

(Dube et al., 2001) Consequences for Physical Health Traumatic experiences in childhood have been linked to increased medical conditions throughout the individuals lives. The Adverse Childhood Experiences (ACE) Study Results demonstrated connection between childhood trauma exposure, high-risk behaviors & chronic illness such as heart disease and cancer, and early death Polyvictimization

Polyvictimization, also known as complex trauma, describes the experience of multiple victimizations of different types, such as sexual abuse, physical abuse, bullying, exposure to family violence, and more. Research shows that the impact of polyvictimization is much more powerful than even multiple events of a single type of trauma. 2014 Citrus Health Network, Inc., all rights reserved. 14

Trauma and CSEC Youth victims of trafficking violations have the highest rates of adverse childhood experiences (ACE) above the general population of youth and offending youth, making them particularly vulnerable to re-victimization throughout adulthood and in most need of psychosocial services. Youth Arrested for Trading Sex Have the Highest Rates of Childhood Adversity: A Statewide Study of Juvenile Offenders: Sexual Abuse: A Journal of Research and Treatment 1-15, 2015 Rachel Naramore, Melissa A. Bright, Nathan Epps,and Nancy S. Hardt Brain Development

Changes in the Physical Structure of the brain Changes to the chemical composition of the brain Heightened Fight or Flight Body dysregulation They over-respond or under-respond to sensory stimuli. hypersensitive to sounds, smells, touch or light unaware of pain, touch, or internal physical sensations. may injure themselves without feeling pain or may complain of chronic pain National Traumatic Stress Network Trauma & Brain Development Brain development remains ongoing throughout adolescence and early adulthood.

The prefrontal cortex (affecting decision-making and planning) may not be fully formed until the age of 25. Children, aged 3-6 and 13-16 have brains that are malleable and much more easily manipulated than adults (McSwane, 2013). Early traumatic experiences and child maltreatment interfere with the structure and function of the brain. (Butler, 2014; McSwane, 2013; Teicher, 2013) 2014 Citrus Health Network, Inc., all rights reserved. 18

Structures of the Brain Amygdala: Helps us manage fear and emotion. Pervasive trauma exposure is linked to reduced amygdala volume. Can result in an inability to calm down, melt downs and over-reactions. Corpus callosum: Connects the left and right hemispheres. The primary function is to integrate motor, sensory, and cognitive performances. A decrease in size of this bridge is correlated with PTSD. This results in less effective brain activity. Hippocampus: responsible for learning, emotion, and consolidating longterm memories. Research has demonstrated a decrease in the size of the hippocampus directly proportional to PTSD symptoms. May result in forgetfulness, or learning problems. 2014 Citrus Health Network, Inc., all rights reserved.

19 Internal Alarm System Fight Flight Freeze 2014 Citrus Health Network, Inc., all rights reserved. 20 How do children react following trauma? Every child reacts to trauma differently

Reaction will depend on: Developmental level Premorbid functioning Previous life experiences Level of exposure to the trauma Parental reactions Subsequent changes in living situation

The majority of children are resilient Source: Centre of National Research on Disability and Rehabilitation Medicine,2011, Childhood Trauma Reactions, Emotional Response Difficulty identifying, expressing, and managing emotions. May lack or have limited language for feeling states. They often internalize and/or externalize stress reactions May experience significant depression Or present with anger, low frustration tolerance and acting out behavior Their emotional responses may be unpredictable or explosive. Become easily overwhelmed and frustrated May react to a reminder of a traumatic event with trembling, anger, sadness, or avoidance.

Interpersonal Relationships Traumas are often of an interpersonal nature, even mildly stressful interactions with others may serve as trauma reminders and trigger intense emotional responses. Having learned that the world is a dangerous place where even loved ones cant be trusted to protect you, children are often vigilant and guarded in their interactions with others and are more likely to perceive situations as stressful or dangerous. While this defensive posture is protective when an individual is under attack, it becomes problematic in situations that do not warrant such intense reactions. Alternately, many children also learn to tune out (emotional numbing) to threats in their environment, making them vulnerable to revictimization

Cited: National Child Traumatic Stress Network Behavior Intense Reactions Lack Impulse control May react defensively and aggressively in response to perceived blame or attack, or alternately, may at times be overcontrolled, rigid, and unusually compliant with adults Dissociation-may seem unfocussed, detached, distant, or out of touch with reality. Without treatment-more likely to engage in high-risk behaviors

Thinking and Learning May have problems thinking clearly, reasoning, or problem solving. They may struggle with sustaining attention or curiosity or be distracted by reactions to trauma reminders. They may be unable to plan ahead, anticipate the future, and act accordingly. When children grow up under conditions of constant threat, all their internal resources go toward survival. When their bodies and minds have learned to be in chronic stress response mode, they may have trouble thinking a problem through calmly and considering multiple alternatives. Self Concept and Future Goals

Shame, guilt, low self-esteem, and a poor self-image are common Learn they cannot trust, the world is not safe, and that they are powerless. They have trouble feeling hopeful In survival mode, Lives from moment-to-moment Consequences for Physical Health Traumatic experiences in childhood have been linked to increased medical conditions throughout the individuals lives.

The Adverse Childhood Experiences (ACE) Study Results demonstrated connection between childhood trauma exposure, high-risk behaviors & chronic illness such as heart disease and cancer, and early death Trauma Informed System of Care According to SAMHSAs concept of a trauma-informed approach, A program, organization, or system that is trauma-informed: Realizes the widespread impact of trauma and understands potential paths for recovery; Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;

Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and Seeks to actively resist re-traumatization." 6 Principles of Trauma Informed Approach

Safety Trustworthiness and Transparency Peer Support Collaboration and Mutuality Empowerment, Voice and Choice Cultural, Historical, and Gender Issues 30 Four tenets of Trauma Informed Care (TIC) 1) SAFETY-Helping clients to recognize how they view safety, create a safety plan to reduce threats, and think through how they can become safer physically, psychologically, socially etc.

2) EMOTIONAL MANAGEMENT- Help clients become less reactive, develop trust, think more clearly, and develop adaptive coping strategies. 3) LOSS- Recognizing that many clients have suffered an enormous amount of LOSS throughout their lives which must be addressed. 4) FUTURE-Support clients as they name, define and move toward achieving their goals. Importance of Safety Establish a sense of safety: Be very clear with expectations and procedure no surprises Establish boundaries and rituals Warn about interruptions Establish Trust:

Follow through on what you said you would do Suspend judgment Emotional connection: Listen and show that you are understanding Allow choices whenever possible Importance of Relationships AVOID Interactions that are humiliating, harsh, impersonal, disrespectful, critical,

demanding, judgmental TRAUMA INFORMED Interactions that express kindness, patience, reassurance, calm demeanor, acceptance Frequent use of words like PLEASE and THANK YOU The importance of trauma informed policies and procedures AVOID

Rules that always seem to be broken (time to take a second look at these rules) Policies and Procedures that focus on organizational needs rather than on client needs Documentation with minimal involvement of clients Many hoops to go through before a clients needs are met Language and cultural barriers TRAUMA INFORMED

Sensible and fair rules that are clearly explained (focus more on what you CAN DO rather than what you CANT DO) Transparency in documentation and service planning Materials and communication in the persons language Continually seeking feedback from clients about their experience in the program The importance of our attitudes and beliefs AVOID Asking questions that convey the idea that there is something wrong with the person Regarding a persons difficulties only as symptoms of a mental health, substance use or

medical problem TRAUMA INFORMED Asking questions for the purpose of understanding what harmful events may contribute to current problems Recognizing that symptoms may be a persons way of coping with trauma or are adaptations Some Immediate Causes of Crisis

Overload of emotional stress Unfairness Humiliation Feelings of helplessness/powerlessness Immaturity Displaced frustrations Depression Decoy

Signs of Agitation Raised voice Rapid Speech Excessive hand gestures

High Pitched voice Balled fists Erratic movements Aggressive posture Direct prolonged contact Major change in behavior Non-Verbals

Appear calm, self- assured, and centered Maintain limited eye-contact Maintain neutral facial expression Maintain relaxed posture Minimize body movements and gestures Position self for safety Stay at eye-level Avoid touching agitated client Avoid standing too close

Meaning in Spoken Communication in Time of Crisis Meaning= Facial Expression (55%) + Tone of Voice(38%) + Words (7%) De-escalation Techniques Once a client begins to escalate, strategies should be implemented to defuse the situation. Strategies should be aimed at ensuring the safety of the client, staff and others involved. Strategies to de-escalate include verbal and non-verbal

techniques. Strategies to Defuse Once a client is observed to be escalating, strategies to defuse should be implemented including: Displaying calmness Creating space between the client and others Speaking in a slow and clear manner Avoiding arguing with the client Verbal Communication Using a calm and controlled tone of voice can promote comfort and calmness in both parties involved.

A raised voice or fast speech can promote excitement, anxiety and disruption for the client. Language should be appropriate and respectful to indicate respect to the client. Verbal De-escalation Effective Verbal De-escalation requires open and fluid communication. Communication with the client should focus on attentive listening and conveying a positive solution focused message.

Listening Skills Attending: Giving your physical and mental attention to the client. Following: Engaging the client using appropriate eye-contact and gestures including nodding in acknowledgement. Verbal De-escalation Tactics Validate and express understanding of the clients concerns and feelings. This does not indicate agreement of the concerns or grievances, but expresses empathy regarding the emotional state.

Offer options and solutions that address the clients emotional state. Acknowledge grievances, concerns and frustrations that the client is expressing. Verbal De-escalation Tactics If you are alone in a room with a client, inform the client that you might want to seek out assistance in providing them with options and solutions to their concerns. Seek out ways to alert someone to the situation either by phone or by signaling out for assistance

in a calm manner that will not further escalate the client. Verbal De-escalation Tactics If bystanders are present, seek out ways to remove them from the situation, such as instructing them to move to another area to provide the client with privacy. Avoid providing the client with an audience to the situation, as this may escalate their feelings of anxiety or anger. Communication Barriers

to Avoid 1. Minimizing 9. Arguing 2. Not listening 10. Complaining 3. Being judgmental 11. Using ultimatums 4. Using intimidation

5. Being Rigid 6. Multi-tasking 7. Engaging in a Power Struggle 8. Criticizing 12. Threatening 13. Being demanding 14. Overreacting 15. Being Overemotional 16. Name-Calling Non-verbal Communication Non-verbal communication includes our gestures, facial

expressions, body position, body language, and personal boundaries. When attempting to de-escalate a client, focus on maintaining a calm and attentive demeanor to reduce hostility and promote safety. Body Language Present yourself in a calm and centered manner to portray self-assurance. Maintain a calm and attentive facial expression in efforts to reduce hostility.

Becoming overly emotional may increase the clients feelings of anxiety and agitation. Eye Contact Maintain appropriate eye contact. Loss of eye contact may be interpreted as fear, lack of interest or rejection to the client. Excessive eye contact may be interpreted as a challenge or threat to the client. Posture Keep a relaxed, yet alert posture. Ensure that there is a safe distance between

yourself and the client, at least three large steps away from the client, to ensure personal safety. Express a relaxed demeanor for the client, yet remain alert to any physical changes in the client that may indicate escalation for physical aggression. Movement Keep a relaxed posture by minimizing body movements. Avoid sudden movements that may startle or be perceived as an attack.

Excessive gesturing, pacing, or fidgeting can increase anxiety and agitate the client. Do not make attempts to touch or physically comfort the client during de-escalation as physical contact may increase anxiety and agitation. Position for Safety When meeting with clients ensure that you are seated closer to the exit than a client to prevent the client from blocking your exit in case of an emergency.

Always remain at eye level with the client. Encourage the client to remain seated, yet if they stand up, stand up as well using calm and fluid movements. Summary of De-escalation Tactics Present with a calm and alert demeanor. Use attentive listening to express understanding to the client

Offer options and solutions for the client. Avoid communication barriers. Attempt to alert others to the situation for assistance. Position yourself for safety by staying alert to the clients behavior and being aware of your exit strategy.

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