Toxic Stress to Safe Zone Level 1: Understanding Trauma Informed Care and Responding to Trauma’S Impact on Behavior

5/8/2017

Toxic Stress to Safe Zone Level 1: Understanding trauma informed care and responding to trauma’s impact on behavior

Toxic Stress to Safe Zone • Brought to you by: Early Childhood Mental Health Initiatives Valerie Alloy, Ph.D. , Lead Whole Child Matters Grant • Created by:  Erin Lucas, LISW-S Early Childhood Programs Director Hopewell Health Centers, Inc. [email protected]

Early Childhood Programs

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Housekeeping: Setting the stage for success • Restroom location • Cell phone reminder • Feel free to pass notes  Refrain from side bar conversations • Respect each other  Opinions  Feedback on videos  During activities

Toxic Stress to Safe Zone:

• Change the First Five Years and You Change Everything Video (from Ounce of Prevention on YouTube.com)

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Agenda: Setting Expectations for the day • 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. • Activity  Fold a piece of paper into thirds 1. What do I know? 2. What do I want to know? 3. What did I learn?

Activity: Setting Expectations for the day

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Objective 1: Understand trauma & toxic stress

Healthy Development

• Experiences Build Brain Architecture • Center on the Developing Child at Harvard University

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Healthy Development

• Serve & Return Interaction Shapes Brain Circuitry • Center on the Developing Child at Harvard University

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Healthy Development

Toxic Stress to Safe Zone: Defining 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 individual’s functioning and mental, physical, social, emotional, or spiritual well‐being.” (SAMHSA, 2014)

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Toxic Stress to Safe Zone: Trauma in Children

• 71% of children are exposed to violence each year (Finkelhor et al, 2013) • 3 million children are maltreated or neglected each year (Child Welfare info, 2013) • 3.5‐10 million witness violence against their mother each year (Child Witness to Violence Project, 2013) • 1 in 4 girls and 1 in 6 boys were sexually abused before adulthood (NCTSN Fact Sheet, 2009) • 94% of children in juvenile justice settings have experienced trauma (Rosenberg et al, 2014)

Toxic Stress to Safe Zone: Trauma in Children • 40‐80% of school age children experience bullying (Graham, 2013) • 75‐93% of youth entering the juvenile justice system have experienced trauma (Justice Policy Institute, 2010) • 92% of youth in residential and 77% in non‐residential mental health treatment report multiple traumatic events (NCTSN, 2011) • In the US, we lose an average of more than 9 children and youths ages 5 to 18 to homicide or suicide per day. (Defending Childhood Study, 2012)

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Toxic Stress to Safe Zone: Types of traumatic events

• Sexual Abuse or Assault • Physical Abuse or Assault • Emotional Abuse/Psychological Maltreatment • Neglect • Serious Accident or Illness/Medical Procedure • Witness to Domestic Violence • Victim/Witness to Community Violence • School Violence • Natural or Manmade Disasters • Forced Displacement • War/Terrorism/Political Violence • Victim/Witness to Extreme Personal/Interpersonal Violence • Traumatic Grief/Separation • System‐Induced Trauma

Toxic Stress to Safe Zone: Understanding our Stress Response

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Toxic Stress to Safe Zone: Stress Response

• Moderate, short‐lived response • Limited time periods • Brief increases in heart rate, • Time for brain to recover hormones • Supportive relationships • Essential in healthy balance effects to prevent development toxicity • Help us develop a sense of mastery • Examples: • Examples: • Death or Illness of a loved • Meeting new people one • Frustration, fear of animals, • Accident, Divorce immunizations, new environments • Persistent discrimination

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Toxic Stress to Safe Zone: Toxic Stress Response

 Occurs when experiencing strong, frequent, and/or prolonged adversity…  Can disrupt the development of brain architecture and other organ systems…  Increases the risk for stress‐related disease and cognitive impairment, well into the adult years

Toxic Stress Derails Healthy Development

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Signs and Symptoms of Trauma: Infant and Toddlers

• Eating & Sleeping disturbance • Reacting to reminders/trauma • Clingy/separation anxiety triggers • Irritable/difficult to soothe • 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 • Easily startled • Aggression (toddlers)

Signs and Symptoms of Trauma: Preschoolers •Avoidant, anxious, clingy •Aggressive and/or sexualized bx •General fearfulness/new fears •Sadness •Helplessness, passive •Repetitive/ post‐traumatic play •Restless, impulsive, hyperactive •Talking about the traumatic •Physical symptoms (headache, etc.) event and reacting to trauma triggers •Inattention, difficulty problem solving •Developmental regression •Irritability •Poor peer relationships and social problems (controlling/over permissive)

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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. 2. How does this perspective change your view of the child’s behavior? 3. How does it change your expectations for their future?

Objective 2: Understand the effect on development

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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:  Development (brain development, self‐regulation, psychosocial development, cognitive functioning and communication)  Attachment relationships (an attuned and responsive caregiver, social environment)  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)

Toxic Stress to Safe Zone: Toxic Stress Response

Protective Factors Risk Factors • Attachment • Trauma history • Initiative • Poverty • Curiosity • Stressful events

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Relationships

Peer

Parent Friends Family

Mother Family Secondary Caregivers

Mother/ Primary Caregiver

Domain of Development Signs of Disruption or Impairment •Difficulty trusting others Social isolation •Uncertain about the reliability/ Difficulty seeking help Attachment predictability of others Clingy, difficulty with separations •Interpersonal difficulty

•Sensorimotor development problems Somatization Physical •Hypersensitivity to physical contact Increased medical problems •Problems with coordination and balance

•Problems with emotional regulation Easily upset and/or difficulty calming •Difficulty describing emotions and internal Problems with communicating needs Affect Regulation experiences •Difficulty knowing and describing internal states

•Poor impulse control Self‐destructive behavior •Aggressive behavior Oppositional behavior Behavioral Control •Excessive compliance Sleep disturbance •Eating disorders Reenactment of traumatic event/past •Pathological self‐soothing practices

•Difficulty paying attention Problems with language development •Lack of sustained curiosity Problems processing information Cognition •Problems focusing on/completing tasks Learning difficulties, develop. delays •Difficulty planning and anticipating consequences

•Lack of continuous/predictable sense of self Self‐Concept •Poor sense of separateness Disturbance of body image •Low self‐esteem Shame and guilt

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Adverse Childhood Experiences •Abuse and Neglect (e.g., psychological, physical, sexual) •Household Dysfunction (e.g., domestic violence, substance abuse, mental illness)

Impact on Child Development •Neurobiologic Effects (e.g., brain abnormalities, stress hormone dysregulation) •Psychosocial Effects (e.g., poor attachment, poor socialization, poor self-efficacy) •Health Risk Behaviors (e.g., smoking, obesity, substance abuse, promiscuity)

Long-Term Consequences Disease and Disability •Major Depression, Suicide, PTSD Social Problems •Drug and Alcohol Abuse •Homelessness •Heart Disease •Prostitution •Cancer •Criminal Behavior •Chronic Lung Disease •Unemployment •Sexually Transmitted Diseases •Parenting problems •Intergenerational transmission of abuse •High utilization of health and social services

Data: www.AceStudy.org, www.nasmhpd.org OhioCanDo4Kids.Org

Context of Behavior Affects Response to Behavior: Oppositional and Defiant ~or~ Scared and Reactive

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Context of Behavior Affects Response to Behavior:

“Any fool can know. The point is to understand.” ~Albert Einstein

State Dependent Functioning Used with permission by Dr. Bruce D Perry, www.childtrauma.org

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Brain Function

Neocortex

Limbic

Brainstem

Used with permission by Dr. Bruce D Perry, www.childtrauma.org

History of Relational Intimacy Barrier Interactions

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Activity 2: Responding to signs of emotional distress

• Sing •Step •Stay •Play • Sing •Less Away Away Calm •Teach Alert •Prep Alarm words Fear •Calm Terror •Stay •Learn •Voice •Step self Calm away •Space •Safety

Objective 3: Creating a safe zone 1.Setting the Stage 2.Preventing Escalation 3.Response to Toxicity

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Creating a Safe Zone: Setting the stage

Creating a Trauma‐Informed Early Learning Setting

Transition Song

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Creating a Safe Zone: Setting the stage • Schedule o Brain breaks o Transitions Use music Give warning • Visual Reminders o Posted schedule o Job duties • Social Emotional Curriculum o Another training 

Creating a Safe Zone: Setting the stage

• Build communication skills Use language Gestures Read Books Sing Songs Chat Tell Stories

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Creating a Safe Zone: Setting the stage • Observe and notice clues: • Sounds • Language • Facial expression • Eye gaze • Actions • Think about the child’s environment • Noise, light, proximity

Creating a Safe Zone: Setting the stage • Resources Teaching Tools for Young Children Routine Based Support Guide Love & Logic in the Classroom Mindfulness Relaxation Activities

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Sample Visuals The following are samples of a variety of supports that are mentioned in the Routine Based Support Guide.

Sample visuals created using pictures from Microsoft Clipart® and Boardmaker®

Musical Truck Barney Computer

Show real items or photograph of items to child to allow to make a toy choice.

Lentini, R., Vaughn, B. J., & Fox, L. (2005). Teaching Tools for Young Children with Challenging Behavior. Tampa, Florida: University of South Florida, Early Intervention Positive Behavior Support.

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Choice Chart

Lentini, R., Vaughn, B. J., & Fox, L. (2005). Teaching Tools for Young Children with Challenging Behavior. Tampa, Florida: University of South Florida, Pictures cut out from Lakeshore Catalog Early Intervention Positive Behavior Support.

Creating a Safe Zone: Set the Stage Resources

• Routine Based Support Guide • Found at cecmhc.org

• Love & Logic http://www.loveandlogic.com/documents/turn‐your‐word‐into‐gold‐ school.pdf

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Creating a Safe Zone: Preventing Escalation

• Regulation • Children are co‐regulators • If the adult is not regulated, the child will not be able to regulate • Respond based on what you think the meaning of the behavior is • If your first try didn’t work; try again • Give toddlers appropriate choices • Use pictures • Teach child about non‐verbal communication • BE THERE for the child

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Toxic Stress to Safe Zone: Preventing Escalation

• Sing •Step •Stay •Play • Sing •Less Away Away Calm •Teach Alert •Prep Alarm words Fear •Calm Terror •Stay •Learn •Voice •Step self Calm away •Space •Safety

Creating a Safe Zone: Responding to Toxicity

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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 3: Group Practice • Join with a group to identify a problem behavior you encounter.

• Is trauma impacting this behavior? • What state is the child functioning in when this behavior occurs? • What immediate response would be helpful for this behavior? • What planned response might reduce this behavior?

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Reflection: Taking key points home with me! What did I learn today? What can I do tomorrow? What can I add next week? What do I need? What can I add next month? What do I need? How can I ensure I am creating a trauma‐ informed early learning setting?!

Future Trainings:

• Level 2: Becoming a Trauma‐Informed Early Learning Professional • Level 3: Becoming a Trauma‐Informed Early Learning Setting • Challenging Behavior

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Closing: Thank you for your time and attention! • Questions • Evaluation • Contact Information: Erin Lucas 740.592.3091 office 740.541.6093 mobile [email protected] Special thanks to Dr. Alloy and the Whole Child Matters grant for making this training possible.

Toxic Stress to Safe Zone: References

• Center for Early Childhood Mental Health Consultation • Georgetown University Center for Child and Human Development Ecmhc.org • Love and Logic Loveandlogic.com

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Toxic Stress to Safe Zone: 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/fpW07.pdf

Toxic Stress to Safe Zone: 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_08‐2010final.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.

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Toxic Stress to Safe Zone: 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:0‐3R) 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/TraumaRelated_needs_children.pdf?CFID=135049&CFTOKEN=44 089600