1. TRAUMA PAST, TRAUMA PRESENT WHAT IS TRAUMA INFORMED PHASE ORIENTED TREATMENT ? Allison Sampson, PhD, LCSW, LICSW, CSOTP

2. What’s all the “trauma” buzz about …  Over the last 10 -20 years there has been an explosion of information provided to us about the relevance and impact of trauma on the brain, on relationships, and on our development …  This explosion has resulted from new abilities to see the brain in ways that we are better connecting life experiences and over all well being (Physical and Mental Health) Information and slide part of Dr. Allison Sampson's Trauma Presentation

3. NCTSN Contributions … This project was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), US Department of Health and Human Services (HHS). The views, policies, and opinions expressed are those of the authors and do not necessarily reflect those of SAMHSA or HHS. Established by Congress in 2000, the National Child Traumatic Stress Network (NCTSN) is a unique collaboration of academic and community-based service centers whose mission is to raise the standard of care and increase access to services for traumatized children and their families across the United States. Combining knowledge of child development, expertise in the full range of child traumatic experiences, and attention to cultural perspectives, the NCTSN serves as a national resource for developing and disseminating evidence-based interventions, trauma-informed services, and public and professional education. Information and slide part of Dr. Allison Sampson's Trauma Presentation

4. NCTSN and Resources for Learning Juvenile Justice http://learn.nctsn.org/index.php Screening and Assessment in Juvenile Justice Settings Juvenile Justice Resource Site Think Trauma Toolkit: Training for Staff in Juvenile Justice Settings Information and slide part of Dr. Allison Sampson's Trauma Presentation

5. What does it mean to be trauma informed … A trauma-informed youth- and family-service system is one in which all parties involved recognize and respond to the impact of traumatic stress on those within the system including youth, caregivers, and service providers. Programs and agencies within such a system infuse and sustain trauma awareness, knowledge, and skills into their organizational cultures, practices, and policies. They collaborate with all those involved, using the best available science, to facilitate and support the recovery and resiliency of the youth and family. A service system with a trauma-informed perspective is one in which programs, agencies, and service providers do the following: 1. Routinely screen for trauma exposure and related symptoms 2. Use culturally appropriate evidence-based assessment and treatment for traumatic stress and associated mental health symptoms 3. Make resources available to youth, families, and providers on trauma exposure, its impact, and treatment 4. Engage in efforts to strengthen the resilience and protective factors of youth and families affected by and vulnerable to trauma 5. Address parent and caregiver trauma and its impact on the family system 6. Emphasize continuity of care and collaboration across youth-serving systems 7. Maintain an environment of care for staff that addresses, reduces, and treats secondary traumatic stress and increases staff resilience Information and slide part of Dr. Allison Sampson's Trauma Presentation

6. Juvenile Justice SafeStart Resources  http://www.safestartcenter.org/resources/toolkit- court-involved-youth-exposure-violence.php http://www.safestartcenter.org/resources/toolkit- court-involved-youth-exposure-violence.php  http://www.nctsn.org/resources/topics/juvenile- justice-system http://www.nctsn.org/resources/topics/juvenile- justice-system Information and slide part of Dr. Allison Sampson's Trauma Presentation

7. Child Welfare and Corrections Systems Integration Initiative (SII) launched at the Child Welfare League of America in 2000 through the support of the John D. and Catherine T. MacArthur Foundation Crossover Youth Practice Model (CYPM) by CJJR in partnership with Casey Family Programs in 2009. http://cjjr.georgetown.edu/pdfs/msy/AddressingtheNeeds ofMultiSystemYouth.pdf Information and slide part of Dr. Allison Sampson's Trauma Presentation

8. Cross-Over Youth (Herz, Lee, Lutz, Stewart, Tuell, & Wiig, pp 2-3) Information and slide part of Dr. Allison Sampson's Trauma Presentation  Also known as dually-involved youth  Majority are male  Disproportionate are female (third to almost one half)  Disproportionate number are children of color  Majority have special education needs, problems in school  Majority have mental health diagnosis/substance abuse issues  Significant number have witnessed interpersonal violence  Need of more intense services

9. Pathways between 2 systems Information and slide part of Dr. Allison Sampson's Trauma Presentation (Herz, Lee, Lutz, Stewart, Tuell, & Wiig, p 3, Figure 2) Example of the many pathways between 2 systems

10. “Henry” and Some Data Relevance of Trauma to Child Welfare Information and slide part of Dr. Allison Sampson's Trauma Presentation

11. 26 Prevalence of Trauma—United States Each year in the United States, more than 1,400 children—nearly 2 children per 100,000—die of abuse or neglect. In 2005, 899,000 children were victims of child maltreatment. Of these: – 62.8% experienced neglect – 16.6% were physically abused – 9.3% were sexually abused – 7.1% endured emotional or psychological abuse – 14.3% experienced other forms of maltreatment (e.g., abandonment, threats of harm, congenital drug addiction) 26 Source: USDHHS. (2007) Child Maltreatment 2005; Washington, DC: US Gov’t Printing Office.

12. 26 Prevalence of Trauma—United States Each year in the United States, more than 1,400 children—nearly 2 children per 100,000—die of abuse or neglect. In 2005, 899,000 children were victims of child maltreatment. Of these: – 62.8% experienced neglect – 16.6% were physically abused – 9.3% were sexually abused – 7.1% endured emotional or psychological abuse – 14.3% experienced other forms of maltreatment (e.g., abandonment, threats of harm, congenital drug addiction) 26 Source: USDHHS. (2007) Child Maltreatment 2005; Washington, DC: US Gov’t Printing Office.

13. 27 U.S. Prevalence, cont'd One in four children/adolescents experience at least one potentially traumatic event before the age of 16. 1 In a 1995 study, 41% of middle school students in urban school systems reported witnessing a stabbing or shooting in the previous year. 2 Four out of 10 U.S. children report witnessing violence; 8% report a lifetime prevalence of sexual assault, and 17% report having been physically assaulted. 3 27 1. Costello et al. (2002). J Traum Stress;5(2):99-112. 2. Schwab-Stone et al. (1995). J Am Acad Child Adolesc Psychiatry;34(10):1343-1352. 3. Kilpatrick et al. (2003). US Dept. Of Justice. http://www.ncjrs.gov/pdffiles1/nij/194972.pdf.http://www.ncjrs.gov/pdffiles1/nij/194972.pdf

14. 28 Prevalence of Trauma in the Child Welfare Population A national study of adult “foster care alumni” found higher rates of PTSD (21%) compared with the general population (4.5%). This was higher than rates of PTSD in American war veterans. 1 Nearly 80% of abused children face at least one mental health challenge by age 21. 2 28 1. Pecora, et al. (December 10, 2003). Early Results from the Casey National Alumni Study. Available at: http://www.casey.org/NR/rdonlyres/CEFBB1B6-7ED1-440D-925A- E5BAF602294D/302/casey_alumni_studies_report.pdf.http://www.casey.org/NR/rdonlyres/CEFBB1B6-7ED1-440D-925A- E5BAF602294D/302/casey_alumni_studies_report.pdf 2. ASTHO. (April 2005). Child Maltreatment, Abuse, and Neglect. Available at: http://www.astho.org/pubs/Childmaltreatmentfactsheet4-05.pdf. http://www.astho.org/pubs/Childmaltreatmentfactsheet4-05.pdf

15. 29 Prevalence in Child Welfare Population, cont'd A study of children in foster care revealed that PTSD was diagnosed in 60% of sexually abused children and in 42% of the physically abused children. 1 The study also found that 18% of foster children who had not experienced either type of abuse had PTSD, 1 possibly as a result of exposure to domestic or community violence. 2 1. Dubner et al. (1999). JCCPsych;67(3): 367-373. 2. Marsenich (March 2002). Evidence-Based Practices in Mental Health Services for Foster Youth. Available at: http://www.cimh.org/downloads/Fostercaremanual.pdf.http://www.cimh.org/downloads/Fostercaremanual.pdf

16. Mismanagement of Trauma Hendrick, H. (2012) Creating Trauma-Informed Child Welfare Systems, p. 6  - Reduces likelihood of reunification (1)  - Increases placement instability (2)  - Increase in restrictive placements (3)  - Increases likelihood of using stronger psychotropic medications (4)  - Increases child perpetuating intergenerational cycle of abuse and neglect when they become a parent (5) 1)Rubin, O’Reilly, Luan, & Localio (2007) Pediatrics, 119 (2) 336-344 2)Hartnett, Leathers, Falconnier & Testa (1999) Placement Stability Study. 3)Pecora et al. (2005) www.nxtbook.com/nxtbooks/casey/alumnistudies/www.nxtbook.com/nxtbooks/casey/alumnistudies/ 4)Raghavan et al. (2005) Journal of Child and Adolescent Psychopathology, 15(1), 97-106 5)Fang & Corso (2007) American Journal of Preventative Medicine, 33(4), 281-290

17. “Our Kids” in Juvenile Justice “ I am a child” Poem Information and slide part of Dr. Allison Sampson's Trauma Presentation

18. Trauma and Juvenile Justice  A growing body of research indicates that victims of violence are more likely than their peers to also be perpetrators of violence, and that individuals most likely to be victims of personal crime are those who report the greatest involvement in delinquent activities (ABA, 2000; Shaffer and Ruback, 2002; Wiebush et al., 2001). Information and slide part of Dr. Allison Sampson's Trauma Presentation

19. “Our Kids” in Juvenile Justice Information and slide part of Dr. Allison Sampson's Trauma Presentation  Studies with antisocial youth have found self reported trauma exposure ranging from 70% to 92% (Greenwald, 2002)  Antisocial youth have high rates of Post Traumatic Stress Disorder (PTSD) ranging from 24% to 65% (Greenwald, 2002)  Research has indicated high levels of trauma in the experiences of conduct- disorder youth (Bowers, 1990; McMackin, Morissey, Newman, Erwin, & Daley, 1998; Rivera & Widom, 1990; and Steiner, Garcia, & Matthews, 1997)  Research suggests that anger and violent acting out often are symptoms of PTSD (Chemtob, Novaco, Hamada, Gross, & Smith, 1997)

20. Trauma and Juvenile Delinquency  Research shows that childhood exposure to domestic and community violence, for example, can cause children to engage in aggressive behavior, suffer from problems such as depression and anxiety, have lower levels of social competence and self-esteem, experience poor academic performance, and exhibit posttraumatic stress symptoms such as emotional numbing and increased arousal (Colley- Quille et al., 1995; ABA, 2000; Osofsky, 1999). Information and slide part of Dr. Allison Sampson's Trauma Presentation

21. The future for “our kids” ….  Being abused or neglected as a child increased the likelihood of arrest as a juvenile by 59 percent and as an adult by 28 percent, and for a violent crime by 30 percent. The abused and neglected cases were younger at first arrest, committed nearly twice as many offenses, and were arrested more frequently (Widom, 1995; Widom and Maxfield, 2001). Information and slide part of Dr. Allison Sampson's Trauma Presentation

22. Data from the National Survey of Adolescents (Kilpatrick et al., 2003b)  47.2 percent of the sexually assaulted boys reported engaging in delinquent acts, compared with only 16.6 percent of those not sexually assaulted  The rate of girls who had been sexually assaulted and then committed delinquent acts was 19.7 percent, five times higher than the rate of girls who had not been sexually assaulted (4.8 percent).  The percentage of boys who were physically assaulted and had ever committed an Index offense was 46.7 percent, compared to 9.8 percent of boys who were not assaulted. Information and slide part of Dr. Allison Sampson's Trauma Presentation

23. Data from the National Survey of Adolescents (Kilpatrick et al., 2003b)  29.4 percent of physically assaulted girls reported having engaged in serious delinquent acts at some point in their lives, compared with 3.2 percent of nonassaulted girls.  About one third (32 percent) of boys who witnessed violence reported ever engaging in delinquent acts, compared with only 6.5 percent of boys who did not witness violence.  About 17 percent of girls who witnessed violence reported lifetime delinquent behavior, compared with 1.4 percent of girls who did not witness violence. Information and slide part of Dr. Allison Sampson's Trauma Presentation

24. Females in Juvenile Justice Nearly three quarters of a million girls below the age of 18 were arrested in 1997, accounting for 26% of juvenile arrests. In the 1990s, the number of juvenile females arrested for violent crime index offenses increased 25%, although there were no increases for male juveniles for the same offenses. The growing number of girls in the juvenile justice system and the high rates of exposure to violence among these girls pose special challenges and obligations for juvenile justice facilities and programs. Information and slide part of Dr. Allison Sampson's Trauma Presentation

25. BIG PICTURE … Why does this matter?  According to NCTSN, each year 2 million children come into contact with the Juvenile Justice System  Hundreds of thousands enter correctional facilities  The 2009 12 month recidivism rates for VA juveniles range from 49.3% - 36.7%  The majority of these youth have directly experienced or witnessed trauma  Trauma informed approaches to their care in the Juvenile Justice System can reduce contact and recidivism Information and slide part of Dr. Allison Sampson's Trauma Presentation

26. What helps ….  Teaching basic skills to children in juvenile justice in a consistent and structured way  Skills need to include self-regulations skills  Identifying emotions  Talking about emotions  Regulating emotions (arousal)  Skills also need to include managing anxiety and increasing social problem solving skills  Including family as much as possible and supporting them with their trauma Information and slide part of Dr. Allison Sampson's Trauma Presentation

27. Support children’s development in three areas  Self-regulation  Positive Self-Identity  Co-Regulation  (relationships with authority and peers) Information and slide part of Dr. Allison Sampson's Trauma Presentation

28. Before we can teach, we must do … Together, we the professionals need to have basic trauma informed knowledge ourselves and practice, practice, practice … 10,000 hours of practice rule Be the change you want to see in them … Information and slide part of Dr. Allison Sampson's Trauma Presentation

29. Defining Trauma … Information and slide part of Dr. Allison Sampson's Trauma Presentation

30. What is trauma ? National Council Definition Trauma occurs when a person is overwhelmed by events or circumstances and responds with intense fear, horror, and helplessness. Extreme stress overwhelms the person’s capacity to cope. There is a direct correlation between trauma and physical health conditions such as diabetes, COPD, heart disease, cancer, and high blood pressure. Information and slide part of Dr. Allison Sampson's Trauma Presentation

31. 21 What Is Child Traumatic Stress? Child traumatic stress refers to the physical and emotional responses of a child to events that threaten the life or physical integrity of the child or of someone critically important to the child (such as a parent or sibling). Traumatic events overwhelm a child’s capacity to cope and elicit feelings of terror, powerlessness, and out-of- control physiological arousal. 21 n

32. 22 What Is Child Traumatic Stress, cont'd A child’s response to a traumatic event may have a profound effect on his or her perception of self, the world, and the future. Traumatic events may affect a child’s: – Ability to trust others – Sense of personal safety – Effectiveness in navigating life changes 22

33. 23 Types of Traumatic Stress 23 Acute trauma is a single traumatic event that is limited in time. Examples include: – Serious accidents – Community violence – Natural disasters (earthquakes, wildfires, floods) – Sudden or violent loss of a loved one – Physical or sexual assault (e.g., being shot or raped) During an acute event, children go through a variety of feelings, thoughts, and physical reactions that are frightening in and of themselves and contribute to a sense of being overwhelmed.

34. 24 Types of Traumatic Stress, cont'd Chronic trauma refers to the experience of multiple traumatic events. These may be multiple and varied events—such as a child who is exposed to domestic violence, is involved in a serious car accident, and then becomes a victim of community violence—or longstanding trauma such as physical abuse, neglect, or war. The effects of chronic trauma are often cumulative, as each event serves to remind the child of prior trauma and reinforce its negative impact.

35. 25 Types of Traumatic Stress, cont'd Complex trauma describes both exposure to chronic trauma—usually caused by adults entrusted with the child’s care—and the impact of such exposure on the child. Children who experienced complex trauma have endured multiple interpersonal traumatic events from a very young age. Complex trauma has profound effects on nearly every aspect of a child’s development and functioning. Source: Cook et al. (2005). Psychiatr Ann,35(5):390-398.

36. Understanding Trauma Processing Information and slide part of Dr. Allison Sampson's Trauma Presentation  Schladale’s Trauma Outcome Process http://www.resourcesforresolvingviolence.com/philoso phy.html http://www.resourcesforresolvingviolence.com/TOP_S Hmanual.pdf

37. Trauma Outcome Process Trauma Outcome Process Adapted by Joann Schladale in 2002 from Rasmussen, L., Burton, J., & Christopherson, B. (1992). Information and slide part of Dr. Allison Sampson's Trauma Presentation Mini Trauma’s Major Trauma’s Trauma Defense Everyday Trigger Events EchoChoices Perceptions Emotional & Physical Responses Barriers Thinking Errors Assault Self-Victimize

38. Variables that impact of trauma Other Sources of Stress Information and slide part of Dr. Allison Sampson's Trauma Presentation

39. 31 Other Sources of Ongoing Stress Children in the child welfare system frequently face other sources of ongoing stress that can challenge workers’ ability to intervene. Some of these sources of stress include: – Poverty – Discrimination – Separations from parent/siblings – Frequent moves – School problems – Traumatic grief and loss – Refugee or immigrant experiences 31

40. 32 Variability in Responses to Stressors and Traumatic Events The impact of a potentially traumatic event is determined by both: – The objective nature of the event – The child’s subjective response to it Something that is traumatic for one child may not be traumatic for another. 32

41. 33 Variability, cont’d The impact of a potentially traumatic event depends on several factors, including: – The child’s age and developmental stage – The child’s perception of the danger faced – Whether the child was the victim or a witness – The child’s relationship to the victim or perpetrator – The child’s past experience with trauma – The adversities the child faces following the trauma – The presence/availability of adults who can offer help and protection 33

42. 34 Effects of Trauma Exposure on Children When trauma is associated with the failure of those who should be protecting and nurturing the child, it has profound and far- reaching effects on nearly every aspect of the child’s life. Children who have experienced the types of trauma that precipitate entry into the child welfare system typically suffer impairments in many areas of development and functioning, including: 34

43. 35 Effects of Trauma Exposure, cont’d Attachment. Traumatized children feel that the world is uncertain and unpredictable. They can become socially isolated and can have difficulty relating to and empathizing with others. Biology. Traumatized children may experience problems with movement and sensation, including hypersensitivity to physical contact and insensitivity to pain. They may exhibit unexplained physical symptoms and increased medical problems. Mood regulation. Children exposed to trauma can have difficulty regulating their emotions as well as difficulty knowing and describing their feelings and internal states. 35

44. 36 Effects of Trauma Exposure, cont’d Dissociation. Some traumatized children experience a feeling of detachment or depersonalization, as if they are “observing” something happening to them that is unreal. Behavioral control. Traumatized children can show poor impulse control, self-destructive behavior, and aggression towards others. Cognition. Traumatized children can have problems focusing on and completing tasks, or planning for and anticipating future events. Some exhibit learning difficulties and problems with language development. Self-concept. Traumatized children frequently suffer from disturbed body image, low self-esteem, shame, and guilt. 36

45. 37 Long-Term Effects of Childhood Trauma In the absence of more positive coping strategies, children who have experienced trauma may engage in high-risk or destructive coping behaviors. These behaviors place them at risk for a range of serious mental and physical health problems, including: – Alcoholism – Drug abuse – Depression – Suicide attempts – Sexually transmitted diseases (due to high risk activity with multiple partners) – Heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease  37 Source: Felitti et al. (1998). Am J Prev Med;14(4):245-258.

46. Trauma and Resiliency Tedeschi and Calhoun (1996, 1999, 2006) Information and slide part of Dr. Allison Sampson's Trauma Presentation Protective Factors include: seeking comfort, reassurance and safety from others Key to assess the meaning of the loss to the individual (varies)

47. Post-Traumatic Growth Tedeschi and Calhoun (1996, 1999, 2006) Information and slide part of Dr. Allison Sampson's Trauma Presentation 1) Emergence of new opportunities and possibilities 2) Deeper relationships and greater compassion for others 3) Feeling strengthened to meet future life challenges 4) Reorder priorities and fuller appreciation of life 5) Deepening spirituality Deepening spirituality http://cust-cf.apa.org/ptgi/

48. TRAUMA AND THE BRAIN

49. Understanding “why” …  http://www.childwelfare.gov/pubs/issue_briefs/br ain_development/effects.cfm http://www.childwelfare.gov/pubs/issue_briefs/br ain_development/effects.cfm Information and slide part of Dr. Allison Sampson's Trauma Presentation

50. Brain and Stress  When stress is predictable and moderate, stress can facilitate resiliency and enhance memory  When stress is unpredictable and severe, stress can create vulnerability and memory impairment  Severe and chronic stress in childhood via multiple traumas from caregivers can impact affect regulation, interpersonal relationship skills, and states become traits (fight/flight/freeze… disassociation or hyper arousal) Information and slide part of Dr. Allison Sampson's Trauma Presentation

51. Three parts of the brain …  Brain Stem  Limbic Brain  Cerebral Cortex Information and slide part of Dr. Allison Sampson's Trauma Presentation

52. Stress and the Brain

54. Vulnerability Mountain Handouts\Chesterfield Presentation\Vunerability Mountain 2.pdf Information and slide part of Dr. Allison Sampson's Trauma Presentation

55. Right and Left Hemisphere Information and slide part of Dr. Allison Sampson's Trauma Presentation

56. Memory Explicit Memory  Semantic: Factual information  Autobiographical: Sense of self in time Implicit Memory  Somatic: Sense of body at time  Perception: Senses  Behavioral: What we did with our body Information and slide part of Dr. Allison Sampson's Trauma Presentation

57. Looking through their eyes … Explicit memory has worked so far today to help us understand the experience of the children we work with … Implicit emotional understanding is more difficult … pay attention to your implicit experience to the music and pictures … Information and slide part of Dr. Allison Sampson's Trauma Presentation

58. Implicit versus Explicit  What is the experience of the implicit memory versus the explicit understanding?  Is one more powerful than the other?  Would having mixed the two sets of pictures lessened or intensified the experience? Information and slide part of Dr. Allison Sampson's Trauma Presentation

59. Big Picture Message … Trauma lives in the body and the mind …. Ask children and caregivers where it lives in there body … help them understand their body !!! Information and slide part of Dr. Allison Sampson's Trauma Presentation

60. 41 Trauma and the Brain Trauma can have serious consequences for the normal development of children’s brains, brain chemistry, and nervous system. Trauma-induced alterations in biological stress systems can adversely effect brain development, cognitive and academic skills, and language acquisition. Traumatized children and adolescents display changes in the levels of stress hormones similar to those seen in combat veterans. – These changes may affect the way traumatized children and adolescents respond to future stress in their lives, and may also influence their long-term health. 1 41 1. Pynoos et al. (1997). Ann N Y Acad Sci;821:176-193

61. 42 Trauma and the Brain, cont’d In early childhood, trauma can be associated with reduced size of the cortex. – The cortex is responsible for many complex functions, including memory, attention, perceptual awareness, thinking, language, and consciousness. Trauma may affect “cross-talk” between the brain’s hemispheres, including parts of the brain governing emotions. – These changes may affect IQ, the ability to regulate emotions, and can lead to increased fearfulness and a reduced sense of safety and protection. 42

62. 43 Trauma and the Brain, cont’d In school-age children, trauma undermines the development of brain regions that would normally help children: – Manage fears, anxieties, and aggression – Sustain attention for learning and problem solving – Control impulses and manage physical responses to danger, enabling the adolescent to consider and take protective actions As a result, children may exhibit: – Sleep disturbances – New difficulties with learning – Difficulties in controlling startle reactions – Behavior that shifts between overly fearful and overly aggressive 43

63. 44 Trauma and the Brain, cont’d In adolescents, trauma can interfere with development of the prefrontal cortex, the region responsible for: – Consideration of the consequences of behavior – Realistic appraisal of danger and safety – Ability to govern behavior and meet longer-term goals As a result, adolescents who have experienced trauma are at increased risk for: – Reckless and risk-taking behavior – Underachievement and school failure – Poor choices – Aggressive or delinquent activity 44 Source: American Bar Association. (January 2004). Adolescence, Brain Development and Legal Culpability. Available at: http://www.abanet.org/crimjust/juvius/Adolescence.pdfhttp://www.abanet.org/crimjust/juvius/Adolescence.pdf

64. TRAUMA AND ATTACHMENT

65. Attachment … what we already know  Review of the exercise … what did you notice about caregiver touch between the two sets of pictures …  What do you think the implicit memories are about caregiving relationships ? About authority figures? About their ability to be safe ? Information and slide part of Dr. Allison Sampson's Trauma Presentation

66. Attachment Many argue that these early relationships (experiences) shape neuronal circuits which regulate emotional and social functioning Information and slide part of Dr. Allison Sampson's Trauma Presentation

67. Attachment’s Purpose Siegel, 1999 Evolutionary Level – biological Infant Survival (Bowlby) Mind Level – biological and social  Caregiver’s brain helps child’s brain to organize regulation  Caregiver’s brain teaches child self-soothing  Child experience of safety allows for exploration Information and slide part of Dr. Allison Sampson's Trauma Presentation

68. Attachment’s Purpose Experience of safety is encoded in child’s implicit memory and provides secure base from which to grow and access higher levels of information processing Information and slide part of Dr. Allison Sampson's Trauma Presentation

69. Impact of Secure Attachment Associated with …  Emotional Regulation  Social Relatedness  Access to autobiographical memory Sense of self in time (presence)  Development of Self-Reflection and Narrative Main (1995), Main et. al. (1985), Fox et. Al. (1994), Oppenheim and Waters (1995) Information and slide part of Dr. Allison Sampson's Trauma Presentation

70. Culture and Development Other impacts of trauma Information and slide part of Dr. Allison Sampson's Trauma Presentation

71. 45 The Influence of Culture on Trauma Social and cultural realities strongly influence children’s risk for—and experience of—trauma. Children and adolescents from minority backgrounds are at increased risk for trauma exposure and subsequent development of PTSD. In addition, children’s, families’ and communities’ responses to trauma vary by group. 45

72. 52 The Influence of Developmental Stage Child traumatic stress reactions vary by developmental stage. Children who have been exposed to trauma expend a great deal of energy responding to, coping with, and coming to terms with the event. This may reduce children’s capacity to explore the environment and to master age-appropriate developmental tasks. The longer traumatic stress goes untreated, the farther children tend to stray from appropriate developmental pathways. 52

73. 53 Young children who have experienced trauma may: – Become passive, quiet, and easily alarmed – Become fearful, especially regarding separations and new situations – Experience confusion about assessing threat and finding protection, especially in cases where a parent or caretaker is the aggressor – Regress to recent behaviors (e.g., baby talk, bed-wetting, crying) – Experience strong startle reactions, night terrors, or aggressive outbursts 53 The Influence of Developmental Stage: Young Children

74. 54 School-age children with a history of trauma may: – Experience unwanted and intrusive thoughts and images – Become preoccupied with frightening moments from the traumatic experience – Replay the traumatic event in their minds in order to figure out what could have been prevented or how it could have been different – Develop intense, specific new fears linking back to the original danger 54 The Influence of Developmental Stage: School-Age Children

75. 55 School-age children may also: – Alternate between shy/withdrawn behavior and unusually aggressive behavior – Become so fearful of recurrence that they avoid previously enjoyable activities – Have thoughts of revenge – Experience sleep disturbances that may interfere with daytime concentration and attention The Influence of Developmental Stage: School-Age Children, cont’d

76. 56 In response to trauma, adolescents may feel: – That they are weak, strange, childish, or “going crazy” – Embarrassed by their bouts of fear or exaggerated physical responses – That they are unique and alone in their pain and suffering – Anxiety and depression – Intense anger – Low self-esteem and helplessness 56 The Influence of Developmental Stage: Adolescents

77. 57 These trauma reactions may in turn lead to: – Aggressive or disruptive behavior – Sleep disturbances masked by late-night studying, television watching, or partying – Drug and alcohol use as a coping mechanism to deal with stress – Over- or under-estimation of danger – Expectations of maltreatment or abandonment – Difficulties with trust – Increased risk of revictimization, especially if the adolescent has lived with chronic or complex trauma 57 The Influence of Developmental Stage: Adolescents, cont’d

78. 58 The Influence of Developmental Stage: Adolescents, Trauma, & Substance Abuse Adolescents who have experienced trauma may use alcohol or drugs in an attempt to avoid overwhelming emotional and physical responses. In these teens: – Reminders of past trauma may elicit cravings for drugs or alcohol. – Substance abuse further impairs their ability to cope with distressing and traumatic events. – Substance abuse increases the risk of engaging in risky activities that could lead to additional trauma. Child welfare workers must address the links between trauma and substance abuse and consider referrals for relevant treatment(s). 58

79. 59 Homeless youth are at greater risk for experiencing trauma than other adolescents. – Many have run away to escape recurrent physical, sexual, and/or emotional abuse – Female homeless teens are particularly at risk for sexual trauma Special needs adolescents are 2 to 10 times more likely to be abused than their typically developing counterparts. Lesbian, gay, bisexual, transgender or questioning (LGBTQ) adolescents contend with violence directed at them in response to suspicion about or declaration of their sexual orientation and gender identity 59 The Influence of Developmental Stage: Specific Adolescent Groups

80. BIG PICTURE …  Many of the symptoms we are seeing in the children we work with are direct results of coping with trauma …  When we try to take away their coping, families and children often withdraw and protect themselves from us …  Be aware of the “invisible suitcase” that our children and parents bring with them as they move into the system and often away from everything they know … Information and slide part of Dr. Allison Sampson's Trauma Presentation

81. BIGGER PICTURE We tend to look and react to the BEHAVIOR Trauma informed practice requires us to seek and respond to the NEED BEHAVIOR WHEEL EXERCISE … Information and slide part of Dr. Allison Sampson's Trauma Presentation

82. CROSS GENERATIONAL TRAUMA... What about the caregivers ….

83. Perspective of a parent …  Poem … perspective on children of trauma who have now grown up to be parents …  Understanding how trauma may be impacting a birth parent  Impact of trauma on communication and decision making of adult caregivers  Data on caregivers needs Information and slide part of Dr. Allison Sampson's Trauma Presentation

84. Cross- Generational Trauma Histories Hendricks (2012) Chapter 12 of Creating Trauma Informed Child Welfare Systems Using Trauma Informed Services to Increase Parental Protective Factors  Why does it matter to us ?  -Affects the emotions and behaviors of the parents and thus their communication and decision-making - All that we have learned about trauma, attachment, and the brain now applies to the parents - Is an important consideration in kinship care and relative placements  Not addressing parental trauma history decreases the parenting abilities of all caregivers in the child’s life … results in disrupted placements and client recidivism Information and slide part of Dr. Allison Sampson's Trauma Presentation

85. Cross-Generational Trauma Hendricks (2012) Chapter 12 of Creating Trauma Informed Child Welfare Systems Using Trauma Informed Services to Increase Parental Protective Factors  If a parents has had chronic trauma in their own childhoods it impacts  - Ability to engage in positive parent child interactions  - Ability to protect their own children  - Ability to help their children recover from trauma  - Ability to cope and function with system (Juvenile Justice or Child Welfare) interventions in support of and with their children Information and slide part of Dr. Allison Sampson's Trauma Presentation

86. Cross-Generational Trauma Hendricks (2012) Chapter 12 of Creating Trauma Informed Child Welfare Systems Using Trauma Informed Services to Increase Parental Protective Factors Women who have experienced trauma are more likely to self- medicate with a substance (55-99%) (1) Intergenerational transmission of trauma (Depression, PTSD) (2) Unresolved childhood trauma can lead to reenactments with partners in adult relationships and/or with their children (3) Unresolved childhood trauma can lead to difficulty forming secure attachments with their children (4) Childhood trauma can result in parenting styles that include threats & violence (2) Childhood sexual abuse survivors can miss “red flags” of sexual abuse with their own children due to avoidance of trauma memories themselves (2) 1)Najavits, Weiss, & Shaw (1997) The American Journal on Addiction, 6 (4), 273-283 2)Hendricks, A. (2012). Using Trauma-Informed Services to Increase Parental Factors (pp. 89-91) 3)Walker (2007) Journal of Social Work Practice, 21 (1), 77-87. 4)Main & Hess (1990) In M. Greenberg, D. Cicchetti, & E. Cummings (Eds.), Attachment in the preschool years: Theory, research, and intervention (pp. 121-160)

87. Cross-Generational Trauma Hendricks (2012) Chapter 12 of Creating Trauma Informed Child Welfare Systems Using Trauma Informed Services to Increase Parental Protective Factors Caregiver functioning following a child’s exposure to trauma is a major predictor of child’s functioning (1 & 2) If we want to improve a child’s outcome, we must address parent’s trauma history … failure to do so can result in (2) … - Failure to engage in treatment services - An increase in symptoms - An increase in management problems - Retraumatization - An increase in relapse - Withdrawal from service relationship - Poor treatment outcomes 1)Linares et al (2001) Child Development, 72, 639-652 2)Liberman, Van Horn, & Ozer (2005) Development and Psychopathology, 17, 385-396 3)Hendricks, A. (2012) pp. 91

88. Pro-Active Approaches with Parents  Utilize trauma focused screening and assessment and treatment services with all family members including the birth family  Don’t just make a referral to general mental health services, substance abuse services, or domestic violence services  Advocate for better trained service providers  Promote awareness of parent trauma across the Juvenile Justice System Promote awareness of parent trauma across the Juvenile Justice System Hendricks, A. (2012) Using Trauma Informed Services to Increase Parental Protective Factors from Chapter 12 of Creating Trauma Informed Child Welfare Systems. (p. 91)

89. JUVENILE JUSTICE AND FOSTER CARE

90. Increased likelihood for Delinquency Campbell, Porter, and Santor (2004) tracked the social development of 226 male and female incarcerated juveniles. The results of this investigation demonstrate that only one psychosocial variable impacted outcomes for most incarcerated juveniles: a history of non-parental living arrangements-i.e. foster care. Information and slide part of Dr. Allison Sampson's Trauma Presentation

91. Criminal Assault and Foster Care  "Foster children were more likely to have committed criminal assault. Among foster children, increased number of foster home placements correlated with increased number of delinquency convictions" (p. 562). Runyan. D.K. (1985). Foster care for child maltreatment: Impact on delinquent behavior. Pediatrics, 75(3), 562-568. Information and slide part of Dr. Allison Sampson's Trauma Presentation

92. Foster Care Outcomes and Data Based on Health and Human Services data (2005), children entering foster care …. 60% will return home 15% will be adopted Remaining children “age out” of foster care (19,000 per year) Information and slide part of Dr. Allison Sampson's Trauma Presentation

93. Impact of being in Child Welfare System  25% will be incarcerated within first 2 years of aging out of the system  More than 20% will become homeless  Only 58% will have a High School Diploma  Less than 3% will have a college education by age of 25  Many will re-enter the system as parents  For children under age of 5, increase likelihood of developmental delays 13-62% compared to 4-10% 1)Conradi, L. (2012) Chadwick Trauma Informed System Project p. 54 2) Leslie et. al. (2005). Developmental and Behavioral Pediatrics 26(3), 177-185 Information and slide part of Dr. Allison Sampson's Trauma Presentation

94. Birth Parent Involvement  Many studies indicate that caregiver functioning is a major predictor of child functioning after child experiences a trauma (Linares et al. 2001, Lieberman, Van Horn, & Ozer 2005)  Birth parent involvement can improve children's depression and lower their externalizing behavior problems (McWey, Acock, & Porter 2010)  See NCTSN Guide for Attorneys and Judges on Birth Parents and “What Children in Foster Care Want You to Know” Information and slide part of Dr. Allison Sampson's Trauma Presentation

95. BIG PICTURE  Often the caregivers … are the kids we as a system “missed”  They come to us with their own trauma histories  Successful outcomes with our clients means successful work with the family  Screening all caregivers and finding them services is critical to the prevention/treatment/reduction of recidivism for children entering the juvenile justice system Information and slide part of Dr. Allison Sampson's Trauma Presentation

96. Trauma and OUR Work Meeting the Trauma Needs of Our Staff … - ACE scores - Secondary Trauma Information and slide part of Dr. Allison Sampson's Trauma Presentation

97. IS IT JUST ABOUT CHILDREN THOUGH … OR IS IT ABOUT ALL OF US ????

98. Adverse Childhood Experiences Felitti, V. J., & Anda, R. F. (2010) Information and slide part of Dr. Allison Sampson's Trauma Presentation Bigger Scope (n=17,337) 2/3 rd of folks responding reported at least 1 ACE factor 1 in 6 had 4 or more ACE factors Factors are linked to higher risks for medical conditions like smoking, severe obesity, and heart disease Factors are linked higher risk for substance abuse, depression and suicide attempts MAJOR PUBLIC HEALH ISSUE Refer back to Trauma Infographic http://www.cdc.gov/ace/index.htm

99. Types of items on ACE Childhood experiences … (short measure)(short measure)  Emotional Violence/Abuse  Physical Violence/Abuse  Sexual Violence/Abuse  Feeling “unloved” or not supported by primary caregivers  Hunger, lack of protection, substance use in family  Loss of Caregiver (separation/divorce)  Witness IPV of mother figure  Living with person with an addiction  Mental health conditions in family/suicide in family  Household member in prison system Information and slide part of Dr. Allison Sampson's Trauma Presentation

100. ACE Data Information and slide part of Dr. Allison Sampson's Trauma Presentation

101. Importance of Knowing Your “Hand”  Importance of knowing what you bring into the “room” with your client  Awareness of your own triggers and trauma echoes  Self-Care … awareness of your risk factors in key areas of physical and mental health  Prevention of Burn Out  Awareness of ACE and impact of secondary trauma Information and slide part of Dr. Allison Sampson's Trauma Presentation

102. Taking Care of Yourself  Always at the end … always the part we race through … one of THE MOST IMPORTANT components of an effective Trauma Informed Child Welfare System  Bride (2007) did a study of master’s level social workers licensed in a southern state. The study found that…  70.2% of workers experienced at least one symptom of STS in the previous week  55 % met the criteria for at least one of the core symptom clusters  15.2% met the core criteria for a diagnosis of PTSD.  The intrusion criterion was endorsed by nearly half of the respondents.  The most often reported symptoms were intrusive thoughts, avoidance of reminders of clients, and numbing responses. Information and slide part of Dr. Allison Sampson's Trauma Presentation

103. 106 Impact of Working with Victims of Trauma 106 Trauma experienced while working in the role of helper has been described as: – Compassion fatigue – Countertransference – Secondary traumatic stress (STS) – Vicarious traumatization Unlike other forms of job “burnout,” STS is precipitated not by work load and institutional stress but by exposure to clients’ trauma. STS can disrupt child welfare and juvenile justice workers’ lives, feelings, personal relationships, and overall view of the world.

104. Impact of Chronic Stress http://www.helpguide.org/mental/stress_signs.htm  raise blood pressure  suppress immune system  increase the risk of heart attack and stroke  contribute to infertility  speed up the aging process (life expectancy)  create vulnerability for anxiety and depression  obesity  skin conditions (ex: eczema)  sleep problems  digestive problems Information and slide part of Dr. Allison Sampson's Trauma Presentation

105. Vicarious Trauma’s Impact Personally (Yassen, 1995)  Emotional  Roller coaster  Overwhelmed  Depleted  Behavioral  Negative coping mechanism  Difficulty sleeping  Absent- mindedness  Cognitive  Spaciness  Apathy  Perfectionism  Minimization Information and slide part of Dr. Allison Sampson's Trauma Presentation

106. Personal Impact … (Yassen, 1995)  Spiritual  Hopelessness  Anger at a Higher Power  Physical  Aches and pains  Impaired immune system  Breathing difficulties  Interpersonal  Withdrawn  Intolerance  Loneliness  Projection of anger and blame Information and slide part of Dr. Allison Sampson's Trauma Presentation

107. Professional Impact (Yassen, 1995)  Performance of Job Tasks  Decrease in quality and quantity  Increase in mistakes  Avoidance of job tasks  Morale  Dissatisfaction  Negative attitude  Detachment Information and slide part of Dr. Allison Sampson's Trauma Presentation

108. Professional Impact (Yassen, 1995)  Interpersonal  Withdrawn from colleagues  Impatience  Poor communication  Staff conflicts  Behavioral  Tardiness  Absenteeism  Faulty Judgement Information and slide part of Dr. Allison Sampson's Trauma Presentation

109. 107 Managing Stress when working with court involved youth Request and expect regular supervision and supportive consultation. Utilize peer support. Consider therapy for unresolved trauma, which the child welfare work may be activating. Practice stress management through meditation, prayer, conscious relaxation, deep breathing, and exercise. Develop a written plan focused on maintaining work–life balance. 107

110. Perry and Cost of Caring http://childtraumaacademy.com/cost_of_caring/index.html Information and slide part of Dr. Allison Sampson's Trauma Presentation

111. What we know …  Impact of trauma on children  Impact of trauma on caregivers  Impact of trauma on our workforce  So what are trauma informed best practices? Information and slide part of Dr. Allison Sampson's Trauma Presentation

112. HOW DO WE APPROACH COMPLEX TRAUMA Phase Oriented Treatment

113. Acknowledgement … Excellent resource for learning … Editors Christine A Courtois and Julian Ford’s 2009 book …. Treating Complex Traumatic Stress Disorders: An Evidence Based Guide Guilford Press Information and slide part of Dr. Allison Sampson's Trauma Presentation

114. Core areas of focus in Complex Trauma Courtois, C. & Ford, J. (2009), Introduction (p.2)  Self-Regulation  Affect Regulation  Disassociation (difficulty in being “present”)  Somatic Dysregulation  Self-Identity  Impaired Self-Concept  Impaired Self-Development  Co-regulation  Secure working model of caring relationship  Disorganized Attachment Patterns Information and slide part of Dr. Allison Sampson's Trauma Presentation

115. Phase Oriented Treatment “Gold Standard” Phase I: Safety and Stabilization Phase 2: Trauma Reprocessing Phase 3: Reintegration Courtois, C., Ford, J., & M. Cloitre (2009), pp.90-100 Information and slide part of Dr. Allison Sampson's Trauma Presentation

116. Phase Oriented Treatment Courtois, C., Ford, J., & M. Cloitre (2009), pp.90-100 PHASE ONE: Safety and Stabilization  Personal and Interpersonal Safety Established: Education/Support/Safety Planning  Enhance Client’s ability to manage extreme arousal (hyper/hypo)  Active engagement in positive/negative experiences (deal with automatic avoidance behaviors, self awareness of avoidance, increase coping skills and use of coping skills)  Education (psychotherapy, trauma, skills to be learned)  Assess and develop relationship capacity (decrease avoidance of relationships or negative thoughts about relationships, build support network, define client’s attachment network) PHASE TWO: Trauma Reprocessing  Disclosure of traumatic memories, development of an autobiographical narrative (identify emotions connected to trauma memories, grieve and mourn losses, resolution of relationships when appropriate, increased awareness, increase interpersonal and self-regulation skills)  Supporting client in maintaining functioning and not getting lost in memories or seeing themselves as “disabled”, need to affirm strengths, promote positive self-esteem, and internal and external resources now available to them PHASE THREE: Re-Integration  Growth and period and reengagement in life  Can be time of client realizing losses, discover of unresolved developmental deficits, fine tuning of self-regulation skills Information and slide part of Dr. Allison Sampson's Trauma Presentation

117. Contextual Models of Care Gold, S. (2009) pp.231-235  Interpersonal Area  Collaborative approach  Attachment in the therapeutic relationship  Practical Area  Skill Development Self-Soothe Being in the Present Cognitive Strategies (problem solving) Release of addiction/maladaptive behaviors Traumatic Stress Reprocessing Engaging in Daily Life  Conceptual Area  Clinician is a guide through the process  Client develops the conclusions and outcomes Information and slide part of Dr. Allison Sampson's Trauma Presentation

118. Creating a Culture for TIC Information and slide part of Dr. Allison Sampson's Trauma Presentation Five Core Values (Fallot, 2009) 1) Safety 2) Trustworthiness 3) Choice 4) Collaboration 5) Empowerment

119. Trans-Diagnostic Features Information and slide part of Dr. Allison Sampson's Trauma Presentation  Therapeutic Relationship  Expectations (Role and Purpose)  Motivation  Feedback

120. Stage Oriented Trauma-Informed Screening and Assessment Trish Mullen, LPC mullenp@chesterfield.gov

121. Intake versus Assessment Information and slide part of Dr. Allison Sampson's Trauma Presentation  What’s the Difference ??  Ways to build assessment  TAPS assessment course http://www.taptraining.net/

122. Stage Oriented Trauma-Informed Screening and Assessment Given that the primary experience of trauma is feeling unsafe and powerless, it is essential that the screening, assessment, and treatment process is directed at restoring a sense of safety and power (Steele, W. 2003). Pacing the process is key!

123. Trauma Informed Screens and Assessment Defined  Universal Screening  Comprehensive Assessment

124. Universal Precautions  Universal screening for trauma history is recommended for all child-serving agencies, but this has a particularly critical application among certain populations, such as youth in substance abuse and delinquency programs.  Once youth enter the juvenile justice system, a formal screening method for trauma is critical in identifying children and adolescents who suffer from stress related to trauma.

125. Trauma Informed Screens and Assessment There are three basic approaches to the assessment of trauma and post-traumatic sequelae in children and adolescents used with children and adolescents in juvenile justice settings.  First, there are a number of instruments designed to directly measure traumatic experiences or reactions in children and adolescents.  Second, there are several omnibus child diagnostic instruments that include PTSD subscales.  Third, there are a number of instruments that assess symptoms. Assessing Exposure to Psychological Trauma and Post-Traumatic Stress in the Juvenile Justice Population National Child Traumatic Stress Network www.NCTSNet.org

126. Essential Components of Trauma-Informed Assessment The “trauma-informed” assessment is a stage oriented process that recognizes:  Trauma is not primarily a cognitive experience  “Witnessing” a traumatic event can be just as traumatizing as experiencing it firsthand  Fight/flight/freeze as initial presentation  The interaction between the event and the child’s personal crisis experiences and perceptions  Developmental and Ethnocultural Factors

127. Essential Components of Trauma-Informed Assessment Cont  Confidentiality  Purpose of screening and assessment explained  Counter-transferential dynamics can interfere with a good assessment  The assessment process can trigger defense mechanisms-- such as denial, minimization, repression, amnesia, and dissociation (Briere, 1992a)Briere, 1992a  The need to pace the interview and doesn’t re-traumatize the client

128. Essential Components of Trauma-Informed Assessment Cont Assessors should be cognizant of children’s perception of their environment and be ready to advocate for them when concerns related to safety arise. In juvenile justice settings, safety also involves explaining clearly to the child and family, and reliably maintaining, definite boundaries and limits concerning confidentiality and sharing of clinical information (e.g., mandated reports or requests for information by courts, correctional staff, child welfare workers, or probation officers). Assessing Exposure to Psychological Trauma and Post-Traumatic Stress in the Juvenile Justice Population National Child Traumatic Stress Network www.NCTSNet.org

129. Stage Oriented Trauma-Informed Screening and Assessment Newman (2002) recommends a “multi-modal” approach to assessment (i.e., multiple informants and multiple forms of assessments, such as interviews and self-report instruments).

130. 3 stages of Trauma Assessment Stage 1: Assessing  Child’s Immediate Safety  Current threat to self? Others?  Is the child safe from revictimization?  Psychological Stability- For both child and caregiver  Safety and Stability of current environment  Trauma Symptomology  Stress tolerance  Strength based self-regulation skills and positive supports  Capacity to discuss traumatic event (s) Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment (Briere & Scott, 2006)

131. 3 stages of Trauma Assessment Stage 2: Assessing  Previous and current traumatic experiences using standardized measures  Traumagenic Dynamics  Self-regulatory strategies  Adult Reactions to the trauma  Traumatic events perspective  The impact on child and family functioning  Cognitive Distortions  Nature of the crisis event  Relationship with those involved  Individual/Personal Vulnerability Factors  Protective Factors Treating Traumatized Children: Risk, Resiliency, and Recovery (Brom, Pat-Horenczyk, & Ford, 2009)

132. 3 stages of Trauma Assessment Stage 3: Assessing  Monitor current stressful or traumatic experiences, family relationships, and developmentally appropriate peer relationships  Use of de-escalation preferences  Trigger Mapping  Ability to self-regulate  Treatment Effectiveness

133. Trauma-Informed Assessment Considerations No child is an island – parental and family dynamics have significant influence on a child’s recovery from trauma. National Child Traumatic Stress Network, Family Systems Collaborative Group. (2011). Family Trauma Assessment: Tip Sheet for Clinicians.

134. Trauma-Informed Assessment Considerations Screening for trauma may be overlooked because the behavioral responses to trauma often resemble the common delinquent behaviors seen in youth referred to the justice system and are therefore under-identified as posttraumatic symptoms. Assessing Exposure to Psychological Trauma and Post-Traumatic Stress in the Juvenile Justice Population National Child Traumatic Stress Network www.NCTSNet.org

135. Chasing Behaviors Agitation Depression Intrusive Memories Nightmares Hopelessness Numbing Insomnia Shame & Self- Hatred Panic Attacks Substance Abuse Somatic Symptoms Eating Disorders Self- Destructive Behavior Dissociation Poor Impulse Control Defiance Withdrawal

136. Trauma-Informed Assessment Considerations Traumatized children cannot assign words to experiences, rather their disorganized states are experienced as physical discomfort, lack of energy, emotional distress, feeling numb or dead. They present with a full range of somatic complaints with no known medical cause. (Carlson and Cicchetti, 1990, van der Kolk, 1997, Krystal, 1978, Saxe, 1996) Trauma Impacts the area of the brain responsible for assigning words to feelings.

137. Assessing Adolescent Brain Source: US News & World Report, 2005

138. Resilience Trumps Aces

139. Knowing Assessment Tools to Use Trauma Exposure and Screening  PTSD Checklist  ACE short version  Life Events Checklist  PTGI (online) Trauma Assessment Measures  Clinician Administered PTSD Scale  Trauma Symptom Inventory-2  UCLA Reaction Index Information and slide part of Dr. Allison Sampson's Trauma Presentation

140. Clinical Case Presentation Information and slide part of Dr. Allison Sampson's Trauma Presentation  Presenting Case (Client, Mom, and Worker)  Assessment Information Available  Review of Possible Assessment Tools  Focus on Trauma Impact and Positive Events  Targets for Change  Collaborative Work with Client around goals for self- regulation, self-identity, and relationships

141. Allison’s Model of Care Information and slide part of Dr. Allison Sampson's Trauma Presentation

142. STEPS … Phase One … Practice  Present themes that often come up for folks who have experienced trauma  Present assessment information to client and family  Safety Planning (plan, monitoring) Safety Planning (plan, monitoring)  Focus on hopes (goals) … move to identifying skills to get thereFocus on hopes (goals) … move to identifying skills to get there Information and slide part of Dr. Allison Sampson's Trauma Presentation

143. Skill Sets to Build – Phase 1  Emotional Distress Tools  Self-regulation Tools  Self-Awareness Tools  Patterns  Cognitive Distortions  Education on Trauma  Relationship Skills Information and slide part of Dr. Allison Sampson's Trauma Presentation

144. CAPPD skills Information and slide part of Dr. Allison Sampson's Trauma Presentation  http://www.multiplyingconnections.org/become- trauma-informed/techniques-cappd http://www.multiplyingconnections.org/become- trauma-informed/techniques-cappd  http://www.multiplyingconnections.org/become- trauma-informed/cappd-cards http://www.multiplyingconnections.org/become- trauma-informed/cappd-cards

145. CAPPD Techniques Information and slide part of Dr. Allison Sampson's Trauma Presentation The following are techniques for behavioral and structural changes you can make when interacting with children. Create Safety Provide Choice and Control Communicate Respect Be Nurturing Provide Stability Get Down on Eye Level Model Open Discussion Discipline Strategies

146. Activities that promote CAPPD Information and slide part of Dr. Allison Sampson's Trauma Presentation  The following activities are focused interactions you can use with children to help them cope with their responses to trauma and any trauma triggers present in the environment Make a Safety Plan Read Stories Breathing Retraining Muscle Relaxation Positive Imagery Creative Activities Playing Outside Free Play Today I Feel… Teaching Attunement Grounding Exercise Treasure Hunt I Spy Interactive Story Telling Simon Says Emotional Matching Dramatic Play

147. Selecting Skills that Match Hopes – Phase 1  Working with client to select skills and contracting to try skills each week  Moving skills into treatment plan  Monitoring emotions and use of skills each week  Diary Cards  Scales Information and slide part of Dr. Allison Sampson's Trauma Presentation

148. Phase Two – Traumatic Stress Reprocessing  Specialized Methods (EBPs) for reprocessing memories  EMDR  Progressive Counting  Gathering a Trauma Narrative  CAPS  Event/Age/SUDS Information and slide part of Dr. Allison Sampson's Trauma Presentation

149. EMDR Eye Movement Desensitization and Reprocessing EMDR is an accelerated form of information processing healthy integration of traumatic memories using an 8 phase approach developed by Dr. Francine Shapiro Information and slide part of Dr. Allison Sampson's Trauma Presentation

150. EMDR Eye Movement Desensitization and Reprocessing EMDR is thought to use bilateral stimulation (i.e. eye movements, taps, or auditory cues) to activate the right and left hemispheres of the brain to promote neural integration of memory, emotions, physical sensations and perception Information and slide part of Dr. Allison Sampson's Trauma Presentation

151. EMDR Eye Movement Desensitization and Reprocessing According to Dr. Dan Siegal, the result of promoting neural integration would be both the result of the alleviation of symptoms and development of an enhanced sense of well being internally as well as more rewarding experiences interpersonally Information and slide part of Dr. Allison Sampson's Trauma Presentation

152. Progressive Counting Greenwald, R. (2012) Progressive counting (PC) is a recently developed trauma treatment, based on the counting method, that appears to be at least as effective and efficient as EMDR, well tolerated by clients, and relatively easy for therapists to learn. Briefly, PC involves having the client visualize a series of progressively longer "movies" of the trauma memory while the therapist counts out loud (first to a count of 10, then 20, then 30, etc.). Case studies and open trials have been promising; results of the first controlled comparison study will be available by later in 2012. http://www.childtrauma.com/pc.html Information and slide part of Dr. Allison Sampson's Trauma Presentation

153. Phase Three - Reintegration  Ongoing use of skills  Amplifying Skills to other life domain areas and challenges in life  Connection to natural supports Support Groups Physical Exercise Friends/Family Information and slide part of Dr. Allison Sampson's Trauma Presentation

154. Wrap up  Lessons Learned  Final Poem of the Workshop  Offering Hope …. Information and slide part of Dr. Allison Sampson's Trauma Presentation

155. Resilience Trumps Aces

156. Trauma and Resiliency (Protective Factors) Information and slide part of Dr. Allison Sampson's Trauma Presentation Positive attitudes, values or beliefs Conflict resolution skills Good mental, physical, spiritual and emotional health Positive self-esteem Success at school Good parenting skills Parental supervision Strong social supports Community engagement Problem-solving skills Positive adult role models, coaches, mentors Healthy prenatal and early childhood development Participation in traditional healing and cultural activities Good peer group/friends Steady employment Stable housing Availability of services (social, recreational, cultural, etc)

157. Protective Factor Framework Information and slide part of Dr. Allison Sampson's Trauma Presentation  Parental resilience  Social connections  Knowledge of parenting and child development  Concrete support in times of need  Social and emotional competence of children https://www.childwelfare.gov/can/factors/protectiv e_factors.cfm

158. Post-Traumatic Growth Tedeschi and Calhoun (1996, 1999, 2006) Information and slide part of Dr. Allison Sampson's Trauma Presentation 1) Emergence of new opportunities and possibilities 2) Deeper relationships and greater compassion for others 3) Feeling strengthened to meet future life challenges 4) Reorder priorities and fuller appreciation of life 5) Deepening spirituality Deepening spirituality http://cust-cf.apa.org/ptgi/

159. Characteristics of Families who Thrive Figley and Kiser (2013) Helping Traumatized Families (pg. 39-41) Information and slide part of Dr. Allison Sampson's Trauma Presentation  Clear acceptance of stressor(s)  Family centered locus of problem (shift from individual)  Solution oriented problem solving (not blame)  High tolerance for each other  Clear and direct expressions of commitment and affections  Open and Effective Communication  High Family Cohesion (fun and enjoyment)  Flexible Family Roles  Predictability  Effective resource utilization  Belief in their ability to succeed  Shared meaning (collaborative coping skills)