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1 UNDERSTANDING AND ADDRESSING CHILDHOOD TRAUMA: THE ROLE OF INFORMED CARE Gordon R. Hodas MD 2012 Conference on the State of Education in Pennsylvania.

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Presentation on theme: "1 UNDERSTANDING AND ADDRESSING CHILDHOOD TRAUMA: THE ROLE OF INFORMED CARE Gordon R. Hodas MD 2012 Conference on the State of Education in Pennsylvania."— Presentation transcript:

1 1 UNDERSTANDING AND ADDRESSING CHILDHOOD TRAUMA: THE ROLE OF INFORMED CARE Gordon R. Hodas MD 2012 Conference on the State of Education in Pennsylvania – Calling for a Trauma- Informed Educational System Cheyney University, Friday, 5/25/12

2 22 INTRODUCTION GORDON R. HODAS MD Statewide Child Psychiatric Consultant to PA Office of Mental Health and Substance Abuse Services (OMHSAS), 19+ years. Child and Adolescent Policy Consultant to Bucks County Behavioral Health System (BHS), 7 years Consultant Psychiatrist & Associate Medical Director, Wordsworth Academy, Fort Washington PA No financial disclosures or conflicts of interest

3 33 INTRODUCTION TRAUMA-RELATED EXPERIENCE/EXPERTISE 1999 – OMHSAS presentation, S/R reduction. 2003 – Consultant to CWLA Workgroup 2004 – Faculty member for NETI/NASMHPD training 2004 – Involvement in DPW S/R, TIC initiative 2005 – Publication by NASMHPD of paper on TIC. 2005 on – Additional articles, T/A documents. 2007 on – Regional SAC (Stakeholders Advisory Committee) for youth in RTFs, initiated by BC. 1992 on – Clinical consultation in Special Ed

4 44 CREATING THE FRAMEWORK SAMHSA’S TEN STRATEGIC INITIATIVES (2010) Priority #2 = Violence and Trauma Reduce the behavioral health impacts of violence and trauma, and integrate trauma-informed services in prevention and treatment programs in States and communities and throughout the health service delivery system, to address root causes of pervasive, harmful, and costly public health problems (my underlining).

5 55 CREATING THE FRAMEWORK THREE KEY ISSUES What are the potential outcomes of significant childhood trauma and adversity, during childhood and over the lifespan? What can be done to decrease the impact, and the frequency, of childhood trauma, and how is this related to trauma informed care? What additional steps can be taken, in the community and in the educational system? Bottom line: TIC an attitude and mind-set about youth, which leads to positive practices.

6 66 HEALTHY DEVELOPMENT Healthy Development

7 77 HEALTHY DEVELOPMENT BRAZELTON AND GREENSPAN: THE IRREDUCIBLE NEEDS OF CHILDREN (1) Focus: “What every child must have to grow, learn, and flourish” – 7 irreducible needs Ongoing nurturing relationships. Physical protection, safety, and regulation. Experiences tailored to individual differences.

8 88 HEALTHY DEVELOPMENT IRREDUCIBLE NEEDS OF CHILDREN (2) Developmentally appropriate experiences. Limit setting, structure, and expectations. Stable, supportive communities & cultural continuity. Protecting the future, at national & international levels.

9 99 HEALTHY DEVELOPMENT BRAZELTON/GREENSPAN – IMPACT OF SAFETY & ONGOING, NURTURANT RELATIONSHIPS Appropriate development of central nervous system. Foundation for development of human emotions. Self-regulation & sense of predictability & security. Thinking, problem-solving, learning. Communication with others. Warmth, intimacy, pleasure. Trust, empathy, compassion, morality.

10 10 CLASSIFICATION OF TRAUMA Disruption of healthy development – trauma

11 11 CLASSIFICATION OF TRAUMA CHARACTERISTICS OF TRAUMA Traumatic event (per DSM IV) involves experiencing, witnessing, or being confronted by event or events that involved “actual or threatened death or serious injury, or a threat to the integrity of self or others.” The individual’s response involved “intense fear, helplessness, or horror” (with children, may have disorganized or agitated behavior). Thus, “trauma” requires a psychological (and often physical) response to a dangerous event.

12 12 CLASSIFICATION OF TRAUMA TYPES OF TRAUMA – INDIVIDUAL, CHILDHOOD Neglect and abuse – physical, sexual, emotional. Witnessing of domestic abuse. Multiple placements and rejection. Traumatic loss. All of above involve unstable caregiving and disruption of primary attachments. Community violence – bullying, rape, witnessing violence. Medical trauma.


14 14 CLASSIFICATION OF TRAUMA OFTEN OVERLOOKED TRAUMA – “THE SYSTEM” Iatrogenic, resulting from contact with mental health and other public systems. People report re-traumatization in both institutional and community service settings. Inpatient psychiatric hospitals are most frightening, but can occur in any level of care. Insensitive staff actions may involve dismissing of concerns, bias and stereotyping, coercion, Inappropriate staff actions can include various forms of abuse.

15 15 CLASSIFICATION OF TRAUMA DSM IV DIAGNOSIS RELATED TO TRAUMA Acute Stress Disorder – within 4 weeks of traumatic event. Posttraumatic Stress Disorder (PTSD): – Re-experiencing – Avoidance/numbing – Hyperarousal Dissociation Disorders. Conversion Disorder.

16 16 CLASSIFICATION OF TRAUMA PTSD AS THE “ORPHAN” TRAUMA DIAGNOSIS Re-experiencing Avoidance/numbing Hyperarousal

17 17 CLASSIFICATION OF TRAUMA HUMAN SERVICE SYSTEMS ALSO EXPERIENCE TRAUMA (1) Repetitive mandate – do more with less. Service rates not on par with actual needs. Rate adjustments infrequent. Policy changes may be sudden and unexpected. Recent economic downturn. Adversarial relationships with funders & regulators.

18 18 CLASSIFICATION OF TRAUMA TRAUMA EXPERIENCED BY HUMAN SERVICE SYSTEMS (2) Organizations and agencies become reactive (Bloom). Work difficult, supervision limited. Organizations may become autocratic. Result: – Trauma for agencies and workforce. – Diminished morale, and staff turnover. – Focus on survival.

19 19 DETERMINANTS OF OUTCOME DETERMINANTS OF CHILD’S RESPONSE TO TRAUMA – RESULT OF 3 SETS OF VARIABLES: Characteristics of the traumatic event(s) Characteristics of the environment Characteristics of the individual child

20 20 DETERMINANTS OF OUTCOME CHARACTERISTICS OF THE TRAUMATIC EVENT(S) Frequency, severity, & duration of event(s) Degree of physical violence and bodily violation Level of terror and humiliation experienced Persistence of threat Physical and psychological proximity to event and perpetrator

21 21 DETERMINANTS OF OUTCOME CHARACTERISTICS OF THE ENVIRONMENT Attitudes and behaviors of first responders. Immediate reaction of caregivers or those close to child. Type, quality of, & access to, constructive supports. Degree of safety following the event. Prevailing community/cultural attitudes and values. Other protective & risk factors in environment.

22 22 DETERMINANTS OF OUTCOME CHARACTERISTICS OF THE INDIVIDUAL CHILD Age and stage of development Prior trauma history Intellectual capacity Strengths, coping, and resiliency skills Vulnerabilities (psychiatric or physical disorders). Child’s culturally based understanding of the trauma

23 23 TRAUMA PREVALENCE Just how common is childhood trauma in society”? Unfortunately, very common.

24 24 TRAUMA PREVALENCE ESTIMATED PREVALENCE IN SOCIETY General population: 34-53% report childhood abuse or sexual abuse. Public mental health clients: 90% with trauma, most multiple experiences. People in treatment for substance abuse: 30-59% of females with PTSD, & 11-38% of males (Najavits). Youth in general: 20-50% have experienced trauma. Youth in inner cities: Up to 80-90% with history of trauma.

25 25 TRAUMA PREVALENCE ESTIMATED TRAUMA PREVALENCE AMONG YOUTH IN JUVENILE JUSTICE One or more traumatic event: – 93% of males. – 84% of females. Witnessed violence or death: – 59% males. – 47% females. Sexual abuse among adjudicated females: more than 75%.

26 26 ACE STUDY ACE Study: Adversity, not just trauma, matters

27 27 ACE STUDY ADVERSE CHILD EXPERIENCES (ACE) STUDY Kaiser Permanente, California, starting in 1995. An ongoing longitudinal study, most significant public health study of natural history of trauma/adversities. Middle class population, able to afford private insurance. Goal: to determine relationship between adverse child experiences (“exposures”) – childhood maltreatment & family stress – and later outcomes. Outcomes tracked for adults and youth.

28 28 ACE STUDY ACE STUDY – CATEGORIES OF ADVERSITIES (1) Physical abuse Did a parent or other adult in the household often or very often push, grab, slap, or throw something at you? Sexual abuse 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? Neglect Did you often or very often feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect you?

29 29 ACE STUDY ACE STUDY – ADVERSITIES (2) Emotional abuse Did a parent or other adult in the household often or very often swear at you, insult you, put you down, or humiliate you? Feeling unloved Did you often or very often feel that no one in your family loved you or thought you were important or special? Domestic abuse Was your mother or stepmother ever repeatedly hit a few minutes or threatened with a gun or knife?

30 30 ACE STUDY ACE STUDY – ADVERSITIES (3) Parental separation or divorce Were your parents ever separated or divorced? Parental mental illness Was a household member depressed or mentally ill, or attempt suicide? Substance abuse in the family Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? Incarceration of parent Did a household member go to prison?

31 31 ACE STUDY KEY FINDINGS OF THE ACE STUDY (1) Range of ACE scores = 0-10. ACE scores based only on categories of exposure, not frequency within categories. 50% of respondents reported at least 1 exposure (ACE score of 1). 25% had ACE score of 2 or more. Adversities found to be additive, graded relationship: Higher ACE score = more severe outcomes.

32 32 ACE STUDY KEY FINDINGS OF THE ACE STUDY (2) Outcomes involve both mental & physical health impairment. Adult outcomes (prospective): poor health status with medical disorders, psychiatric disorders, & substance abuse disorders. Adolescent outcomes (retrospective): high risk behaviors, including smoking, substance use, frequent & unprotected sex, suicide attempts.

33 33 ACE STUDY SPECIFIC EXAMPLES: ACE STUDY & DEPRESSION AND SUICIDALITY ACE score of 0: less than 2% adults made suicide attempt. ACE score of 4+ (compared with score of 0): 460% more likely to have depression. ACE score of 4+: nearly 20% made a SA (e.g., 12x more likely to attempt suicide than person with 0). ACE score of 7+: SA is 51x more likely, as youth. ACE score of 7+: SA is 30x more likely, as adult.

34 34 ACE STUDY ACE STUDY & VICTIMIZATION ACE score of 4+ (compared with score of 0): over 8 times more likely to be victimized by rape. ACE score of 4+ (compared with score of 0): 5 times more likely to be victimized by domestic abuse.

35 35 ACE STUDY ACE STUDY & SUBSTANCE ABUSE ACE score of 4+ (compared with score of 0): 5-7 times more likely to struggle with alcohol abuse. ACE score of 6+ (compared with score of 0): 46 x more likely to engage in IV drug use.

36 36 ACE STUDY ACE STUDY & PHYSICAL HEALTH: SCORE OF 4+ Smoking: twice as likely as those with ACE of 0. Heart disease: twice as likely. Cancer: twice as likely. Emphysema & chronic bronchitis: Four times as likely. Early death common.

37 37 The ACE Study (Anda & Filetti)

38 38 OTHER CONSEQUENCES ACE STUDY – NOT FULLY REFLECT REAL CHALLENGES IN COMMUNITIES Middle class population with resources & ability to afford private insurance – 74% attended college. Public sector children, families, and adults often lack basic resources. Study not ask about poverty. Poverty associated with abuse & negative outcomes. Study not ask about bullying or community violence.

39 39 OTHER CONSEQUENCES OF TRAUMA Many other negative consequences of trauma

40 40 OTHER CONSEQUENCES ADULT PSYCHIATRIC DISORDERS AFTER TRAUMA (SEPARATE FROM PTSD) Affective disorder: almost 3 times more likely. Anxiety disorder: almost 3 times more likely. Phobia: almost 2½ times more likely. Panic disorder: more than 10 times more likely. Antisocial personality disorder: 4 times more likely. Self-harm: suicide attempts, cutting, self-starving. Auditory hallucinations. – Increased likelihood, if exposed to trauma during childhood.

41 41 OTHER CONSEQUENCES CRITICAL LINK: TRAUMA AFFECTS ATTACHMENT The earlier the maltreatment, the greater the impact on attachment. Cannot consider one without other. Attachment is the basis for child’s safety, emotions, learning, identity, coping, etc. Insecure attachments create significant risk for child, and likelihood of multiple disabilities across lifespan. Conversely, if trauma or adversity occurs after child has attached well to primary caregivers, less impact.

42 42 OTHER CONSEQUENCES JAMES GILLIGAN: SHAME AND VIOLENCE (2001: Preventing Violence. New York: Thames and Hudson) Central role of shame & disrespect in violence: The purpose of violence is to force respect from other people.

43 43 OTHER CONSEQUENCES INCREASE IN ARREST & VIOLENCE, WITH TRAUMA Increased arrest, as consequence of childhood abuse or neglect: – Arrest as juvenile, 53% more likely, with trauma. – Arrest as young adult, 38% more likely. Increased violent crime leading to arrest: Those with trauma history 38% more likely to be arrested for violence than those without trauma history.

44 44 OTHER CONSEQUENCES IF YOUTH COULD VERBALIZE & SPOKE FREELY “The world is unsafe, threatening, and bewildering.” “The world is punitive, judgmental, and blaming.” “People are unpredictable.” “Very few are to be trusted.” “I don’t have control over my life.” “My survival is uncertain.” “If I admit a mistake, things will be worse.” When challenged, I must defend my honor & self- respect.”

45 45 OTHER CONSEQUENCES PRACTICAL IMPACT: IMPAIRED SELF- REGULATION Internal discomfort. Impaired daily functioning. Impaired learning & problem solving. Impaired ability to form relationships. Impaired ability to experience & display empathy. Youth may not present as “likable,” and elicit negative feelings within involved adults.

46 46 OTHER CONSEQUENCES RELATED SOCIAL AND OTHER CONSEQUENCES Homelessness. Criminal behavior. Unemployment and under-employment. Physical health problems. Lower intelligence (Putnam; Koenen et al). High-end needs and greater cost, re services. Ineffectiveness of usual interventions.

47 47 BRAIN CHANGES DUE TO TRAUMA Chronic, severe trauma gives rise to significant brain changes – structural, neurobiological, and functional.

48 48 BRAIN CHANGES DUE TO TRAUMA SUMMARY OF SPECIFIC BRAIN CHANGES Structural – smaller overall brain size, plus specific areas affected (pre-frontal cortex, corpus callosum). Neurobiological: – Over-activity of catecholamines, leading to emotional and behavioral dysregulation: hyperarousal, impaired judgment, and limited capacity for self-regulation. – Increase in vagal tone, leading to dissociation. Functional: – Interruption of usual brain circuitry/patterns. – Progressive shut-down of higher brain structures, in response to severe stress.

49 49 BRAIN CHANGES DUE TO TRAUMA BRAIN CHANGES: NEW RESEARCH Violence and trauma damage the integrity of the individual’s chromosomes, which contain DNA. This damage is to the telomeres, found on the tips of chromosomes in cells. Telomeres protect DNA. Damage to telomeres – shrinking in size – can cause cell death, premature aging, even premature death. Impact may not be evident early on, but may become more significant later in lifespan.

50 50 “ADVERSITIES” VS. “TOXIC STRESS” “ADVERSITY” NEED NOT LEAD TO “TOXIC STRESS” Toxic stress = “the excessive or prolonged activation of the physiologic stress response systems, in the absence of buffering protection afforded by stable, responsive relationships” (my italics) (AAP, 2012). Implication: Stable, caring relationships can mitigate the physiologic and emotional impact of adversities. This is a key way that trauma can be addressed, and re-traumatization prevented.

51 51 TRAUMA INFORMED CARE Making a difference – trauma informed care

52 52 TRAUMA INTERVENTIONS TRAUMA INFORMED CARE TIC = set of beliefs & practices implemented within an organization, applicable to all individuals served. TIC attempts to create a culture of safety and empowerment. TIC is an approach rather than a specific treatment. TIC is distinguished from trauma specific services – specific, clinical trauma treatments for those who need it. Without a trauma informed setting, clinically-based trauma treatment unlikely to be helpful.

53 53 TRAUMA INFORMED CARE TRAUMA INFORMED CARE (1) Trauma informed care involves a commitment to relationships, programs, and interventions that seek to mitigate the effects of past traumatic experiences, and to prevent new trauma and re-traumatizing experiences, for the person and others. Trauma informed care thus involves both individual interactions with the person and a public health approach that supports safe, non-violent relationships and settings.

54 54 TRAUMA INFORMED CARE TRAUMA INFORMED CARE (2) When used in treatment and care settings, TIC involves the provision of interventions and relationships informed by an understanding of the pervasiveness of trauma and its consequences, including the loss of safety, trust, sense of control, and self-efficacy. In so doing, TIC also promotes the person’s resilience and recovery.

55 55 TRAUMA INFORMED CARE ELABORATION OF “TRAUMA INFORMED SERVICES” (Ann Jennings, 2004) “Trauma informed” services are not specifically designed to treat symptoms or syndromes related to sexual or physical abuse or other trauma, but they are informed about, and sensitive to, trauma-related issues present in survivors….

56 56 TRAUMA INFORMED CARE WHAT TIC ENTAILS (1) Universal precautions: TIC applicable for everyone. Safety is primary – physical and emotional. Focus on the person, not just the behavior. Understanding how the person “got there” – e.g., “what happened to you,” rather than “what’s wrong with you.” Presumption: Behavior is adaptive. Focus on person’s strengths. Empathy, caring, and support from adults. Avoidance of power struggles.

57 57 TRAUMA INFORMED CARE WHAT TIC ENTAILS (2) Supporting self-expression and self-advocacy. Development of interpersonal skills. Development of constructive coping skills. Development of healthy, reciprocal relationships. Development of prosocial life goals. Maintaining accountability and personal responsibility, in a mentoring, non-punitive manner. Ensuring that shaming and humiliation do not occur.

58 58 TRAUMA INFORMED CARE WHAT TIC DOES NOT ENTAIL AND AVOIDS Blaming the victim. Stigmatizing and disqualifying the person (e.g., student is “manipulative” and “attention-seeking”). Minimizing person’s concerns. Threats and coercion. Use of seclusion and restraint, “laying on of hands.” Punitive practices. Psychotropic medication for staff convenience. Expectation of “compliance” and “obedience.”

59 59 TRAUMA INFORMED CARE FORMULATIONS OF TRAUMA INFORMED CARE Roger Fallot, Community Connections: 5 core principles for trauma informed care Sandra Bloom, Andrus Center, NY and Center for Non-violence and Social Justice, Drexel University School of Public Health: Sanctuary – S.E.L.F. (safety, emotions, loss, future). – Seven Sanctuary Commitments (non-violence, emotional intelligence, social learning, open communication, social responsibility, democracy, growth and change).

60 60 TRAUMA INFORMED CARE FALLOT’S 5 CORE PRINCIPLES OF A TI SYSTEM Safety – physical and emotional, the sine qua non. Trustworthiness – built on honesty, transparency, and consistency. Choice – creating opportunities for daily decision- making & experiencing an internal locus of control. Collaboration – working together and sharing power, as a corrective to prior abuse of power. Empowerment – prioritizing validation, competency, and skill-building.

61 61 TRAUMA INFORMED CARE SOME POSITIVE OUTCOMES OF TIC Increased sense of safety and mastery. Decrease need for vigilance. Calmer, more regulated internal state conducive to learning, planning, other executive functioning. Decrease in impulsivity. Decreased likelihood of violence.

62 62 TRAUMA INFORMED CARE PA’s INITIATIVES FOR RESIDENTIAL PROGRAMS Funding of Sanctuary Program for 29 facilities. Certification after 3 years & necessary changes (23 funded programs in PA have gained certification). Trainings in TF-CBT (trauma-specific Rx), to support expansion of trauma-competent workforce (13 RTFs with TF-CBT training). Collaboration among state agencies re TIC – OMHSAS, OCYF (Office of Children, Youth & Families), ODP (Office of Developmental Programs). County and BH-MCO-based initiatives.

63 63 TRAUMA INFORMED CARE TIC IS IN “THE EYE OF THE BEHOLDER” The individual needs to experience the 5 core principles, continuously. Interruption of core elements disrupts sense of safety and trust. Thus, staff efforts to implement core principles are insufficient, if the person is not asked about them. Essential: a “trauma lens,” and trying to understand the individual’s subjective needs and experience.

64 64 TRAUMA INFORMED CARE FALLOT’S EXAMPLE: TRAUMA INCOMPETENCE AND ITS TRANSFORMATION Sign upon entering D&A provider agency: “Denial stops here.” What is the likely impact of this on an anxious individual reluctantly looking for help and support? How could the provider’s sign be more trauma informed and strengths-based? “Optimism starts here.”

65 65 TIC IN COMMUNITY SETTINGS TIC is applicable beyond residential care settings

66 66 TIC IN THE COMMUNITY CORE PRINCIPLES ARE TRANSPORTABLE Core principles (safety, trustworthiness, choice, collaboration, empowerment) promote child’s psychosocial development. Applicable to education, child welfare, juvenile justice, D&A, primary care. Applicable to parenting and the community. Synergy between TIC, gender resocialization, and commitment to non-violence.

67 67 TIC IN THE COMMUNITY ROLE OF CARING ADULTS IN THE COMMUNITY Core values can be modeled by adults, who offer: respect, trustworthiness, collaboration, support. All involved adults can provide TIC to youth: – Teachers, principals, guidance counselors – Mental health professionals and paraprofessionals – Child welfare workers and/or juvenile probation officers – Pediatricians – Coaches – Ministers and other spiritual leaders. – Parents and guardians

68 68 TIC IN THE COMMUNITY GENDER RESOCIALIZATION Masculinity redefined – what it means to be “a man”: – Focus on altruism (Ehrmann: “a man built for others”). – Focus on non-violence – using words, not fists or weapons. – Promoting emotional expression, nurturance, & compassion (Canada). Female empowerment: – Continued support for commitment to family and to others. – Support for personal dignity & self-determination. – Moving beyond boyfriends and sexuality as primary sources of validation.

69 69 TIC IN THE COMMUNITY PRIMARY CARE AND THE MEDICAL HOME Recognition that primary care physicians and others in the medical home see many more children than mental health professionals. Increased interest in coordinating and integrating behavioral health and medical care. National mandate, and part of healthcare reform. AAP (2012): “The reduction of toxic stress in young children ought to be a high priority for medicine as a whole and for pediatrics in particular.”

70 70 TIC IN THE COMMUNITY TRAUMA INFORMED PARENTING Principles of TIC are readily applied to parenting, whether by bio parent, kinship caregiver, or other. Avoiding responses that trigger or exacerbate child’s dysregulation and disrupt his/her sense of safety. Serving as role model for emotional regulation. Foster care: Need to promote attachment & provide nurturance, not just “room and board” (Zeanah et al). Serving as strengths-based, supportive mentor/ coach, with awareness that child is work-in-progress.

71 71 TIC IN THE COMMUNITY TRAUMA INFORMED EDUCATION (1) Awareness of potential impact of trauma on student performance, expectations, and social interactions. Promoting safety, within school setting & community. Use of trauma screening & safety plans. Recognizing practical issues – hunger/basic needs. Valuing student relationships. Taking student concerns seriously.

72 72 TIC IN THE COMMUNITY EDUCATION (2) Abandoning dismissive labels of “manipulative” and “attention-seeking,” in favor of deeper understanding Recognizing the empowering impact of positive staff interactions & relationships with student. Adults as mentors & facilitators, not enforcers. Adults as “carriers of hope,” when necessary. Making “TIC” an explicit part of the philosophy of “School-Wide Positive Behavior Support” in PA. Building TIC into primary prevention.

73 73 TIC IN THE COMMUNITY EDUCATION (3) Addressing bullying, at all three prevention levels. Engaging students in classroom & in activities. Teaching to student strengths & interests. Developing alternatives to out-of-school suspension. Ensuring that the student voice is heard, & that the student’s experience guides teacher responses. Reinforcing kindness and prosocial behavior. Creating a trauma informed culture within education.

74 74 SUMMARY TIC IS NOT ROCKET SCIENCE: BASIC NEEDS Safety Respect Support (Hodas’ “Cardinal Rule”) Nurturance, attachment, and love Understanding of student life experiences to date Patience/compassion Non-punitive limits Joyfulness

75 75 REFERENCES OVERVIEW, CHILDHOOD TRAUMA & TIC Hodas, G (2006): “Responding to childhood trauma: The promise and practice of trauma informed care.” National Association of State Mental Health Program Directors (NASMHPD). Easy access via web search: “Hodas” with “NASMHPD” -Multiple additional references at end.

76 76 REFERENCES SOME KEY WEBSITES National Child Traumatic Stress Network Center (NCTSN) Substance Abuse and Mental Health Services Administration (SAMHSA) ACE Study Community Connections (Fallot and Harris) The Anna Institute National Center for Trauma Informed Care (NCTIC)

77 77 REFERENCES BOOKS OF INTEREST (1) Anderson, E. (1999): Code of the Street: Decency, Violence, and the Moral Life of the Inner City. New York: Norton. Bloom, S (1997): Creating Sanctuary: Toward the Evolution of Sane Societies. New York: Routledge. Brazelton, T and Greenspan, S (2000): The Irreducible Needs of Children: What Every Child Must Have to Grow, Learn, and Flourish. Cambridge, MA: Perseus. Canada, G (1998): Reaching Up for Manhood: Transforming the Lives of Boys in America. Boston: Beacon Press. Garbarino, J. (1999): Lost Boys: Why Our Sons Turn Violent and How We Can Save Them. New York: Free Press.

78 78 REFERENCES BOOKS OF INTEREST (2) Gilligan, J. (2001): Preventing Violence. New York. Thames and Hudson Inc. Groves, B (2002): Children Who See Too Much: Lessons form the Child Witness to Violence Project. Boston: Beacon. Hughes, D (2009): Attachment Focused Parenting: Effective Strategies to Care for Children. New York: Norton. Marx, J (2003): Season of Life: A Football Star, a Boy, a Journey to Manhood. NY: Simon & Shuster. Mollica, R: Healing Invisible Wounds: Paths to Hope and Recovery in a Violent World. New York: Harcourt. Tough, P (article): “The Poverty Clinic,” New Yorker, March 21, 2011.

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