Trauma-Informed Approaches to Assessing and Treating Teens Carolyn Castro-Donlan A.L.M., M.A. “Over time as most people fail the survivor's exacting test of trustworthiness, she tends to withdraw from relationships. The isolation of the survivor thus persists even after she is free.” ― Judith Lewis Herman, Trauma and Recovery

Welcome and Thank you for taking this workshop for your interests, acknowledgement of the related issues and efforts to develop skillsets that enhance and engage/ Dedicate this workshop and our continued discussions and skillset development with gratitude to those before us – not only clinicians but clients and patients that had to acknowledge their trauma and experiences in order for us to even get to a point that we need trauma informed or trauma responsive approaches. Participant Introductions and goals for the workshop. Introductions First Name, current role/job, What you would like to gain from today’s workshop

Workshop Objectives Discuss current research documenting the prevalence and correlation between trauma and substance use among adolescents. Discuss current trauma-informed approaches specific to the assessment, engagement and intervention processes with adolescents presenting for care. Demonstrate and apply at least one trauma-focused technique to current adolescent assessment and engagement practices.   Interactive two hour workshop for clinicians working with the adolescent population that will introduce trauma-informed approaches to their clinical and/or programmatic practices. Participants will gain an overview of current research findings related to trauma and substance use among the adolescent population, inclusive of findings specific to HIV and/or HCV risks and prevalence. Participants will also discuss current trauma-focused techniques that can be applied to their current clinical practices as well as distinguish programmatic policies that may support or impede the assessment and engagement of adolescents. Workshop will be interactive and aimed to meet the specific needs of participants. All participant will be able to demonstrate and apply at least one trauma-focused technique to their current assessment and engagement practices as well as identify one related programmatic policy that will support the practice. Identified resources will also be shared for participants' review and continued learning post the workshop presentation. Participants will leave with a greater understanding of trauma, trauma-informed approaches in addition to the ability to identify and redirect ineffective approaches of assessment and engagement. During the interactive discussions we can jot down key terms or common ideas - perhaps brief flow chart of intake processes to identify where program procedures can actually impede trauma-informed care. 

“After a traumatic experience, the human system of self-preservation seems to go onto permanent alert, as if the danger might return at any moment.” ― Judith Lewis Herman, Trauma and Recovery Introduction to – 1 Discuss current research documenting the prevalence and correlation between trauma and substance use among adolescents. As the understanding of traumatic experiences increases among clinicians, mental health theories and practices are changing. It is important for service providers to understand the values and principles of trauma-informed care and to provide such care for the survivors they serve. At its most basic, trauma-informed services do the following: Take the trauma into account; Avoid triggering trauma reactions or re-traumatizing the woman; Adjust the behavior of counselors and staff members to support the teen/woman/client/patient’s coping capacity; and Allow survivors to manage their trauma symptoms successfully so that they are able to access, retain, and benefit from the services. Harris, M. and Fallot, R. (Eds.) (2001). Using Trauma Theory to Design Service Systems. New Directions for Mental Health Services. San Francisco: Jossey-Bass; p. 1

What is Trauma ? SAMHSA defines as experiences that cause intense physical and psy­chological stress reactions. It can refer to “a single event, multiple events, or a set of circumstances that is experienced by an individual as physically and emotionally harmful or threatening and that has lasting adverse effects on the individual’s physical, social, emotional, or spiritual well­ being” Definition: Experiencing, witnessing, or being threatened with an event or events that involve actual serious injury, a threat to the physical integrity of one’s self or others, or possible death. The responses to these events include intense fear, helplessness, or horror. Source Enhancing Substance Abuse Recovery Through Integrated Trauma Treatment, p.1 (National Trauma Consortium). SAMHSA -Categories of trauma include: Physical, sexual and institutional abuse; Neglect; Intergenerational trauma; and Disasters that induce powerlessness, fear, recurrent hopelessness, and a constant state of alert.

Sociocultural Perspective   Individual Factors Interpersonal Factors Community and Organizational Factors Societal Factors Cultural and Developmen­ tal Factors Period of Time in History Age, biophysi­cal state, mental health status, temper­ament and other personal­ity traits, education, gender, coping styles, socioeconomic status Family, peer, and significant other interac­ tion patterns, parent/family mental health, parents’ histo­ ry of trauma, social network Neighborhood quality, school system and/or work environ­ ment, behavioral health system quality and acces­ sibility, faith- based settings, transportation availability, com­ munity socioeco­ nomic status, community em­ ployment rates Laws, State and Federal economic and social policies, media, societal norms, judicial system Collective or individualistic cultural norms, ethnicity, cultural subsystem norms, cogni­tive and mat­urational development Societal attitudes related to military service mem­bers’ home­ comings, changes in diagnostic understanding between DSM­ III-R* and DSM-5** Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57 Think Intersectionality --

Adolescent Prevalence of Trauma 60% of adults report experiencing abuse or other difficult family circumstances during childhood. 26% of children in the United States will witness or experience a traumatic event before they turn four. Based on National Survey of Children’s Exposure to Violence within the past year: More than 60% of children were exposed to at least one type of violence More than 10 % reported 5 or more exposures to violence About 10 % of children surveyed suffered from child maltreatment, were injured in an assault, or witnessed a family member assault another family member. About 25% were victims of robbery or witnessed a violent act. Nearly half of children and adolescents surveyed were assaulted at least once. Source - National Center for Mental Health Promotion and Youth Violence Prevention, "Childhood Trauma and Its Effect on Healthy Development," July 2012 http://www.promoteprevent.org/sites/www.promoteprevent.org/files/resources/childhood%20trauma_brief_in_final.pdf Review - Prevalence data and sources Reality is most of teens presenting for services have experienced trauma – home, community, school, juvenile justice system and/or behavioral health settings etc – So we aim to provide trauma informed/responsive care to all regardless of what we know or don’t know.

Adolescent Prevalence of Trauma 4 in10 children in American say they experienced a physical assault during the past year, with one in 10 receiving an assault-related injury. 2% of all children experienced sexual assault or sexual abuse during the past year, with the rate at nearly 11% for girls aged 14 to 17. Nearly 14% of children repeatedly experienced maltreatment by a caregiver, including nearly 4% who experienced physical abuse. 1 in 4 children was the victim of robbery, vandalism or theft during the previous year. More than 13% of children reported being physically bullied, while more than 1 in 3 said they had been emotionally bullied. 1 in 5 children witnessed violence in their family or the neighborhood during the previous year. Source - JAMA Pediatrics, May 2013 (http://www.unh.edu/ccrc/pdf/05-13%20PED%20childhood%20exposure%20to%20violence.pdf) Given these statistics and the adolescence developmental phase – is a time for many changes. Physically, socially adolescence is a time when the individual is striving to gain independence and establish their own identify and purpose in life. Teen are prone to taking risk and experimenting activities. Adolescents in general are at highest risk for experiencing sexual harassment or assault, dating violence, sexual victimization, community violence, assault by peers or school threats. Finkelhor, David; Turner, Heather; Ormrod, Richard; Hamby, Sherry; Kracke, Kristen (October 2009). "Children's Exposure to Violence, a Comprehensive National Survey." Office of Justice Programs Juvenile Justice Bulletin. (https://www.ncjrs.gov/pdffiles1/ojjdp/227744.pdf)

Adolescent Trauma and Substance Use For many adolescents, early experimentation eventually progresses to abuse of or dependence on – illicit drugs or alcohol. It is estimated that 29% of adolescents—nearly one in three—have experimented with illegal drugs by the time they complete eighth grade, and that 41% have consumed alcohol. 1 in 5 American adolescents between ages 12-17 engages in abusive/dependent or problematic use of illicit drugs or alcohol. Trauma Substance Use Individuals who have experienced trauma are at an elevated risk for substance use disorders, including abuse and dependence; mental health problems (e.g., depression and anxiety symptoms or disorders, impairment in rela­tional/social and other major life areas, other distressing symptoms); and physical disorders and conditions, such as sleep disorders. This TIP focuses on specific types of prevention (Institute of Medicine et al., 2009) Risk Factor

Symptoms Adolescents with trauma histories can experience a number of symptoms clustered into three broad categories: Re-experiencing the traumatic event through intrusive thoughts or dreams of the event, or intense psychological distress when exposed to reminders of the event Persistent avoidance of thoughts, feelings, images, or locations that remind the adolescent of or are associated with the traumatic event Increased arousal, such as hypervigilance, irritability, exaggerated startle response and sleeping difficulties (APA, 2000) Adolescents who are using substances may exhibit symptoms such as: Failing to fulfill major obligations at work, home, or school, or use of substances when it is physically hazardous Legal, social, or interpersonal problems Severe substance abuse can warrant a diagnosis of substance dependence. This occurs if substance use leads to tolerance, withdrawal symptoms, problems cutting down on consumption and other major difficulties (APA, 2000) www.bu.edu/atssa Source - http://www.bu.edu/atssa/Resources/Publications/IdentifyingT&SA.pdf Interventions designed to target multiple maladaptive behaviors resulting from trauma and substance abuse will be most effective. Treatment of adolescents with traumatic stress and substance abuse begins by properly recognizing and identifying the problem. A complete inventory of an adolescent’s specific problem behaviors as well as signs and symptoms of trauma and substance abuse should be incorporated into an individualized treatment plan when administering psychological services. Common signs of trauma include -- Flashbacks or frequent nightmares Being very sensitive to noise or to being touched Always expecting something bad to happen Not remembering periods of one’s life Feeling numb

Post Traumatic Stress A child's risk of developing PTSD is related to the seriousness of the trauma, whether the trauma is repeated, the child's proximity to the trauma, and his/her relationship to the victim(s). PTSD in children and adolescence requires the presence of re-experiencing, avoidance and numbing, and arousal symptoms. Criteria for PTSD include age-specific features for some symptoms. The National Comorbidity Survey Replication- Adolescent Supplement is a nationally representative sample of over 10,000 adolescents aged 13-18. Results indicate that 5% of adolescents have met criteria for PTSD in their lifetime. Prevalence is higher for girls than boys (8.0% vs. 2.3%) and increase with age (Merkangas, K. et al., 2010). Current rates (in the past month) are 3.9% overall (Kessler, R., et al,2012). American Academy of Child & Adolescent Psychiatry http://www.aacap.org/App_Themes/AACAP/docs/facts_for_families/70_posttraumatic_stress_disorder_ptsd.pdf Post-Traumatic Stress Disorder (PTSD) is a debilitating mental disorder that follows experiencing or witnessing an extremely traumatic, tragic, or terrifying event. PTSD, once referred to as shell shock or battle fatigue, was first brought to public attention by war veterans, but it can result from any number of traumatic incidents. Theorists speculate upon facing overwhelming trauma, the mind is unable to process information and feelings in a normal way. It is as if the thoughts and feelings at the time of the traumatic event take on a life of their own, later intruding into consciousness and causing distress. PTSD is a human response to markedly abnormal situations, and it involves specific chemical changes in the brain that occur in response to a person experiencing a traumatic event. Many of the symptoms of PTSD seem to be a direct result of such brain changes. Not every traumatized person gets full-blown PTSD, or experiences PTSD at all. PTSD is diagnosed only if the symptoms last more than a month and causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The American Psychiatric Association characterizes the clinical presentation of PTSD by the presence of several symptom clusters that can be remembered by the mnemonic (memory aid) “TRAUMA”: A Traumatic event occurred in which the person experienced, witnessed, or was confronted by actual or threatened serious injury, death, or threat to the physical integrity of self or other and, as a response to such trauma, the person experienced intense helplessness, fear, and horror. The person Reexperiences such traumatic events by intrusive thoughts, nightmares, flashbacks, or recollection of traumatic memories and images. Avoidance and emotional numbing emerge, expressed as detachment from others; flattening of affect; loss of interest; lack of motivation; and persistent avoidance of activity, places, persons, or events associated with the traumatic experience. Symptoms are distressing and cause significant impairment in social, occupational, and interpersonal functioning (patients are Unable to function). These symptoms last more than 1 Month. The person has increased Arousal, usually manifested by startle reaction, poor concentration, irritable mood, insomnia, and hypervigilance. http://www.ptsd.va.gov/professional/treatment/children/ptsd_in_children_and_adolescents_overview_for_professionals.asp Merikangas, K. et al. (2010). Lifetime prevalence of mental disorders in the U.S. Adolescent Comorbidity Survey Replication-Adolescent Sample. Journal of the American Academy of Child and Adolescent Psychiatry, 49, 980-988. Kessler, R, Et al, 2012 Prevalence, persistence, and sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Sample. Archives of General Psychiatry, 69, 372-380.

Cultural responsiveness and cultural competence These terms used interchangeably, with “responsiveness” applied to services and systems and “competence” applied to people, to refer to “a set of behaviors, attitudes, and policies that…enable a system, agency, or group of profes­sionals to work effectively in cross-cultural situations” (Cross, Bazron, Dennis, & Isaacs, 1989, p. 13). Culturally responsive behavioral health services and culturally competent providers “honor and respect the beliefs, languages, interpersonal styles, and behaviors of individuals and families receiving services…. Cultural competence is a dynamic, ongoing developmental process that requires a long-term commitment and is achieved over time”

Cultural Considerations Related to Trauma and Substance Abuse National Child Traumatic Stress Network -http://www.nctsn.org/resources/topics/culture-and-trauma Girls Girls entering substance abuse treatment have significant co-occurring mental health issues Gender differences in victimization are frequently reported among substance-abusing youths, with females more likely than their male peers to have a history of child abuse, have experienced multiple types of abuse, have been sexually abused, and have more severe problems related to child abuse Disabilities and Deaf/Hard of Hearing Individuals with disabilities have increased rates of maltreatment Girls with hearing loss had the highest rates, followed by girls without hearing loss Gender references - (Deykin & Buka, 1997; Grella & Joshi, 2003; Hawke, Jainchill, & DeLeon, 2000; Rounds-Bryant, Kristiansen, Fairbank, & Hubbard, 1998; Shane et al., 2006; Titus, Dennis, White, Scott, & Funk, 2003; Titus, 2007). Girls with significant co-occurring disorders references (Grella & Joshi, 2003; Shane et al., 2006; Stevens, et al., 2009; Stevens et al., 2004; Titus et al., 2003) Individuals with disabilities have increased rates of maltreatment (Herschkowitz et al., 2007) Girls with hearing loss had the highest rates, followed by girls without hearing loss (Titus, 2009)

Cultural Considerations Related to Trauma and Substance Abuse Sexual Minorities Sexual minorities—lesbian, gay, bisexual, and transgendered (LGBT) youth—are especially vulnerable to mental health problems, particularly depression, loneliness, psychosomatic illness, withdrawn behavior, delinquency, and social problems Ethnic/Racial Minorities changing demographics in the United States and acculturation historical trauma culturally responsive assessment and services inclusion of family and parental beliefs

A Trauma-Informed Approach A trauma-informed approach to the delivery of behavioral health services includes an understanding of trauma and an awareness of the impact it can have across settings, services, and populations. It involves viewing trauma through an ecological and cultural lens and recognizing that context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic. May 2012, SAMHSA convened a group of national experts who identified three key elements of a trauma-informed approach: “(1) realizing the prevalence of trauma; (2) recognizing how trauma affects all individuals involved with the program, organi­zation, or system, including its own workforce; and (3) responding by putting this knowledge into practice”

“Changes in Relationship with others: It is especially hard to trust other people if you have been repeatedly abused, abandoned or betrayed as a child. Mistrust makes it very difficult to make friends, and to be able to distinguish between good and bad intentions in other people. Some parts do not seem to trust anyone, while other parts may be so vulnerable and needy that they do not pay attention to clues that perhaps a person is not trustworthy. Some parts like to be close to others or feel a desperate need to be close and taken care of, while other parts fear being close or actively dislike people. Some parts are afraid of being in relationships while others are afraid of being rejected or criticized. This naturally sets up major internal as well as relational conflicts.” ― Suzette Boon, Coping with Trauma-Related Dissociation: Skills Training for Patients and Therapists Discussion point prior to – 2. Discuss current trauma-informed approaches specific to the assessment, engagement and intervention processes with adolescents presenting for care. How do you currently work with teens with trauma – current challenges, questions, program policies that support or conflict ? Use newsprint to list for further discussion later in th workshop --- program policies, clinician skillsets Group Discussion

Trauma-Informed Approach According to SAMHSA’s concept of a trauma-informed approach, “A program, organization, or system that is trauma-informed: Realizes the widespread impact of trauma and understands potential paths for recovery; Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and Seeks to actively resist re-traumatization.” http://www.samhsa.gov/nctic/trauma-interventions A trauma-informed approach can be implemented in any type of service setting or organization and is distinct from trauma-specific interventions or treatments that are designed specifically to address the consequences of trauma and to facilitate healing. At its best, trauma-informed care (TIC) is resilience-informed care. It is an overall approach, at the individual, organizational, and systemic levels, that uses respect and consideration of trauma histories to create safety and hope for clients. Truly effective TIC recognizes human vulnerability, but still insists on finding and mobilizing survivors’ strengths, resources, and capacity for healing and recovery. (Implementing Trauma-Informed Approaches in Access to Recovery Programs) TIC is not a specific intervention or treatment. Instead it is a philosophical approach to care comprised of specific principles that guide policy and practice with trauma survivors. TIC involves providing the foundation for a basic understanding of the psychological, neurological, biological, and social impact that trauma and violence have on many of the individuals we serve (gathered gently, with respect, and over a period of time); TIC includes: An appreciation for the high prevalence of traumatic experiences in persons who receive mental health and addiction services. Promotes dignity, respect, trust and safety in a therapeutic, healing environment; A treatment design, therapeutic relationships, and accommodations that meet patient’s needs; Reflects recovery and person-centered principles; and Reflects patient satisfaction, engagement, and self-empowerment. The patient/client is in partnership with you! Allows patients time to build trust with staff and safety to share their story about what happened; Is dependable, predictable, and creative with permission of patient. Keeps agreements; and Does no harm. Knows each patient, respects their fears and remains trustworthy. (Trauma Informed & Trauma Sensitive…the only way to do business! DHS-Oregon State Hospital Education & Development Department; Pat Davis-Salyer, M.Ed.,2004) Trauma-informed organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization. http://www.samhsa.gov/nctic/trauma.asp A “trauma informed” program has an awareness of the pervasiveness of traumatic events and translates that awareness into integrated services that support the coping capacity of clients. This capacity enables a woman to stay and participate in treatment, to engage in a positive therapeutic alliance, and to learn to cope with the aftermath or consequences of trauma. (SAMHSA TIP 51 ) TIC is not “designed to treat symptoms or syndromes related to sexual or physical abuse or other trauma, but is informed about, and sensitive to, trauma-related issues present in survivors.” (Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services, CMHS 2008 p.10/Harris, M. and Fallot, R. (Eds.) (2001). Unlike trauma-specific services, TIC is not an additional practice. TIC is an approach, a philosophy, and a cultural change in the way current practices are delivered. (Implementing Trauma-Informed Approaches in Access to Recovery Programs, p. 2)

SAMHSA’s Six Key Principles of a Trauma-Informed Approach A trauma-informed approach reflects adherence to six key principles rather than a prescribed set of practices or procedures.  These principles may be generalizable across multiple types of settings, although terminology and application may be setting- or sector-specific: Safety Trustworthiness and Transparency Peer support Collaboration and mutuality Empowerment, voice and choice Cultural, Historical, and Gender Issues From SAMHSA’s perspective, it is critical to promote the linkage to recovery and resilience for those individuals and families impacted by trauma.  Consistent with SAMHSA’s definition of recovery, services and supports that are trauma-informed build on the best evidence available and consumer and family engagement, empowerment, and collaboration.

V Establish a culture that fully reflects each of the five core values in each contact, physical setting, relationship, and activity and that this culture is evident in the experiences of staff as well as consumers, then the program’s culture is trauma-informed. https://www.healthcare.uiowa.edu/icmh/documents/CCTICSelf-AssessmentandPlanningProtocol0709.pdf http://wichildrenstrustfund.org/files/PreventionGuidingPrinciples.pdf http://www.multiplyingconnections.org/sites/default/files/field_attachments/Multiplying%20Connections%20Core%20Competencies%20(rev%205-10)%5B1%5D.pdf The fundamental elements of a trauma-informed system are identified and the necessary supports for bringing about system change are highlighted. The basic philosophy of trauma-informed practice is then examined across several specific service components: assessment and screening, inpatient treatment, residential services, addictions programming, and case management. Modifications necessary to transform a current system into a trauma-informed system are discussed in great detail as well as the changing roles of consumers and providers.

The Five Core Values re Safety — is everything being done to ensure physical and emotional safety (welcoming, respectful, sufficient personal space, consistency) Trustworthiness — are expectations and interactions for everyone clear and consistent (boundaries, respect, non-judgmental) Choice — is a condition being created so individuals experience a feeling of choice and control (providing options, choices, optional program supports) Collaboration — is the approach one of sharing and collaboration in all interactions (learning from each other, seeking input, listening first) Empowerment — is there a fostering of the individual's strengths, experiences, and uniqueness for building upon (recovery, hope, skill building) Allow time to discuss each of the 5 Core Values – in depth with examples and interactive discussion with participants. Ask for specific examples from participant experiences and organizational policies Role play – if time permits -- http://www.samhsa.gov/co-occurring/news-and-features/shifting-perspective.aspx Harris, M. and Fallot, R. (Eds.) (2001). Using Trauma Theory to Design Service Systems. New Directions for Mental Health Services. San Francisco: Jossey-Bass.

Engaging Youth and Family/Primary Caregivers • Welcoming rituals that promote positive youth development • Assisting families in identifying strengths and successes in their daily lives • Clearly defining expectations for participation and change • Identifying people who can potentially be trusted to make up a social support network and participate in treatment • Deciding how each social support network member can help • Initiating contact with social support network members • Clarifying the role each social support network member will play • Participating in service activities • Teaching self-soothing activities to enhance stress reduction and affect regulation • Demonstrating respectful behavior • Actively giving and receiving feedback • Positive reinforcement – strength based responses • Monitoring program policies that support or challenge engagement Source - Resources for Resolving Violence, Inc.

“These problems are real, and you can't turn off real life “These problems are real, and you can't turn off real life. So I won't try. Instead, I'll give you a set of tools to help you deal with real life.” ― Sean Covey, The 7 Habits Of Highly Effective Teens Group discussion point prior to reviewing Trauma –Specific screening , assessment and Interventions tools/EBPs Group Discussion

Validated Assessment Instruments for Traumatic Stress and Substance Abuse Disorders Resource Brief Description Source Adquest2 Adolescent Intake Questionnaire2 This self-report measure allows adolescents to identify various issues of concern, which the therapist can then use to engage adolescents in discussion on a variety of topics including health, sexuality, safety, substance abuse and friends. Peake, K., Epstein, I., and Medeiros, D. (2005). Clinical and research uses of an adolescent mental health intake questionnaire: What kids need to talk about. Binghamton, NY: The Haworth Press, Inc. CANS-TEA Child and Adolescent Needs and Strengths-Trauma Exposure and Adaptation Version This clinician-report instrument assesses a variety of domains including trauma history, traumatic stress symptoms, emotional and behavioral regulation (e.g., anxiety, depression, self-harm, substance abuse), environmental stability, caregiver functioning, attachment, child strengths and child functioning. For information on the guidelines for use and development contact Cassandra Kisiel: (312) 503-0459 c-kisiel@northwestern.edu GAIN Global Appraisal of Individual Needs3 The GAIN is a series of clinician-administered biopsychosocial assessments designed to provide information useful for screenings, diagnosis, treatment planning, and monitoring progress. Domains measured on the GAIN-Initial (GAIN-I) include substance use, physical health, risk behaviors, mental health, environment, legal and vocational. Several scales are derived from the GAIN-I, including substance problem, traumatic stress, and victimization indices. Dennis, M., White, M., Titus, J., and Unsicker, J. (2006). Global Appraisal of Individual Needs (GAIN): Administration guide for the GAIN and related measures (Version 5.4.0). Bloomington, IL: Chestnut Health Systems. Retrieved April 17, 2008, from http://www.chestnut.org/LI/gain/ GAIN_I/GAIN-I_v_5-4/Index.html. TSCC Trauma Symptom Checklist for Children4 The Trauma Symptom Checklist for Children is a self-rating measure used to evaluate both acute and chronic posttraumatic stress symptoms. John Briere, Ph.D. Psychological Assessment Services http://www3.parinc.com/products/product. aspx?Productid=TSCC UCLA PTSD RI for DSM-IV University of California Los Angeles Posttraumatic Stress Disorder Reaction Index5 This scale is used to screen for exposure to traumatic events and DSM-IV PTSD symptoms. Three versions exist: a self-report for school-age children, a self-report for adolescents, and a parent report. An abbreviated version of the UCLA PTSD RI is also available. This nine-item measure provides a quick screen for PTSD symptoms. UCLA Trauma Psychiatry Service 300 UCLA Medical Plaza, Ste 2232 Los Angeles, CA 90095-6968 rpynoos@mednet.ucla.edu Source - The National Child Traumatic Stress Network www.NCTSN.org

Validated Assessment Instruments for Traumatic Stress and Substance Abuse Disorders Screening and Assessing Adolescents for Substance Use Disorders: Treatment Improvement Protocol (TIP) Series 316 This guide provides information regarding screening and assessment of adolescents with substance use disorders including descriptions of specific assessment instruments. Substance Abuse and Mental Health Services Administration. (1999). TIP 31: Screening and assessing adolescents for substance use disorders. Rockville, MD U.S. Dept. of Health and Human Services. Retrieved April 18, 2008 from http://www.ncbi.nlm.nih.gov/books/ bv.fcgi?rid=hstat5.chapter.54841. POSIT Problem Oriented Screening Instrument for Teenagers This scale was designed to identify potential problems in need of further assessment, and potential treatment or service needs, in 10 areas including substance abuse, mental health, physical health, family relations, peer relations, educational status, vocational status, social skills, recreation, and aggressive behavior/delinquency. National Institute on Drug Abuse (NIDA), National Institutes of Health Elizabeth Rahdert, Ph.D., 6001 Executive Blvd, Bethesda, MD, 20892 Email: Elizabeth_Rahdert@nih.gov CPSS Child Posttraumatic Stress Disorder Symptom Scale The CPSS was adapted from the adult Posttraumatic Diagnostic Scale (PTDS). The CPSS is a self-report measure that assesses the frequency of all DSM-IV-defined PTSD symptoms and was also designed to assess PTSD diagnosis. The measure yields a total Symptom Severity score as well as a daily functioning and impairment score. To obtain the CPSS, contact: Edna Foa, Ph.D. Center for the Treatment and Study of Anxiety University of Penn. School of Medicine Department of Psychiatry 3535 Market Street, Sixth Floor Philadelphia, PA 19104 CRAFFT The CRAFFT is a six-item measure that assesses adolescent substance use. The measure assesses reasons for drinking or other substance use, risky behavior associated with substance use, peer and family behavior surrounding substance use, as well as whether the adolescent has ever been in trouble as a result of his or her substance use. The CRAFFT questions were developed by The Center for Adolescent Substance Use Research (CeASAR). To get permission to make copies of the CRAFFT test, email info@CRAFFT.org.

Trauma-Specific Interventions The survivor's need to be respected, informed, connected, and hopeful regarding their own recovery The interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety The need to work in a collaborative way with survivors, family and friends of the survivor, and other human services agencies in a manner that will empower survivors and consumers Only well-trained and experienced professionals with appropriate credentials and ongoing supervision should provide trauma-specific treatment or interventions , that is, working directly on the specific trauma (this direct treatment is not the focus of this workshop.

Adolescent Trauma-Specific Interventions Addiction and Trauma Recovery Integration Model (ATRIUM) Essence of Being Real Risking Connection® Sanctuary Model® Trauma Affect Regulation: Guide for Education and Therapy (TARGET) Trauma Recovery and Empowerment Model (TREM and M-TREM)

Based on Goals from Introduction and Demonstrate and apply at least one trauma-focused technique to current adolescent assessment and engagement practices.   What can you do differently in your current work with teens with trauma – based on identified current challenges, questions, program policies that support or conflict from today’s discussions Suggested – walkthrough , basic exercises with clients/patients breathe, trust building time and dialogue, Group Discussion Based on today’s workshop and discussions – 1) Discuss 1-2 follow up changes, skills, action items and/or resources 2) Anticipated impact of each

Resources http://store.samhsa.gov/product/TIP-57-Trauma-Informed-Care-in-Behavioral-Health-Services/SMA14-4816 This TIP’s target population is adults. Beyond the context of family, this publication does not examine or address youth and adolescent responses to trauma, youth-tailored trauma- informed strategies, or trauma-specific inter­ ventions for youth or adolescents, because the developmental and contextual issues of these populations require specialized interventions. Providers who work with young clients who have experienced trauma should refer to the resource list in Appendix B page 260 – 263 for resources specific for children and adolescents. Assists behavioral health professionals in understanding the impact and consequences for those who experience trauma. Discusses patient assessment, treatment planning strategies that support recovery, and building a trauma-informed care workforce.

Resources NCTIC@NASMHPD.org National Center for Trauma-Informed Care offers consultation and technical assistance to stimulate and support interest in developing approaches to eliminate the use of seclusion, restraints, and other coercive practices and to further develop the knowledge base related to the implementation of trauma-informed approaches, consistent with SAMHSA’s conceptual framework for trauma and trauma-informed practice, in publicly funded systems and programs. NCTIC@NASMHPD.org

Additional Resources Adolescent Traumatic Stress and Substance Abuse Treatment Center at The Center for Anxiety and Related Disorders, Boston University http://www.bu.edu/atssa/Resources/Publications/IdentifyingT&SA.pdf Community Connections http://www.communityconnectionsdc.org/web/page/597/interior.html Institute for Health and Recovery (IHR) – Cambridge, MA Developing Trauma-Informed Organizations – A Tool Kit http://www.healthrecovery.org/ Resources for Resolving Violence, Inc. http://resourcesforresolvingviolence.com/publications/ The National Child Trauma Stress Network http://www.nctsn.org/ http://www.nctsn.org/resources/topics/adolescence-and-substance-abuse

Questions, Comments and/or Feedback?

Thank you Carolyn Castro-Donlan Castro-Donlan Consulting, LLC CCDConsulting@gmail.com www.linkedin.com/in/ccdconsulting/