Trauma-Informed Care and Practices in School-Based Settings Mark R. Groner, MSSA, LISW-S Joan Blackburn, MSSA, LISW-S Carol Hoffstetter, MSW, LISW-S Dominic Ferrante 1

Learning Objectives 1: Convey the importance of a trauma-informed care approach when screening, assessing, treating trauma II. Impart knowledge about the use of trauma- informed care evidence-based practices in school settings in order to advance resiliency as a buffer to adversity and trauma, as well as to address trauma and complex trauma III. Impart knowledge about the benefits and challenges of school-based service provision when treating trauma and complex trauma in school- based settings 2

Beech Brook, providing 163 years of hope to children and families.

A word about our history of being an early adopter of trauma-informed care. 4

Our approach has included: Use of an internal Trauma-Informed Care Team with ongoing self-study and continuous performance improvement activities Use of state and national learning communities Development of internal experts Use of evidence-based trauma-informed care practice models 5

Why is a trauma-informed care approach so essential? 6

Let’s define “trauma,” “complex trauma,” and “secondary traumatic stress.” 7

What kinds of experiences result in trauma What kinds of experiences result in trauma? What aspects of child development get derailed? 8

Psychological Trauma Impacts the Brain Part of Brain Role Impact Amygdala (becomes over-reactive) Management of emotions Emotional dysregulation Hippocampus (shrinks) Memory and memory consolidation Impaired memory Broca (gets smaller and deactivated) Speech Shuts down speech Prefrontal Cortex Executive functioning Impaired thinking, judgment, and processing Cortisol (gets over-produced) Hormone (chemical secreted by an endocrine gland) Triggers amygdala resulting in fight, flight, freeze responses Norepinephrine (gets released) Neurochemical (chemical released from a nerve cell) Hypervigilence Research is increasingly showing that psychological trauma impacts such brain areas as the amygdala (involved in emotion management), and the hippocampus (involved in memory and memory consolidation). If trauma occurs repeatedly or over a prolonged period, cortisol (a hormone released during times of stress) is released too much, subsequently activating the amygdala and causing even more cortisol to be released. It is a self-perpetuating cycle that leaves the individual with heightened sympathetic arousal (“fight” or “flight” response). Research has shown that the hippocampus shrinks in volume in individuals with Post Traumatic Stress Disorder (PTSD), which can have negative effects on memory. 9

Definition of Trauma-Informed Screening and Assessment Trauma-informed screening: a brief, focused inquiry, often in the form of a tool, to determine whether or not an individual has experienced specific traumatic events. Trauma assessment: a more in-depth exploration of the nature and severity of the traumatic events, the sequelae of those events, and current trauma-related symptoms. 10

Our general approaches to trauma treatment Provide & ensure safety. Fix a broken system. Maintain a positive and consistent therapeutic relationship. Tailor the therapy, taking into consideration client realities. Take gender and sociocultural issues into account. Practice ethically, within sound standards of care, and with appropriate boundaries to prevent “counteractivation” (unwittingly becoming unduly assertive or passive). Take care of yourself and your team. 11

Models of trauma treatment Over 500 documented treatments available for children and adolescents (Kazdin, 2000). NCTSN lists over 40 evidence informed treatments that focus specifically on trauma and new ones are constantly being developed (NCTSN at http://www.nctsn.org/resources/topics/treatments-that-work/promising- practices 12

PATHS Promoting Alternative THinking Strategies 13

PATHS What is PATHS? Why Promote it? -Evidenced Based Curriculum for promoting social and emotional awareness in children Research findings: - 23% improvement in social and emotional skills - 9% improvement in attitudes about self, others school - 9% improvement in classroom behavior - 9% decrease in aggression - 10% decrease in emotional distress such as anxiety and depression - 11 percentile point gain in achievement test scores 14

Compliments PATHS Kid of the Day Impulse Control Key Components Compliments PATHS Kid of the Day Impulse Control Do the Turtle! Feelings and Behaviors Comfortable and Uncomfortable OK and Not OK 15

Key SEL Competencies 16

Evidenced Based Models Trauma Focused Cognitive Behavioral Therapy (TFCBT) A structured, evidence based model of therapy that addresses the unique biopsychosocial needs of children with PTSD or other problems related to traumatic life experiences Children and parents are provided knowledge and skills related to processing the trauma -Psycho Education Normalize the response of the trauma -Relaxation/Stress Management Breathing exercises progressive muscles relaxation Thought stopping -Affect Regulation “Emotions Color Wheel” good resource All feelings are OK 17

Evidenced Based Models Trauma Focused Cognitive Behavioral Therapy (TFCBT) -Cognitive Coping Goal: practice the skill of developing many ways to thing about a given situation Positive self talk, challenge thinking errors Cognitive triangle Recognize how one is coping well -Trauma Narrative Gradually desensitize the traumatic event Use words, pictures, poems, song- get them to tell their story -In-Vivo Gradual exposure, dealing with remaining avoidant behaviors Conjoint Parent Child Sessions -Prepare parent for narrative sharing, sharing and praise for progress Enhancing Future Safety and Development 18

Evidenced Based Models Alternatives for Families Cognitive Behavioral Therapy (AFCBT) An approach for working with families that experience frequent conflicts that may result in excessive arguments or use of physical force or discipline. Appropriate for use with physically coercive/abusive parents and their school aged children Adopts a comprehensive approach to treatment targeting the contributors of the angry and aggressive behaviors and the impact of these behavior's on a child’s development The model is designed to help parents take responsibility for what has occurred and learn new ways of problem solving, conflict resolution and parenting skills. 19

Evidenced Based Models Outcomes of AFCBT Caregiver/child verbal and physical aggression Family conflict Recidivism (caregiver) Child safety Child social competence Parental nurturing Family cohesion Kolko, 1966, Kolko et al., 2011, 2012, 2014 20

Trauma and Grief Component Therapy for Adolescents Assessment-driven manualized individual and group treatment model for trauma-exposed or traumatically bereaved older children and adolescents. Designed for youth and transitional youth between the ages of 12 and 20 years, including those impacted by community violence, traumatic bereavement, natural and man-made disasters, war/ethnic cleansing, domestic violence, witnessing interpersonal violence, medical trauma, serious accidents, physical assaults, gang violence, and terrorist events 21

Trauma and Grief Component Therapy for Adolescents The intervention is assessment-driven, with specific treatment modules selected based on clients' problems, needs, and strengths. Model contains a variety of components.: An initial assessment, case conceptualization, and treatment planning Psychoeducation Emotional regulation skills Addressing youths' and families' traumatic stress experiences and reactions Promoting adaptive coping (e.g., social support, problem-solving, contending with trauma and loss reminders), Addressing maladaptive beliefs relating to trauma and loss, Promoting adaptive developmental progression Addressing grief and loss, Maintaining adaptive routines, Relapse prevention, and (k) ongoing monitoring, surveillance, and evaluation of treatment response. Family/parent sessions are offered at key points in treatment. Assessment tools are available to measure all major targeted therapeutic outcomes. 22

Cognitive Behavioral Interventions for Trauma in Schools - CBITS “CBITS is a school-based, group and individual intervention. Designed to reduce symptoms of post- traumatic stress disorder (PTSD), depression, and behavioral problems, and to improve functioning, grades and attendance, peer and parent support, and coping skills.” CBITS uses cognitive-behavioral techniques to help youth, grades 5-12, who may have experienced a variety of stressful and traumatic life events. The model incorporates psycho-education, relaxation, social problem-solving, cognitive restructuring, and exposure. http://cbitsprogram.org 23

Outcome Data 2013 & 2014 2013 & 2014 201 20132 24

Actively Caring For People May 5th, 2012 Creating a more compassionate community through intentional acts of kindness 25

AC4P Actively Caring For People Founded by E. Scott Geller, Ph.D., Director of the Center for Applied Behavior Systems, Virginal Tech University initially focusing on workplace safety, psychology of safety, behavioral safety interventions. In 2007, the AC4P movement at Virginia Tech began to develop a kinder, more compassionate and interdependent culture. In 2009, Shane McCarty, Ph.D. candidate, Department of Organizational Psychology, Virginia Tech University, expanded AC4P to focus on enhancing school climate. 26

Foundations of AC4P AC4P is about “intentional acts of kindness. Random implies chance. Requires personal interaction with others. Takes moral courage. Behavior based feedback to support desired behavior. Emphasizes a youth led, peer-to-peer model. Research done on the Elementary and Middle School approaches show promising outcomes (McCarty & Geller, 2013) and (McCarty, Teie, Langerman & Geller, 2014). 27

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McCarty, 2014 29

There are advantages of providing trauma treatment in schools. 30

There are disadvantages of providing trauma treatment in schools. 31

This is a plug for attention to secondary traumatic stress and burnout. 32

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