1. Integrating Trauma Informed Care Into an ABA Model
Terry J. Page, PhD, BCBA-D
New Jersey Association of Community Providers
Annual Statewide Conference
Atlantic City, New Jersey
November 18, 2016 1

2. Topics What is Trauma Informed Care?
How do Trauma Informed Care and Applied Behavior Analysis conflict ?
How does Trauma Informed Care complement Applied Behavior Analysis?
How can we provide better trauma informed care?

3. What is Trauma Informed Care?

4. Universal Ideals World peace Democracy Freedom Equality
Trauma Informed Care

5. Trauma Acute episodic trauma Interpersonal trauma
Life-threatening event over which one has no control
Interpersonal trauma
Personal experience, or observation, of interpersonal violence

6. Trauma
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
Directly experiencing the traumatic event
Witnessing the event as it occurred to others
Learning that the event occurred to a close family member or close friend
Experiencing repeated or extreme exposure to aversive details of traumatic events (e.g. first responders, police officers)
Diagnostic and Statistical Manual of Mental Disorders DSM-5

7. Sequelae of Trauma in Youth
Among youth who experience trauma the following are more likely:
School Problems
Emotional Difficulties
The rate of these issues increases as the number of traumatic events increase
Lower IQ is a risk factor

8. What is Trauma Informed Care?
Many individuals we serve have experienced trauma in their lives

9. What is Trauma Informed Care?
Individuals we serve may encounter restrictive interventions that mirror the loss of power and control experienced in past abusive relationships that caused trauma

10. What is Trauma Informed Care?
It is important that we recognize the presence of trauma symptoms and acknowledge the role trauma plays in people’s lives
More specifically, it is critical to recognize role of trauma in serving as establishing operations in affecting unwanted behaviors

11. What is Trauma Informed Care in Terms of Prescriptive Initiatives?

12. What is Trauma Informed Care?
Safety
Empowerment
Connections
Programmatic Romance
Programmatic Friendships
Karyn Harvey
Trauma-Informed Behavioral Interventions:
What Works and What Doesn’t

13. What is Trauma Informed Care?
Trauma informed care is not an additional practice
Trauma Informed care is an approach, a philosophy, and a cultural change in the way current practices are delivered
Substance Abuse and Mental
Health Services Administration

14. What is Trauma Informed Care?
Safety and stabilization: assuring that
treatment experience is caring and
comfortable
2. Processing of traumatic material: Providing
a context for consumers to acknowledge
experience, and normalize emotions and
cognitions associated with trauma
3. Reconnection and reintegration: Supporting
the consumer in developing a “new sense of
self”
Kevin Huckshorn

15. What is Trauma Informed Care?
1. Realizes widespread impact of trauma and
understands paths for recovery
2. Recognizes signs and symptoms of trauma
in clients, families, staff, and others
3. Responds by integrating knowledge about
trauma into policies, procedures, and
practices
4. Seeks to actively resist re-traumatization
Substance Abuse and Mental Health
Services Administration

16. How Does Trauma Informed Care Conflict with Applied
Behavior Analysis?

17. Other Perspectives
Through functional assessment, we give staff the message that they are in charge and responsible for the behavior of the individual
Karyn Harvey, 2012

18. Other Perspectives
Why do we assume that individuals with intellectual disability who are having behavioral issues are doing so to gain some outcome or to manipulate someone?
Karyn Harvey, 2012

19. Other Perspectives
Behavior Plans put the onus of control in the hands of staff, and take power away from the individual
Karyn Harvey, 2012

20. How Does Trauma Informed
Care Conflict with ABA?
Lack of attention to environmental events that may be impacting behavior 
Focus on doing trauma work and belief that everything then will get better
Christopher DeHon & Deborah Napolitano
NYSABA Conference 2015   

21. How Does Trauma Informed
Care Conflict with ABA?
Description of behavior as a result of trauma determines the reason for behavior is topography rather than function 
People make the assumption that someone
who is engaging in aggression must be doing
it because they have attachment issues
Persons who engage in fecal smearing must
have been sexually abused
Christopher DeHon & Deborah Napolitano

22. How Does Trauma Informed
Care Conflict with ABA?
Trauma informed care is used as a rationale for reinforcing challenging behavior
If behavior is a result of trauma then we
should be soothing and supporting rather
than developing function-based
interventions (and being soothing and
supportive)
Christopher DeHon & Deborah Napolitano

23. How Does Trauma Informed
Care Conflict with ABA?
Imprecise language affects the ability to generalize effective interventions
Relationships (attachments) are important
How should we identify what is important about the interactions with a person with whom a positive relationship exists vs. those with a non-positive relationship  
Christopher DeHon & Deborah Napolitano

24. How Does Trauma Informed Care Conflict with ABA?
It is not well understood
There is no widely accepted definition
It is not evidence-based
It is sparse on specific systems

25. How Does Trauma Informed Care Complement Applied
Behavior Analysis?

26. How Does Trauma Informed Care Complement ABA?
Who knew?
Functional assessment
Positive reinforcement
Replacement behaviors
Choice opportunities
Antecedent interventions
Behavioral momentum

27. Lightbulb Moments Floyd 15 years old
Bi-polar Disorder, ADHD, Asperger Syndrome
Severe aggression and self-injury associated with evening hygiene
Sexual abuse by older brother for 9 months
Substituted baths for showers

28. Lightbulb Moments Vern 41 years old
Institutionalized since a small child
Severe physical and sexual abuse
Severe aggression upon admission
“Are you going to hurt me?”
Spider

29. Operationalizing Trauma Informed Care
Conceptualize trauma as aversive event
Loss of a significant source of reinforcement (e.g. death of a caregiver, out of home placement)
Event that threatens the safety of the individual (e.g. accidents, natural disasters, physical abuse, sexual abuse)
History of aversive conditioning
Keith Gordon & Deborah Napolitano
NYSABA Conference 2015

30. Operationalizing Trauma Informed Care
Trauma as Aversive Condition
Ongoing states of stimulus deprivation
Consistent lack of food, shelter, clothing, etc.
Lack of access to caregiver attention
Establish deprived stimuli as highly reinforcing
Keith Gordon & Deborah Napolitano

31. Operationalizing Trauma Informed Care
Differential Reinforcement of Challenging Behavior
State of deprivation (e.g. restricted access to caregiver attention).
Pro-social behaviors may be ineffective within such an environment.
Challenging behaviors may have been most effective at producing access to attention or other desired stimuli, as well as escape and avoidance
Keith Gordon & Deborah Napolitano

32. Operationalizing Trauma Informed Care
Quality of Life Impact
Development of challenging behavior
Increased likelihood of out-of-home placement
Label as withdrawn or violent
Restricted access to community settings/resources
Diminished opportunity for pro-social behaviors to be learned and reinforced
Keith Gordon & Deborah Napolitano

33. Operationalizing Trauma
Conditioned Punishers
Stimuli associated with trauma become conditioned punishers.
Similar stimuli act as establishing operations that alter the value of escape as negative reinforcement.
Individuals develop repertoires of behaviors maintained by negative reinforcement.
Keith Gordon & Deborah Napolitano

34. Operationalizing Trauma
Discriminative Stimuli
Events that signal the presence of
conditioned punishers become SDs for
negative reinforcement
These events are commonly referred to as “triggers” or “trauma reminders”
These SDs can limit an individual’s ability to
function in settings in which they occur
Keith Gordon & Deborah Napolitano

35. Operationalizing Trauma
Repeated Exposure
If current stimulus conditions share characteristics with trigger SDs, current stimuli may acquire increased value as punishment
Patterns of negatively reinforced behavior may be strengthened
Events with diverse characteristics may impact an individual’s response to a range of environmental stimuli
Keith Gordon & Deborah Napolitano

36. How Can We Provide Better Trauma Informed Care?

37. Trauma Prevention Make key information available to staff
List of known triggers
List of difficult anniversaries
List of positive people
List of safety factors

38. Positive Development Make key information available to staff
Ways for staff to facilitate positive experiences
Ways for staff to facilitate peer relations

39. Behavioral Incident Prevention
Make key information available to staff
List of stressors
Ways to redirect
What to do if triggers occur
What to do when anniversaries occur
How to promote a sense of safety
How to monitor psychiatric issues

40. Crisis Intervention Staff training
How to remove from difficult situations
Effective de-escalation techniques
Avoidance of restrictive interventions
De-briefing
Post intervention connection

41. Engineering the Culture
Staff training
Treating individuals with dignity and respect
Individuals should receive the same dignity and be treated with the same respect as others with whom you have interactions
Individuals should be treated the way one would expect a loved one to be treated

42. Engineering the Culture
Staff training
Person centered thinking and choice
Encourage normal conversation, not I’m the staff and you’re the client, and you’ll do as I say.
Build in choice making

43. Engineering the Culture
Staff training
Ensuring appropriate communication with individuals, parents and agencies
Tone, posture, and volume are key to effective communication, particularly in crisis situations
Be respectful, calm, use normal voice tone and do not argue.

45. The Professor

46. Don’t’s Don’t take things personally. Don’t lose your composure.
Don’t yell.  
Don’t threaten.
Don’t hold a grudge.
Don’t blame the individual.  
Don’t discuss individuals’ problem behaviors in their presence.
Don’t expect justice.
Don’t bring your personal life to work.

47. Dos Do be positive, upbeat, and enthusiastic.
Do stay calm and maintain professional demeanor.
Do show an interest in individuals.  
Do listen and be understanding.
Do remember why behavior problems occur.
Put yourself inside the heads of the individuals you work with.
Be consistent.
Be fair.

48. Take Home Points
Behaviors occur for a reason. Understand this. Do not forget it when you are dealing with annoying situations as well as when you are in the middle of a behavioral crisis.
Catch individuals being good. Do this often. Expect your fellow staff to do it often

49. Take Home Points Do not provide attention for inappropriate behaviors.
4. Treat all individuals the way you would want to
be treated or the way you would want a loved
one treated if they attended AdvoServ.

50. What will you do to provide trauma informed care?

51. Enable people to feel safe
Help individuals learn to trust
Be positive
Treat people with
dignity and respect
Be sensitive to past traumas
Individuals
Fellow staff

52. How Can We Provide Trauma Informed Care?
General Steps in Trauma Informed Care:
Identify situations that may be re-traumatizing
Assess the function of dangerous behaviors and teach replacement behaviors
Positive reinforcement—noncontingent interactions
Build in choice opportunities
Help individuals to feel safe
Look for incidental teaching opportunities
Train staff in trauma informed care and help them understand their role. Expect high rates of positive interactions among staff and individuals

53. Thank you!

54.
Brief.
No time to go into detail.