1. Using Trauma Informed Care Approaches with Students who are Deaf or Hard of Hearing
Michelle Niehaus, LCSW
Program Administrator
Deaf and Hard of Hearing Services
KY Division of Behavioral Health
Angela Simpson
School Social Worker
Kentucky School for the Deaf

2. Imagine for a Moment…
You have a six year old boy in your classroom. He has difficulty sitting down in class and occasionally erupts in anger when asked to do something he doesn’t want to do. He is African-American and currently lives with a white foster family. He experienced physical abuse in his family of origin. He is very behind academically and struggles with both written English and sign. He has hearing aids but rarely brings them to school. …Later…you see him in middle school. He is aggressive towards others and some say he is sexually acting out with other boys in his dorm. He can communicate his wants and needs in concrete terms yet doesn’t seem to connect his actions and consequences. Sometimes he “tunes out” for long periods of time which frustrates school staff and his peers. His behaviors are putting him at risk of expulsion.

3. What is it with this kid. We’ve tried everything. Or Have We
What is it with this kid? We’ve tried everything!... Or Have We? Explore with us today…
What “trauma” is – what can be labeled trauma in general and with Deaf or Hard of Hearing children in particular
Behaviors that may be trauma-related and how to reframe them
Coping Skills for Children who have Experienced Trauma
Resources for addressing trauma and for helping your students

4. Psychological Trauma occurs when…
Often leaves the individual feeling helpless and/or powerless
Overwhelms ordinary self- care that provides the individual with a sense of control, connection, and meaning in life
The person experiences a threat to life, bodily integrity, or sanity;
The circumstances of the event include abuse of power, betrayal of trust, entrapment, helplessness, pain, confusion, and/or loss
The ability to cope (integrate emotional experience) is overwhelmed
Pearlman& Saakvitne, 1995; Giller, 2003)

5. What do we mean by “trauma?”
It is the individual’s personal experience of an event that determines whether it is or is not traumatic
The meaning
The feelings
The severity
The loss of control
The unexpectedness

6. Thinking of these definitions, what are some of the traumas your students have experienced?
Which are experiences that any child may have?
Which are unique to being Deaf or Hard of Hearing?

7. Types of Trauma Traumas all Children May Experiences
Traumas Unique to Children who are Deaf or Hard of Hearing
Physical Abuse**
Sexual Abuse**
Neglect
Witnessing Domestic Violence
Natural Disasters
Death of a Loved One
Divorce
Abandonment / Separation
Language Deprivation
Educational Deprivation
Information Deprivation Trauma (IDT)
Multiple Medical Procedures

8. Statistics on Trauma among Children who are Deaf or Hard of Hearing
A 2010 Study at Rochester Institute of Technology (RIT) found that 77% of Deaf or Hard of Hearing respondents vs 49% of hearing respondents had experienced maltreatment (
Increased severity of hearing loss was correlated with increased rate and severity of maltreatment
Having a deaf parent or a family member who signs, or being part of the deaf community, did not reduce the risk of childhood maltreatment
The rate of depression and post-traumatic stress was also higher among all deaf and hard-of-hearing respondents regardless of maltreatment

9. Kentucky School for the Deaf (information up to date as of 10/31/2017)
District: Kentucky School For The Deaf (part state agency, part school)
Founded: Apr 10, 1823
Current Enrollment: 28 elementary, 16 Middle, 56 High School
School type: Public
K-12
Takes children from all across the state of Kentucky.
Offers a residential/student life program
Awarded the AWARE grant in 2016.

10. Our Students at KSD
*Currently we have students in therapy dealing with loss of loved ones, witnessing domestic violence, being a victim of child abuse/neglect, and other issues involving trauma, as well as other mental health issues.
*Approximately 20% of our students received school based mental health services to address this, and several also receive case management services. This will continue to grow as new children are identified and referred on a regular basis, and as our network of mental health providers grow.
*Some of the trauma has manifested in acting out behavior, self harm, and threats of suicide. It may also manifest as difficulty with interpersonal relationships or learning difficulties/difficulty focusing in the classroom. A lot of this acting out behavior is not seen during the day in the classroom but in the dorms. This is why the Mental Health First Aid was so important for all of our staff, not just teachers, to have.
*Some of the students we have are refugees and had experienced trauma prior to coming to the US. These children deal with a double issue of having trauma and often language deprivation resulting in the inability to express what they have experienced.

11. Trauma and “The ACEs”

12. Past Trauma Can Add Layers and Affect Interpretation

13. For Many Deaf Individuals, System Experiences were Traumatizing

14. Re-Traumatizing Environments: A Lesson from Jan DeVinney
“No energy. Battles to do. No accessible tty. Closed captioning on the tv? I doubt it. Educating them. Last night the nurse told me I would learn this weekend to accept help…wrong! I have to care for myself as usual…I’m getting more and more isolated with less and less energy to help myself, as well as less desire to try.”
p.Xxv in Glickman’s
Mental Health Care of Deaf People

15. Language Deprivation Syndrome
Overview of Language Deprivation Syndrome
Indicators of Language Deprivation Syndrome
Language dysfluency
Fund of knowledge deficits
Disruptions in thinking, mood, and/or behavior.
See Full Article: Hall, W.C., Levin, L.L. & Anderson, M.L. Soc Psychiatry Psychiatr Epidemiol (2017) 52:
For more in depth information, see Dr. Gupta’s lecture at Brown University:

16. Behaviors Sometimes Seen in Trauma Survivors….and Why…

17. What Could the Trauma Look Like?
People who have endured trauma often experience fear, depression, anxiety, lack of trust, and difficulty feeling safe
An individual’s affect may not reflect the level of emotions experienced
A range of emotions can be experienced and expressed in different ways – seeing the individual is critical
A person may have difficulty staying in the “here and now”
Memories are typically fragmented, non-sequential, and filled with gaps
Timelines may be distorted
Gaps could be filled in with that seems logical (vs. accurate)

18. Think About… How may a trauma reaction mirror language dysfluency?
Could it be misunderstood as a cognitive issue?
Could the survivor have a different way of describing his or her experience?
Do those involved understand the “typical” ways of expression in the deaf community?
Is the interpreter equipped to handle the information?
Do those investigating understand Deaf culture, ASL, and how to work with Deaf children?

19. Did You Know?
Developmental Trauma Can Be Framed as a Type of Brain Injury

20. Trauma Affects the Brain: Lateral Ventricles Measures in an 11 Year Old Maltreated Male with Chronic PTSD, Compared with a Healthy, Non-Maltreated Matched Control
This slide demonstrates the physical impact of trauma on the brain. This work comes from an important study by Dr. Michael DeBellis (pronounced: Bayless with a long ‘a’) and his colleagues that was published in Biological Psychiatry in Dr. DeBellis studied the brains of children who were abused and compared them to the brains of children who were not abused.
Dr. DeBellis found that the brains of children who had been abused were different. (Again, it might be helpful to use a laser pointer here.) If you look on the left side, the healthy child’s brain, you see a thin external layer covering the brain (white area arching over brain image). If you look at the image on the right, you see a thicker white band. This shows atrophy or shrinkage of the cerebral cortex. Besides the cortex, other structures of the brain change, like the hippocampus and the amygdala. These structures also decrease in size. But the lateral ventricles, on the other hand, increase in size in people who are traumatized. See this black triangle shapes on left image and how much larger they are in the MRI image of the child with trauma on the right? Trauma physically effects the brain and how it functions.
Karestan Koenen, a researcher from Boston, published a groundbreaking twin study in She looked at twins who were discordant for trauma, meaning one had a history of trauma and one did not. What she found was that the twin who had a trauma history, had on average, an 8-point reduction in IQ scores – the only distinguishing variable was the trauma. Lowered IQ is a significant risk factor for other negative outcomes, like school failure and juvenile delinquency. What this means is that people with trauma histories, can also have brains that have been adversely effected by that experience. So, trauma can directly effect learning and day-to-day functioning of the people we serve, for the rest of their lives.
(De Bellis et al., 1999) 34

21. How the brain is affected…possibly for life…
Dr. Michael DeBellis (pronounced: Bayless with a long ‘a’) and his colleagues published a study in Biological Psychiatry in Dr. DeBellis studied the brains of children who were abused and compared them to the brains of children who were not abused.
Dr. DeBellis found that the brains of children who had been abused were different.
The thick white band or cerebral cortex has atrophied or shrunk
The hippocampus and the amygdala. These structures also decrease in size.
The lateral ventricles, on the other hand, increase in size in people who are traumatized. See this black triangle shapes on left image and how much larger they are in the MRI image of the child with trauma on the right? Trauma physically effects the brain and how it functions.
Karestan Koenen, a researcher from Boston, published a groundbreaking twin study in She looked at twins who were discordant for trauma, meaning one had a history of trauma and one did not. What she found was that the twin who had a trauma history, had on average, an 8-point reduction in IQ scores – the only distinguishing variable was the trauma. Lowered IQ is a significant risk factor for other negative outcomes, like school failure and juvenile delinquency. What this means is that people with trauma histories, can also have brains that have been adversely effected by that experience. So, trauma can directly effect learning and day-to-day functioning of the people we serve, for the rest of their lives.

22. Review of Brain Structure and its Functions…
From

23. Behaviors Sometimes Seen in Children
Looks like….
ADHD
Anger / Outbursts
“He just knows how to push my buttons!”
BIG emotions! Or….no emotions shown (Over- or Under-Reacting to events, people, and environment)
Anxiety, Fear, Worry
Discussing or drawing death or dying
Changes in behavior including grades
Difficulty with authority
As you develop your “trauma lens,” think about what behaviors may be telling you…..

24. Taking a “Bottom Up” Approach to Developmental Trauma
v=FOCTxcaNHeg

25. Strategies to Help Children who have Experienced Trauma
We Have to Start Somewhere…

26. Creating a Compassionate Holding Environment
Establish a solid communication foundation
Respect individual language needs
Value the individual in all aspects of care
Use neutral, objective and supportive language
How could sign choice affect a person’s perception?
Individually flexible plans and approaches
If a Deaf child is the only one in a school, how could that add to the trauma?
What strategies could mediate that isolation?
Avoid shaming or humiliation at all times
Recognize when a child is going into survival mode and respond in a kind and compassionate way.
Create calm, predictable transitions.
Praise publicly and criticize privately.
Adopt or Adapt mindfulness practices.
Take care of yourself!
/the_silent_epidemic_in_our_classrooms

27. Building Resiliency…Changing the Contents of the “Invisible Backpack”
What messages do your students bring with them to school…
…due to their hearing loss and/or other disabilities?
…due to their race or ethnicity?
…due to their Socioeconiomic Status?
…due to their home environment?
What messages do you want to send them home with?
How can / do you partner with parents to make those messages consistent at home and school?

28. Skills Educators Can Use to Address Trauma in Children
Establish Safety
Use Clear, Consistent, Specific Behavior Management Techniques
Teach Stress Management / Self Regulation / Relaxation Skills
Teach Emotional Vocabulary / Model Expression of Emotions and Coping Skills
Identify and Connect with Social Supports Including Role Models
Enhance Future Safety by Working with Team around the Child
Practice Patience….and Don’t Take Behavior Personally!
Manage Your Own Personal and Professional Stress

29. In Trauma-Informed Work…
Clinicians are Trying To…
Educators Can Help By…
Maintain Calm/Continuous/
Engaged State
Prevent Discontinuous States
Build Cognitive Structures
that allow choices
Validating the individual by recognizing when a flashback may be occurring
Checking with the Survivor for clarity as needed
Helping to ground the student in the “here and now.” Using repetitive phrases or a touchstone.
Discussing with parents and the school counselor or team how to handle dissociative states at home and school
Using visuals if needed to establish timelines
Showing patience and allow the survivor to set the pace
Realizing that confusion is probably not about resistance or unwillingness to “cooperate”

30. Emotional and Physical Pain
Trauma Informed Care…Going from “What’s wrong with you?” to “What happened to you?”
Emotional and Physical Pain
Victim Blaming
Many of us walk around with hidden wounds. Trauma informed work is like using universal precautions for emotions.

31. Considerations for Trauma-Informed Work
A Dysregulated Nervous System
Fight or Flight Mechanisms
“The Reptile Brain”
Info Dumping
Cognitive vs. Sensory Based or Safety Based Interventions
The Effects of the Environment
Current and Past
Validating or Invalidating
And For Deaf Victims…
Effectiveness and Accuracy of the Interpreting
Cross-Cultural Understanding
Fund of Information regarding Abuse Issues

32. Be Aware of Potential Triggers
A trigger is something that sets off an action, process, or series of events (such as fear, panic, upset, agitation):
Situations that mirror when or where abuse or incident happened
What examples can you think of?
How would you sign “trigger?”
What is one sign choice that could re-traumatize?

33. Protective Factors: Building Resilience and Connection
Families Must be Supported and Equipped: Kentucky’s Strengthening Families Initiative
Protective Factors
Nurturing and Attachment
Knowledge of Child Development
Concrete Support in Times of Need
Social and Emotional Competence of Children
Social Connections
Parental Resilience
Parent Cafes as a Means to Grow Connection
Research has shown a correlation between connection with the Deaf community and reduced PTSD and symptoms of trauma (file:///H:/Child%20Maltreatment%20and%20Trauma%20Exposure%20in%20Deaf%20Children%20a nd%20Youth.pdf)
Being part of the Deaf community
Having access to others who are Deaf
How can we connect children who use listening and spoken language more effectively? How can we be more inclusive of ALL children and families?

34. COMMUNICATION as Essential: A Vital Protective Factor
Children MUST be able to communicate basic safety concerns at home and school
Consider incorporating safety and self advocacy goals into IFSPs and IEPS. For resources on this…
col.wiki.educ.msu.edu/Silence+is+NOT+an+Option
KSD Outreach Consultants offer local sign language dinners and other socials where parents can strengthen their sign communication skills
RESPECT the communication choices of families and support them to get what they need for effective communication in the home (ex. Telehealth for speech therapy)

35. Considering Mediated Treatment: The Impact of An Interpreter in Trauma Work
Not all ASL interpreters are equipped for working with people who have experienced trauma
Interpreters are at risk for vicarious trauma as well
Conflicts of interest / Dual relationships will be common in educational settings and rural areas
Promising work is being done out of Boise, Idaho on “The Equitable Triad” and Healing Encounters at their Center on Refugees

36. Resources for Helping Children who are at Risk for or Who have Experienced Trauma

37. Observe, Understand & Respond: the O.U.R. Children's Safety Project
A wealth of information on abuse prevention specifically for children who are Deaf or Hard of Hearing developed through a Hands & Voices network:
Hotline Specifically for D/HH Population
One of the accomplishments of this project is partnering with ChildHelp.org and the creation of a toll-free number specifically for support for children who are dhh.  This number can be called by anyone anonymously who needs information/support about a particular situation.  The number is  

38. Kentucky’s Specialists in Deaf Mental Health Care
Community Mental Health Centers
Other Providers
Therapists
Laura Burg, LCSW – Bluegrass
Erin Schilling, LCSW – Centerstone
Julie Dalbom, LPCC - Centerstone
Targeted Case Managers
Rhonda McQuery – Bluegrass
Dodie Karr – Cumberland River
Therapists
Holly Bean – Family Works Therapy Services, Bowling Green area
Dennis Wagner – Forensic Evaluations, Louisville area

39. CMHC Point People for Deaf and Hard of Hearing Services
Four Rivers
David Hedrich
Pennyroyal
Kelly Robertson
River Valley
Mary Kay Lamb
Lifeskills
Renee Hudson
Communicare
Calvin Jackson
Centerstone
Erin Schilling
NorthKey
Larry Lindeman
Comprehend
Steve Lowder
Pathways
Elizabeth Fitzer
Mountain
Heather Greene
Kentucky River
Kathy Gilliam
CRCC
Greta Baker
Adanta
Angelia Bryant
DDID
Kathrina Riley
Bluegrass
Laura Burg

40. KY Managed Care Organizations (MCO) Behavioral Health Hotlines
Aetna Better Health of Kentucky
Anthem Blue Cross Blue Shield Medicaid
Humana CareSource
Passport Health Plan
Wellcare of Kentucky
Behavioral Health Hotlines are available 24 hours.

41. KSD Approaches to Trauma Informed Care in the School
KSD had been awarded the AWARE (Advancing Wellness and Resilience Education) grant.
Trauma Training through CTAC had already been initiated and trainings had taken place.
There was a mental health team up and running. They discussed the needs of the students and what actions/interventions were needed. They also discussed the lack of services available at the time and how to address those.
ABRI was working with KSD and PBIS was being discussed.
Mental Health First Aid trainings were in the process of being initiated.

42. What the AWARE Grant DID for KSD…..
Educated our teachers and staff about mental health
*All staff received Mental Health First Aid training.
*Some staff attended the ADARA Conference which focuses on Mental Health in Deaf Services. Even more staff attended various other mental health conferences. The information was brought back and shared with other staff and community partners.
Increased Awareness/decreased the stigma
*Mental Health Awareness Days have been used to educate both students and staff about mental heath issues. We focus on fun activities that teach coping skills, executive functioning, help students set goals, and try to normalize Mental Health by addressing as being no different then having a physical health condition. We have also used these days to bring in numerous community partners such as law enforcement, mental health agencies, the health department, and others to help promote community partnerships.
Gave better access to equal mental health treatment
*Without the AWARE grant our children who are on Passport insurance, have straight Medicaid, or need to see their therapist for an emergency session would not have access to an interpreter. The AWARE grant currently pays for interpreters for these children on an ongoing basis.

43. For Additional Study…
Clinicians, DCBS Workers, Medical Providers, School Counselors, Families, and YOU may benefit from..
Addressing the Trauma Treatment Needs of Deaf Children and the Hearing Children of Deaf Parents. Available in pdf format at Hearing_Children.pdf
DMH Facts: Trauma and the Deaf Community. Available in pdf format at
Tate, Candice. (2012). Trauma in the Deaf Population: Definition, Experience, and Services. Alexandria, VA: National Association of State Mental Health Program Directions (NASMHPD).
Hegge and Goffman. Childhood Trauma: Identification, Treatment, and Hope. Available online at
Live Trainings and Networking Opportunities
This workshop can be adapted and presented in your community!
O.U.R. Children Project offers monthly calls
#DEAFED Twitter Chats held monthly
System of Care Academy DHHS Track – June 19-21st in Lexington

44. References / Special Thanks to..
Fran Belvin, Sally Mason, and Lynn Posze for their slides and input on this presentation originally given for interpreters
Joseph Batiano and Morag MacDonald for their ongoing advice and perspective as well as their May 2016 trainings in Kentucky

45. Remember the little boy we started discussing?
We hope this workshop has helped you to see him through a different lens and to consider how you may approach him differently when next you meet

46. Please Stay in Touch!
Michelle Niehaus, LCSW Program Administrator Deaf and Hard of Hearing Services KY Division of Behavioral Health (502) (V) (502) (VP)
Angela Simpson School Social Worker Kentucky School for the Deaf (859)