Trauma Informed Care in Early Childhood

Trauma Informed Care in Early Childhood
Understanding trauma informed care and responding to trauma’s impact on behavior Welcome to Trauma Informed Care in Early Childhood Understanding trauma informed care and responding to trauma’s impact on behavior

Trauma Informed Care in EC
Brought to you by: Early Childhood Mental Health Initiatives Valerie Alloy, Ph.D. , Lead Whole Child Matters Grant Created by: Erin Lucas, LISW-S Early Childhood Programs Director Hopewell Health Centers, Inc. Nicole Kennedy, LISW Early Childhood Programs Coordinator Stress Early Childhood Programs

Objectives Understand trauma & toxic stress
Learn effects on social and emotional development Learn strategies to respond to trauma’s effect on behavior Review planned training objectives

Understand trauma & toxic stress
Objective 1: Understand trauma & toxic stress Now we will start by understanding trauma and the meaning of toxic stress.

Defining Trauma: SAMHSA
“Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” (SAMHSA, 2014) There are many ways to define trauma. Today we won’t be talking about PTSD or other DSM 5 diagnoses, we will be talking about the response we feel to experiences. The definition of trauma we will use today was developed by a workgroup of researchers, practitioners, trauma survivors, and family members convened by the Substance Abuse and Mental Health Services Administration (SAMHSA, 2014) . It is important because it creates a framework for understanding the complex nature of trauma. Defining Trauma includes the SAMHSA definition, “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” In this definition there are three key phrases, an event…experienced…as harmful…that has lasting adverse effects. The stress from this experience can lead to an increase in cortisol within the child’s brain which fuels the fight, flight or freeze response. If the child is experiencing large amounts of stress, they are more inclined to have challenging behaviors due to this heightened stress response.

Circumstances cause trauma
The Three E’s in Trauma Events Circumstances cause trauma Experience Effects The focus on events places the cause of trauma in the environment not in some defect of the individual. This is what underlies the basic credo of trauma-informed approaches: “It’s not what’s wrong with you, but what happened to you.” Events can be a single event, a series of events and/or chronic conditions – individuals may experience it directly, witness it or feel threatened hearing about event that affects someone they know. Trauma can be caused by events that the individual doesn’t remember, such as events that occurred in early childhood. Future slides but given for reference: The focus on experience highlights the fact that not every child or adult will experience the same events as traumatic. The identification of a broad range of potential effects reminds us that our response must be holistic—it’s not enough to focus on symptoms or behaviors. Our goal is to support a child to learn and grow or an adult to live a satisfying life.

Traumatic Events: (1) render victims helpless by overwhelming force;
(2) involve threats to life or bodily integrity, or close personal encounter with violence and death; (3) disrupt a sense of control, connection and meaning; (4) confront human beings with the extremities of helplessness and terror; and (5) evoke the responses of catastrophe. (Judith Herman, Trauma and Recovery, (1992) These statements are 25 years old….from her book Still ring true currently Traumatic events have potential to cause these reactions/responses from individuals #3 in most every traumatic situation, this feeling is universal among victims.

Potential Traumatic Events
Abuse Emotional Sexual Physical Domestic violence Witnessing violence Bullying Cyberbullying Institutional INTERACTION question Ask audience to share examples of abuse relevant to populations they serve and/or impact they have observed Partial list of examples – we don’t rule trauma in or out because of this list There is a very wide range of events that can potentially cause trauma.

Loss Abandonment Neglect Separation Natural Disaster Accidents Terrorism War Death INTERACTION question Ask audience to share examples of loss relevant to populations they serve and/or impact they have observed Partial list of examples – we don’t rule trauma in or out because of this list There is a very wide range of events that can potentially cause trauma.

Chronic Stressors Poverty Racism Invasive medical procedures Community Trauma Historical Trauma Family member with substance abuse disorder Family member with a mental illness Bullying INTERACTION question Ask audience to share examples of chronic stress relevant to populations they serve and/or impact they have observed Partial list of examples – we don’t rule trauma in or out because of this list There is a very wide range of events that can potentially cause trauma. Trauma can be caused by an event that didn’t happen to the person but to a group that he or she identifies closely with—as in slavery or the Holocaust or the genocide of the Native American people. Over time, chronic stressors can accumulate and create trauma response. Later we will look out how the stress response can impact a developing child’s brain.

ACE Study Adverse Childhood Experiences
Early Death Disease, Disability and Social Problems Adoption of Health-Risk Behaviors Social, Emotional and Cognitive Impairment Disrupted Neurodevelopment Adverse Childhood Experiences The Adverse Childhood Experiences Study (ACE Study) is a research study conducted by Kaiser Permanente health maintenance organization and the Centers for Disease Control and Prevention (CDC). Participants were recruited to the study between 1995 and 1997 and have been in long-term follow up for health outcomes. Compares adverse childhood experiences against adult status, on average, a half century later. Define Adverse Childhood Experiences Collaboration between Kaiser Permanente and CDC Participants were enrolled in the health maintenance organization in California. 17,000 patients undergoing physical exam as part of an obesity weight loss clinic provided detailed information about childhood experiences of abuse, neglect and family dysfunction ( ) The ACE study indicates: Adverse childhood experiences are the most basic and long-lasting cause of health risk behaviors, mental illness, social malfunction, disease, disability, death, and healthcare costs Reference for additional information and citations Sources: Robert F. Anda MD at the Center for Disease Control and Prevention (CDC) September 2003 Presentation by Vincent Felitti MD “Snowbird Conference” of the Child Trauma Treatment Network of the Intermountain West “The Relationship of Adverse Childhood Experiences to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Healthcare” Book Chapter for “The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease” Lanius & Vermetten, Ed)

ACES: CDC.GOV Growing up in household with:
Common adverse experiences reported in study were grouped into three categories: abuse, neglect, and household dysfunction. First two areas are more often directly experienced by the individual First time that this study expanded to household dysfunction. Goes beyond just the individual and created foundation for TIC approach, what happened to you (experience, out of individual control) vs. what is wrong with you (individual deficit, can be perceived as blame) Results indicated that there were 10 common adverse experiences grouped in three general categories: Recurrent and severe physical abuse Recurrent and severe emotional abuse Sexual abuse Growing up in household with: Alcohol or drug user Member being imprisoned Mentally ill, chronically depressed, or institutionalized member Separation/Divorce Mother being treated violently Both biological parents absent Emotional or physical abuse (Fellitti,1998)

Adverse Childhood Experiences are Common!
Of the 17,000 Participants… 1 in 4 was exposed to 2 categories of ACEs 1 in 16 was exposed to 4 categories 22% were sexually abused as children 66% of the women experienced abuse, violence or family strife in childhood It is important to recognize that Adverse Childhood Experiences are Common. First, The 17,000 HMO members who were interviewed were middle class, with jobs and medical insurance – not likely to have been exposed to street violence, extreme poverty, malnutrition, dislocation, natural catastrophes or war terror. Of 17,000 HMO members: 72% had attended college 77% were white 62% were 50 or older. 1 in 4 were exposed to 2 categories of ACE’s –which would equate to 1/4th of this audience 1 in 16 were exposed to 4 categories 22% were sexually abused as children. That’s over 20% of this audience. Over one in every 5 of us. 66% of the women experienced abuse, violence or family strife in childhood. Two-thirds of the women in this audience more than likely had that experience as children. This is of epidemic proportions and indicates the need to address childhood trauma as a major public health issue.

Ace Score and Health Risk
As the ACE score increases, risk for these health problems increases in a strong and graded fashion: Results of ACE study indicate that as ACE scores increase, risk for heath risk behaviors and negative physical and mental health outcomes increase in a strong and graded fashion. Health risk behaviors identified should also be considered regulatory behavior in response to coping with trauma and chronic stress.

Circumstances and dosage matter
The Three E’s in Trauma Events Circumstances and dosage matter Experience Effects The focus on events places the cause of trauma in the environment not in some defect of the individual. This is what underlies the basic credo of trauma-informed approaches: “It’s not what’s wrong with you, but what happened to you.” The focus on experience highlights the fact that not every child or adult will experience the same events as traumatic. The identification of a broad range of potential effects reminds us that our response must be holistic—it’s not enough to focus on symptoms or behaviors. Our goal is to support a child to learn and grow or an adult to live a satisfying life. For reference….will cover in future slide Research indicates that with the appropriate supports and interventions – people can overcome traumatic experiences, however, most people go without these services and supports Individuals with experiences with trauma are found in multiple services sectors – not just in behavioral health

Circumstances and dosage matter:
Experience of trauma affected by: How? When? Where? How Often? The individual’s experience of trauma may be profoundly affected by when, how, where and how often it occurs. Trauma can result from a single devastating event, called single-episode trauma (sometimes called acute trauma), or it can result from multiple traumatic events over time. Most individuals served in the public system have complex trauma, which comes from experiencing multiple sources of trauma over a lifetime. Trauma can be totally unintentional, as when an organization does harm through its procedures. For example, the routine practice of undressing for a medical exam can re-traumatize a person. Systems can also unintentionally replicate the dynamics of an earlier trauma, causing re-traumatization. Trauma can occur from hearing about, watching, or interacting with others who have had traumatic experiences. The accumulation of multiple traumas has a more negative impact on individual functioning than any singular trauma regardless of intensity.

Circumstances that Increase Impact
Context, expectations, and meaning Threat to life, bodily integrity, or sanity Practices, policies, procedures Humiliation, betrayal, or silencing Subconscious or unrecognized TIP and ORGANIZATIONAL Context/expectation/meaning – universal understanding of TRAUMA and direction within own organization – common language Example – not respecting my participation in treatment…not understanding my behavior has meaning Threat to life/bodily integrity – The way in which I present myself…function…perceived…interact etc.. Example – invasion admission procedures, strip searches/visual body exams Practice/policy/procedures – what is the standard for your facility, are they shared, is there an awareness, are they TIC Example – permissive use of seclusion and restraint – limited personal freedom. Humiliation and betrayal/silencing – not heard as a staff, client, trust is violated, opinion/personal stories not valued Example –breaking confidentiality within the facility, ignoring patient concern, not allowing client express/identify needs Subconscious/unrecognized – responses that happen as a regular basis that are not sensitive to individuals who have experienced trauma Example – not taking client concerns seriously, proceeding with business as usual. ..insufficient recourse to meet client need.

Why are traumatic events different for individuals?
Circumstances may enhance risk or circumstances can help an individual be resilient. Ask participants to discuss why some events may be traumatic for one person but not for another. ADD KEY POINTS Resiliency buffers trauma Having trauma validated Being silenced Intersectionality of population Risk and protective factors How can the same event be traumatic for one person and not for another?

Learn effects on social and emotional development
Objective 2: Learn effects on social and emotional development Now we will discuss trauma’s impact on development. Through our mental health lens, we specialize in social emotional development but recognize that all domains are connected, requiring an integrated response with considerations of trauma’s impact on cognitive, gross and fine motor, speech, language, and behavior.

Healthy Development When this process occurs with minimal disruptions and with healthy repair and reconnection with a primary attachment figure, healthy development occurs and lays a solid foundation for other development.

Normal response to an abnormal situation
The Three E’s in Trauma Events Normal response to an abnormal situation Experience Effects The identification of a broad range of potential effects reminds us that our response must be holistic—it’s not enough to focus on symptoms or behaviors. Our goal is to support a child to learn and grow or an adult to live a satisfying life. Our take home point for effects of trauma is that outcomes and behavioral responses to trauma are NORMAL responses to an ABNORMAL situation. We expect children express experience and expectations through interactions and behavior, both positive and negative. Identifying effects as a normal response can help us approach with a greater level of empathy and some level of explanation for behavior. Discuss explanation vs. excuse of behavior.

Signs and Symptoms of Trauma: Infant and Toddlers
Eating & Sleeping disturbance Reacting to reminders/trauma triggers Clingy/separation anxiety Difficulty engaging in social interactions through gestures, smiling, cooing Irritable/difficult to soothe Repetitive/post-traumatic play Developmental regression Persistent self-soothing behaviors, for example, head banging Language delay General fearfulness/new fears, Easily startled Aggression (toddlers) So how do we know if an infant or toddler has been exposed to trauma or levels of toxic stress? Any of these can be age appropriate behaviors, however, extreme versions of these behavior may be a red flag to screen for the presence of traumatic events in the child’s life.

Signs and Symptoms of Trauma: Preschoolers
Avoidant, anxious, clingy Sadness General fearfulness/new fears Repetitive/ post-traumatic play Helplessness, passive Talking about the traumatic event and reacting to trauma triggers Restless, impulsive, hyperactive Physical symptoms (headache, etc.) Developmental regression Inattention, difficulty problem solving Poor peer relationships and social problems (controlling/over permissive) Irritability Aggressive and/or sexualized behavior How might a preschooler display signs of trauma differently than an infant or toddler?

Activity 1: Think of a child you have known that displayed signs of trauma and/or toxic stress. Turn to an elbow partner and share what that looked like, signs and symptoms you’ve observed. What events might have contributed to these signs/symptoms? How does this knowledge increase your empathy for the child/family you serve? Activity Handout: Child Outline Use child outline in folder to start “creating” your own child visual. On the inside of the child, please write signs/symptoms they’ve displayed, challenging behavior, etc. On the outside of the child, please write events, or stressors in the environment that may be contributing to these signs/symptoms

Foster care placement for 6 months Meltdowns
Witnessed domestic violence Transitions Expelled from 2 previous preschools 3 adults 4 kids 2 bedroom home Hitting Fidgeting Hiding “No” Grandpa died 3 months ago Separation anxiety Cussing Family substance abuse Audience invited to share out signs/symptoms and environmental factors Trainer builds “child” along with the group throughout slides. Behaviors and environmental factors shared based on common consultation concerns, requests and shared or suspected histories. Kicked out of babysitter’s house 6 different caregivers in last 3 months Running Inattention

Being silenced or not believed Perpetrator is trusted caregiver
Compounding Effects Early occurrence Blaming or shaming Being silenced or not believed Perpetrator is trusted caregiver The younger the age when trauma occurs, the more likely the consequences. We will discuss why this is true—even when the individual has no memory of the trauma—when we briefly discuss how trauma affects the brain, or the neurobiology of trauma. Shame and humiliation are core features of the trauma experience for many people. These emotions can be devastating and impede healing. One of the most important messages you can give a trauma survivor is that no matter what happened, it wasn’t their fault in any way. Sometimes trauma survivors are intimidated by their perpetrators into not telling what happened. Other times, when they do try to talk about what happened to them, they are ignored or disbelieved. One of the most important things you can do for trauma survivors is to give them the chance to tell their stories. Healing starts when a person’s personal experience is heard and validated. Bullying could be a example of this form of trauma. The impact of trauma is magnified when the perpetrator is a trusted figure—a relative, religious leader, coach, teacher, or therapist. This kind of trauma is often called “betrayal trauma” because the sense of betrayal can be so profound.

Effect: Strengths vs. Risks
Protective Factors Risk Factors Attachment Initiative/Curiosity Self- Regulation Trauma history Poverty Stressful events Just like there are plenty of factors that can compound the effect of trauma, there are other factors that can mitigate risk. We know that the presence or absence of protective factors affects the way in which risk factors impact our life experience. )

Trauma and Development
A child's ability to adapt, use internal coping resources, and employ defense mechanisms in the face of trauma are determined by: Development (brain development, self-regulation, psychosocial development, cognitive functioning and communication) Attachment relationships (an attuned and responsive caregiver, social environment) Resilience (ability to bounce back from life's adversity based on protective factors such as good health, easy going temperament, close relationships, consistent parenting, etc.) (Cook et al, 2003; Blumenfeld et al, 2010) Each of us experience the effects of events differently in our lives due to these factors.

Speech IEP Meltdowns Foster care placement for 6 months
Witnessed domestic violence Transitions Expelled from 2 previous preschools 3 adults 4 kids 2 bedroom home Hitting Fidgeting Hiding “No” Grandpa died 3 months ago Separation anxiety Cussing Family substance abuse Note if your “child” has identified or suspected developmental delay(s) in any of the following domains: Cognitive, Speech/Language, Motor (Fine/Gross), Social-emotional Kicked out of babysitter’s house 6 different caregivers in last 3 months Running Inattention

How Trauma Impacts the Brain
Early Death Disease, Disability and Social Problems Adoption of Health-Risk Behaviors Social, Emotional and Cognitive Impairment Disrupted Neurodevelopment Adverse Childhood Experiences

State Dependent Functioning
Used with permission by Dr. Bruce D Perry, See Handout: State Dependent Functioning. Dr. Bruce Perry shares this chart that explains the link between our state of regulation and our brains ability to function. Dr. Perry explains that when we are calm and feeling safe and secure, we are able to participate in abstract thinking, using our neocortex or frontal lobes. Now this graph does not pretend that the brain is so simple that the other parts of the brain are “turned off” when our neocortex is working. It says that the other parts of the brain are calm enough that this part can lead our thinking and “be in charge” in some sense. When we become mildly stressed, we move into an alert mental state. In this mental state, we are best at engaging in concrete thinking. It will become harder to engage in abstract thought because our subcortex and limbic systems are more active (switch to next photo as needed and switch back). In this mental state, we will be more vigilant if we are hyper-aroused or maybe avoidant if not feeling safe enough to be vigilant. (Provide example here of a time you were alert and what vigilance and avoidance might look like. Maybe me when I am presenting a training. When I am feeling confident, I am vigilant for questions, if not so confident, I might avoid participants that seem confused.) If something happened (give example such as: my phone rings during presentation) my brain will move quickly to a state of alarm. In this state, I am best at emotional thinking. (A good example of this is an upsetting . Has anyone ever given an emotional response to an upsetting ? What was that like? Look for signs of resistance or compliance and point those out.) In this state our limbic system fights to be in charge. Has anyone ever had a resistant child in class? What does that look like? Maybe they are slow to move to the next station, make life difficult? What about the overly compliant? Anyone experienced a “honeymoon” with a child? Often we are tricked into thinking that the child was “fine” must have felt safe, they were nice to everyone and did whatever was asked. It is possible that they were feeling fine and relaxed, but it is also possible that they were in a state of alarm and didn’t yet feel safe enough to resist instruction. Some of our children live in this state of alarm. Toxic stress can cause our resting state to be alert or alarm. If this is the case, it doesn’t take much added stress, (ie. Asking child a question or requesting them to transition to the next activity, something that would only move a calm child to a state of alert, preparing them for what is next) to move this child into a state of fear. When we are feeling fear, we are reactive. This means I am not using my “thinking” brain to make decisions. I am using my responsive brain, fight or flight. This part of my brain doesn’t problem solve or think of many alternatives, it responds to the stimulus in the way it was trained. Someone touches me, I fight. This is why we see defiant behavior in this state. The brain is telling the child in that moment that there is danger and the world isn’t safe. If I don’t feel safe enough to be defiant I will probably dissociate. Has anyone worked with a child who has signs of dissociation? “That kid is just checked out.” “He/She isn’t even here with us, he/she is in their own world” these are all signs of a child who is in their fear brain. It will not take much stress to move their state of regulation to terror. In this state, I am no longer even sending mesesages to my brain to interpret, I am reflexive. This is the type of reaction that occurs when you touch a hot stove. Your hand moves back before your brain even thinks. That child’s hand hits someone before they even think about it. In some trainings participants have talked about children who hold their breath and faint. It is possible that they are in a state of terror in that moment and no longer feel safe enough to be aggressive. This behavior is led by our brainstem, the part of our brain responsible for survival. These children have been exposed to such toxic levels of stress that their brain often jumps to this state easier than a person that has not had these experiences. This chart sparks lots of conversation. Spend time talking about behavior that they experience and what state the person displaying the behavior might be in. Talk about adults and children with this slide to introduce the concept that we all display different behavior and thought processes based on the mental state we are experiencing.

Recognizing signs of emotional distress
Activity 2: Recognizing signs of emotional distress Calm Alert Alarm Fear Terror Handout “Recognizing signs of emotional distress” Under each arrow, write symptoms that a child might display when they are in the corresponding mental state. This can happen in small groups or audience share out of sign/symptoms identified with their “child” and trainer helps identify state of functioning child is operating in based on stressors and response. *It is helpful to move back to full chart if using share out discussion

Shift in Thinking: Through the trauma lens…
Instead of… How about? What is your diagnosis? What is your story? What has brought you here? What are your symptoms? How have you coped and adapted? How can I best help or treat you? How can we work together to figure out what helps? Integrating our knowledge of the Three E’s helps us shift our perspective and look through a trauma lens Through this lens, we can challenge our approach to partnering with children and families from collecting information to partnering to build relationships and facilitate new experiences Review each column and engage audience in their response to the two different approaches. Which questions would make you feel more connected? Understood? Valued? Willing to share?

Shift in Thinking: Coping mechanisms
Mislabeled “Normal” Responses Survival Responses Coping Behaviors Labeled by Systems Fight Struggling to regain or hold on to power, especially when feeling coerced “Non-compliant” “In denial” “Combative” “Challenges authority” “Treatment resistant” Flight Giving in to whoever/whatever is in a position of power “Passive” “Can’t be helped” “Using the system” Freeze Disengaging completely: keeping to oneself, leaving services, abandoning housing, etc . “Chronic” “Unmotivated” Review fight, flight, and freeze responses and the brain’s intended function to increase safety, control, survival through coping behavior. How do we mislabel these responses? How can we facilitate change and healing with a label that limits hope? Through this shift in thinking, we can use the intended function of the coping behavior to support children and families in creating safety and control through relationship and strengths based approach. We will revisit use of strengths based intervention this afternoon as we discuss the planning process for responding to challenging behavior and responses to trauma. When coping behaviors are labeled as “symptoms” or problems, they can easily become the focus of relationships. This is NOT how people heal!

Strategies to respond to trauma’s impact on behavior
Objective 3: Strategies to respond to trauma’s impact on behavior We will share practical resources and strategies to build early childhood protective factors Most importantly, we will practice using a planning model for implementation within the context of routines and state dependent functioning

Strategies to Respond: Understanding opportunity
Remember that there are two types of opportunities to promote change through promoting protective factors and responding to risk factors. We can’t erase a traumatic experience or mitigate all of the associated risks, but focusing on protective factors and strengths in planning can build resiliency and a child’s ability to bounce back from future events.

Speech IEP Foster care placement for 6 months Meltdowns
Witnessed domestic violence Transitions Expelled from 2 previous preschools Hitting 3 adults 4 kids 2 bedroom home Fidgeting Hiding “No” Grandpa died 3 months ago Separation anxiety Cussing Add in strengths, visual, and what this child needs to “bounce back” from challenges, events, stressors etc. Strengths: helping hands, caring heart, “checks-in” with peers who are upset Areas to build to help child bounce back: hard hat represents creating feelings of safety, chain and heart connections to trusted adults, breathe button for regulatory skills and support Family substance abuse Kicked out of babysitter’s house 6 different caregivers in last 3 months Running Inattention

Strategies to Respond: Action planning cycle
Assess Plan Implement Evaluate When determining how to respond to trauma’s impact on behavior, it is important to use a tool such as the action planning cycle to ensure a planned response rather than responding in the heat of the moment. Remember, most of us are co-regulators too on some level and when children become dysregulated, we often join them!! If we want to use a rational decision making process, we need to use this planning cycle when we can be calm and rational.

Action Planning Cycle: Assessment Phase
Components: Parent & Early Learning Professional (ELP) Interview Parent & ELP Questionnaire Observation of Child Assess The place to start is with Assessment. In this phase, we are looking for three components of assessment. An interview with the adults who spend time with the child, an observation of the child and some sort of standardized questionnaire. In the next slides, we will discuss trauma informed purpose of assessing challenging behavior and examples of each component. In each component, how might you use a trauma informed perspective in gathering information?

Assessment Phase: Interview and Questionnaire
Trauma Informed Purpose Gather information and history to guide planning Understand Experience Obtain feedback between settings and caregivers Understand Environment Identify routines, strengths, and potential areas for growth Understand Protective Factors Share trauma informed purpose of interview and questionnaire Components and considerations for interview: Open ended questions (no assumptions) Getting to know family system Developmental Domains – Language, Motor, Sensory Culturally Competent Routines/Environment Strengths, areas for growth, partnering with families for a purpose, wealth of knowledge and experience with their child!

Parent & ELP Interview: Suggested Tools
DECA Preschool Program Discussion Questions and Family Questionnaire Team Meeting Preparation Questions Georgetown Model Family Routines and Activities Questionnaire Functional Behavior Assessment Help Me Grow Early Intervention Routines Based Interview Trauma Treatment and Training Center Childhood Trust Events Survey: Caregiver Form Give overview of suggested tools and resources Handouts: DECA discussion questions and Childhood Trust Events Survey Discuss guidelines for use of CTES: Interview style with caregiver, provide rationale for use of the tool, may be supported in use with ECMHC, school counselor, outside provider, CPS etc. ***Be mindful of CTES opening door for disclosure, validating feelings and experiences, mandated reporting guidelines, and linkage to appropriate referrals

Parent & ELP Questionnaire: Suggested Tools
Devereux Early Childhood Assessment (DECA) DECA-I/T DECA-P2 Ages and Stages Questionnaires ASQ-3 ASQ:SE-2 Help Me Grow Early Intervention Bayley-III and Batelle Social Emotional Parent Questionnaire Batelle Others: ODE ODJFS Questionnaire can be completed as part of Caregiver and ELP interviews Components: Developmentally appropriate items Standardized tool Includes Strengths and areas for growth Pre, mid, post comparisons Evaluative ASQ - Communication, gross motor, fine motor, problem solving, and personal-social ASQ SE - Self-regulation, compliance, social-communication, adaptive functioning, autonomy, affect, and interaction with people

Action Planning Cycle: Observation of Child
Trauma Informed Purpose Observe behavior in context of routines and interactions Observe Behavior Assess overlapping developmental domains Observe Impact Identify potential themes, trends, or cycles of behavior Observe Meaning Observation Components: Variety of structured and unstructured activities Routines and transitions Peer and adult interaction Objective documentation (what child and adults say/do in routines)

Observation of Child: Suggested Tools
DECA Preschool Program Child Observation Form (I/T and Preschool) Georgetown Model Observation Toolkit for Mental Health Consultants Help Me Grow Early Intervention Bayley-III Batelle Others: ODE ODJFS DECA and Georgetown models include documentation forms, Bayley and Batelle are evaluation tools that engage child in completing tasks, preferably in a natural environment Classroom observations are intended to be objective notes (i.e. routine observed, who is present, what children adults say/do) save interpretation for later

Taking your “child” through the assessment phase
Activity 3: Taking your “child” through the assessment phase Assess

Identifying Strengths: What are this child’s existing strengths?
How could these strengths be used in our setting? When can these strengths be used within our routine? Small group discussion or share out from “child” outline

Identifying Areas for Growth: What are they?
How could trauma or toxic stress be impacting this behavior? What state is this child functioning in when this behavior occurs? Where are opportunities in the daily routine to build these skills? Review from previous discussion continued in small group or share out, more time may be spent on #3-4

How is my “lens” impacting my perception of this child?
Adjusting Our Lens: How is my “lens” impacting my perception of this child? Their behavior? Their caregivers? Other professionals? Reflect together in small group or share out how perspective has shifted from content this morning ad walking through assessment considerations

Action Planning Cycle: Developing a Plan
Components: SNAP: Strengths, Needs, Abilities, Preferences Goal(s) Strategies Evaluation and Follow up Plan Review SNAP model Goals should be specific, developmentally appropriate, positively stated Strategies include prevention, developing new skills, outlining responses to behavior Planned method of evaluation and frequency of follow up with planning team (ELP, caregivers, ECMHC, etc.) Discuss using a trauma informed perspective in engaging caregivers and professionals in planning

Developing a Plan: Suggested Planning Tools
DECA Planning Model Child Strengths, Goals, and Strategies Plan Positive Guidance Plan Georgetown Planning Model Facilitating Individualized Interventions to Address Challenging Behavior Toolkit Help Me Grow Early Intervention Model Individualized Family Service Plan (IFSP) Others: ODE ODJFS Review planning tools for documenting implementation and following Handout: DECA Planning tool (we will use later to practice developing plan for implementation)

Action Planning Cycle: Developing a Plan
Trauma Informed Purpose Use assessment information to outline future responses Plan for Events Change expectations using strategies that promote protective factors Create new Experience Support behavior congruent to new events, stressors, and experiences Change Effects Remember our “Three E’s of Trauma?” They give a new, trauma informed purpose for planning our interventions: 1.Planning for new or future events and how to respond based on assessment information, being able to think and process in a regulated state 2. Goal is to create a new experience (changing expectations through building attachment, establishing feelings of safety, supporting regulation and other social-emotional skills) 3. To change the effects of trauma on signs and symptoms we’ve discussed (development, challenging behavior, etc.) By creating a new experience and promoting protective factors, we support matching behavior responses to appropriate situations. Refer back to effects slide that discussed traumatized children/adults having “normal response to an abnormal situation.” Helping create new experience separate from the “abnormal situation.” They may be no longer in that situation, especially when they are in your classroom, but their brain might respond as if they were. By creating new experiences, expectations, during these events, we are helping them feel safe and ultimately return to a more regulated state. This allows their responses/behavior to more appropriately match the event or reminder that typically caused dysregulation.

Resources: Building Emotional Intelligence
Discuss how resources from Day 1 that build EQ are also helpful tools to prevent/respond to challenging behavior. Feelings check in: helps you know where a child is and facilitate conversation How big is my problem: helps a child share the severity of their problem from their perspective. We know from our “Three E’s” that trauma hx and experience can change our perception of a problem, stressor, reminder etc. What may be a glitch to an adult, could be a BIG problem for a traumatized and/or dysregulated child. Zone thermometer: May be used with an older child to plan, debrief, express how they feel in each zone (emotional, physical), what reminders or events may escalate to the next level, and ideas to help support in each zone

Resources: Sesame Street
Topic specific videos with printable resources and tools for educators and families: Divorce Grief Incarceration Military Families Resilience Support After An Emergency Topic specific videos and resources. Increase awareness, identify typical responses, and strategies for support. Resiliency tool kit includes free classroom curriculum guide with social-emotional lesson plans. Take participants to this website to explore and find tools.

Resources: Trauma and Loss
The National Institute for Trauma and Loss in Children Resources for professionals and families One Minute Interventions for Traumatized Children and Adolescents Brief intervention strategies for ages 3-18 Themes: safety, worry, hurt, fear, anger, relaxation, and survivor Crisis Intervention Tips Toolkits from site include brief interventions strategies and tips for responding to trauma and loss. Sample items will be included in resource planning packets. Handout: Crisis Intervention Tips and links to referenced sites on resource list

Resources: Devereux Center for Resilient Children
Website has the free planning form resources and strategies to promote social-emotional development. Take participants to this website to explore and find tools. *Highlight FLIP IT as trauma informed strategy for validating feelings, promoting safety through appropriate limit setting, and using inquiries and prompts to redirect behavior/response Centerforresilientchildren.org

Resources: Georgetown
Teaching Tools for Young Children Taking Care of Ourselves: Stress Reduction and Relaxation Georgetown’s website is full of resources to help parents engage with children, promote their own resiliency and even look for areas of stress in their relationship with their child. Take participants to this website to explore and find tools. Ecmhc.org

Strategies: ECMH Consultant
See Sample Handout: Morning Rituals Circle Time Songs for Transitions End of Day Rituals Clearly Defined Learning Space Visual Routines Alone Time Helper Duties Labeled Praise Music Movement Social Stories Zones of Emotional Regulation Non-Verbal/Visual Cues ECMH consultation tools include strategies that promote attachment and regulation within routines that help children feel safe You have sample handouts in you folders for zones of regulation, labeled praise, creating a safe space, and good morning rituals The rest are available on trainer USB/File in Action Plan: Strategy folder

Toxic Stress to Safe Zone: Preventing Escalation
Play Teach Learn Calm Sing Prep Voice Alert Less words Step away Alarm Step Away Calm self Space Fear Stay Away Stay Calm Safety Terror Review handout, how do we prevent a child’s escalation? Any new ideas to add? Where might some of these strategies be helpful? Walk through this handout and talk about what might escalate a child and what might help regulate a child. Skill building and prevention can happen in more regulated states. As a child moves up the continuum, we are more mindful of safe space and calm demeanor to support co-regulation. There’s not much else we can do in fear/terror states but debriefing afterward, taking time for self-care, and revisiting plan/future prevention strategies is important. Ask audience to share social-emotional strategies they are already using, where do they plug them in? Example: Teaching turtle technique in calm/alert, using visuals and prompts in alarm etc. From planning activity questions: What immediate response would be helpful for behavior? What planned response might reduce behavior?

Creating a Safe Zone: Responding to Toxicity
Regulation Children are co-regulators If the adult is not regulated, the child will not be able to regulate Step Back Give Space Process after the child has calmed down Remember there isn’t much we can do once a child or adult enters terror. At this point, we are best equipped when we are able to keep ourselves calm, step away and give the person some space. Save processing for when the child/adult has calmed down! Debrief with others and revisit needed changes in planning to prevent escalation or continue skill building in more regulated states.

Using resources to practice planning
Activity 4: Using resources to practice planning Plan Break into groups select age appropriate kit(s) Review resources/strategies *Give 5 minutes to review kits

You’ve created a classroom!
(use slide animation to add children to the group as talking and end with you’ve created a classroom) 9 clicks –kids So far, we have focused on building an individual “child” but the reality is that you are educators, providers, etc. working with children. Groups of children! We know based on the ACE study and discussion of widespread impact that there’s likely not just one “child” in your setting impacted by trauma, chronic or toxic stress. There are multiple! Just like the “children” you’ve created today. With your groups, imagine that these “children” make up a classroom of students…

Share out with the larger group when finished
With your group, answer the following and document your plan using the sample form: Identify overlapping strengths and areas for growth amongst the children in your “classroom” Select a strategy or resource from your kit that could be used to prevent or respond to challenging behavior in this “classroom” How could this strategy be used in a daily routine? Share out with the larger group when finished Briefly share your “child” SNAP Look for overlaps and differences to guide planning Select a resource, strategy or response you could use for children in this classroom How does it fit into a routine? DECA planning form is one of our sample tools. Use this to document your plan and share out to large group. *Give ample time for groups to review resources, discuss, and plan. Visit with groups around the room to help plug in strategies and routines.

Action Planning Cycle: Implementation
Techniques for Implementation Teaming Approach: Regular contact for consultation between providers and caregivers Support or coach adults for implementation in the natural environment Continue to share strategies and resources with caregivers Implement Using a trauma informed approach, How might your current implementation look the same? How might it look different?

Action Planning Cycle: Evaluation
Components Repeat assessment phase interviews, questionnaires, and observations Analyze pre/post data Review and revise plan, as needed Evaluate How might your current evaluation look the same? How might it look different?

Reviewing Our Objectives…
Understand trauma & toxic stress. Learn effects on social and emotional development. Learn strategies to respond to trauma’s effect on behavior.

Reflections, Questions, and Takeaways…

Thank you for your time and attention!
Closing: Thank you for your time and attention! Please complete evaluations Special thanks to Dr. Alloy and the Whole Child Matters grant for making this training possible.

Trauma Informed Care in EC: References
Blumenfeld, S., Groves, B.M., Rice, K.F., & Weinreb, M. (2010). Children and trauma: A curriculum for mental health clinicians. Chicago: The Domestic Violence & Mental Health Policy Initiative. Chadwick Center for Children and Families (2009). Assessment-Based Treatment for Traumatized Children: A Trauma Assessment Pathway (TAP). San Diego, CA: Author. Retrieved August 17, 2010 from Center on the Developing Child (ND) Toxic Stress Response: Questions & Answers. Boston: Harvard University. Available at Cohen, E. & Walthall, B. (2003) Silent Realities: Supporting Young Children and Their Families Who Experienced Violence. Washington DC: The National Child Welfare Resource Center for Family-Centered Practice. Cook, A., Blaustein, M., Spinazzola, J., & van der Kolk, B. Eds., (2003). Complex trauma in children and adolescents: White paper. National Child Traumatic Stress Network. Retrieved July 2005 from Cooper, J.L., Masi, R., Dababnah, S., Aratani, Y., & Knitzer, J. (2007). Strengthening policies to support children, youth, and families who experience trauma: Unclaimed Children Revisited, Working Paper No.2. Retrieved August 5, 2010 from Early Promotion and Prevention Research Consortium (2008). Research to Practice: Lessons learned from interventions to address Infant Mental Health in Early Head Start. Administration for Children & Families, Health and Human Services, Office of Planning, Research, and Evaluation. Retrieved August 14, Early Trauma Treatment Network, (ND) Trauma definition. University of San Francisco. Groves, B.M. (2002) Children Who See Too Much: Lessons from the Child Witness to Violence Project. Beacon Press. Groves, B.M. (2007). Early intervention as prevention: Addressing trauma in young children in Traumatic Stress/Child Welfare. Focal Point: Research, policy,& practice in children's mental health. Winter 2007, Research and Training Center, Portland OR: Portland State University, policy & Practice. Available at

Trauma Informed Care in EC : References
Lieberman, A.F., Padron, E., Van Horn, P, & Harris, W.W. (2005). Angels in the Nursery: The intergenerational transmission of benevolent parental influences. Infant Mental Health Journal, 26, Masten, A.S. (2001). Ordinary magic: Resilience Processes in Development. American Psychologist, 56(3), National Center for Child Traumatic Stress (2010) Current and Affiliated NCTSN Organizational Members. Retrieved on August 10, 2010 from National Center for Child Traumatic Stress, Zero To Six Collaborative Group (2010) Early Childhood Trauma. Retrieved on August 23 from National Research Council and Institute of Medicine (2000). From Neurons to Neighborhoods: the Science of Early Childhood Development. Committee on Integrating the Science of Early Childhood Development. Jack P. Shonkoff and Deborah A. Phillips. Ed.s Board on Children, Youth, and Families, Commission on Behavioral and Social Sciences and Education. Washington, DC: National Academy Press. National Scientific Council on the Developing Child (2010). Persistent Fear and Anxiety Can Affect Young Children's Learning and Development: Working Paper #9. Boston: Center on the Developing Child at Harvard University. Available at National Scientific Council on the Developing Child (2005). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper #3. Boston: Center on the Developing Child at Harvard University. Available at National Scientific Council on the Developing Child (ND). In Brief: The Impact of Early Adversity on Children's Development. Boston: Center on the Developing Child at Harvard University. Available at National Scientific Council on the Developing Child (ND). In Brief: The Science of Early Childhood Development. Boston: Center on the Developing Child at Harvard University. Available at National Scientific Council on the Developing Child (2007). The Timing and quality of Early Experiences combine to Shape Brain Architecture: Working paper #5. Boston: Center on the Developing Child at Harvard University. Available at National Child Traumatic Stress Network (2008). Child Welfare Trauma Training Toolkit. Retrieved on August 20, 2010 from Osofsky, J.D. (1996). When the helper is hurting. In J. Osofsky and E. Fenichel (Eds.), Islands of Safety Washington, DC: Zero to Three. Office of Planning, Research, and Evaluation, Administration for Children and Families (2000, 2006) The Family and Child Experiences Survey (FACES). Washington DC: U.S. Department of Health and Human Services. Reports available at Rice, K. F. & Groves B.M. (2005). Hope & healing: A caregiver's guide to helping young children affected by trauma. Washington DC: ZERO TO THREE Press.

Trauma Informed Care in EC : References
Saakvitne, K., Gamble, S, Pearlman L, & Tabor Lev, B (2000). Risking Connection: A Training Curriculum for Working with Survivors of Childhood Abuse. Baltimore, MD: Sidran Press. Scheeringa, M. Personal communication on August 10, 2010 co-author of Preschool PTSD Treatment (PPT) Scheeringa, M.S. & Zeanah, C. H. (2001). A relational perspective on PTSD in early childhood. Journal of Traumatic Stress, 14(4), van der Kolk, B., Pynoos, R., Cicchetti, D., Cloitre, M., D'Andrea, W., Ford, J., Liebermann, A., Putnam, F., Saxe, G., Spinazolla, J., Stolbach, B., & Teicher, M. (2009). Proposal to include a developmental trauma disorder diagnosis for children and adolescents in DSM-V. Retrieved September 24, 2010 from van der Kolk, B. (2005). Developmental trauma disorder: Towards a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35, Van Horn, P. (2008). Children Exposed to Domestic Violence: A Curriculum for DV Advocates. Chicago: Domestic Violence & Mental Health Policy Initiative. ZERO TO THREE (2005). Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, Revised (DC:0-3R) Washington DC: ZERO TO THREE Press ZERO TO THREE (ND). FAQ's On the Brain. Washington DC: Author Retrieved on August 13, 2010 from Zindler, P. Hogan, A. & Graham, M. (2010). Addressing the unique trauma-related needs of young children. Tallahassee: Florida State University Center for Prevention & Early Intervention Policy. Retrieved August 25, 2010 from

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