Presented By Kym Asam, LICSW, QMHP November 18, 2015

Presented By Kym Asam, LICSW, QMHP November 18, 2015
Creating a Trauma Informed Learning environment within a Multi-tiered System of Supports Presented By Kym Asam, LICSW, QMHP November 18, 2015

Webinar Logistics Orient to Webinar Screen 2 Ways to Interact:
Raise your hand using the icon on your screen Type a question into the text box Intermittently we will provide opportunities to interact. This webinar will be recorded. Please note, your microphone will be muted unless otherwise indicated.

Objectives Differentiate between PTSD and developmental trauma
Understand the impact of trauma on multiple domains of functioning Understand the students’ states of arousal and how it impacts their functioning in school Key skills in working with children who have experienced developmental trauma Increase understanding of how trauma informed schools intersect with MTSS The tiered approaches are looking at interventions through the PBIS lens. 3

“Raise your hand” Have you already received some training on developmental or complex trauma?

Source: Helping Traumatized Children Learn
Grounding Principles Trauma-Sensitive Schools benefit all children – those whose trauma history is known, those whose trauma will never be clearly identified and those who may be impacted by their traumatized classmates. Schools are the Central Community for most children. Analogy – Ritalin Trauma informed systems are a universal approach to supporting students Universal approach – it benefits all children and adults as well which is critical to supporting students. The Universal approach is not stigmatizing! We will talk later about how to maximize creating this environment for students who are receiving targeted and/or intensive levels of supports Also, when we talk about interventions, they align well with PBIS and do not take considerable amount of time away from teaching. Source: Helping Traumatized Children Learn

Definitions What is trauma?
Trauma is not just the event itself, but rather a response to a stressful experience in which a person’s ability to cope is dramatically undermined. Commonly misunderstood that in order for a person to have symptoms related to trauma they should have experienced a single incident or extremely violent experiences), i.e. vets. However, research now shows that chronic exposure to stress leads to behaviors and symptoms that are a result of trauma and impact learning and functioning across all environments. The response is often one of fear, horror or helplessness 6

“Trauma is not a story of what happened to you a long time ago, it is what is in your body.”
-Bessel van der Kolk

What is Developmental Trauma?
A psychological and neurobiological injury that results from protracted exposure to stressful events Derails typical development across all domains (attachment, affect, biology, behavior, cognitive, dissociation, self-concept) Experiences often occur in the caregiving system. Impact is immediate and long term Effects will require all tiers of intervention We often work with kids who don’t fit in the PTSD mold Emphasize who complicated it is because abuse often happens in the caregiving environment RELATIONALLY REACTIVE If the primary caregiver is providing care and perpetrating abuse, increase in misattribution of human interactions and relationships occur. Increase in psychological distress during human interactions because pain is associated with human interactions. Hostile attribution bias CARD GAME – poker for 2 minutes We live with the cards we are dealt. 8

Toxic Stress Pyramid Felitti – did obesity study and examined why participants would not adhere to the regimen necessary to address their obesity. Gene expression also impacts potential for disease. Let’s talk about some of the stats ACE study, Felitti, 2014

Pervasiveness in children
Overall substantiated child maltreatment in 2013 = approximately 678,932 (746 in Vermont) Sexual Abuse = 9% (67.8% in Vermont) Physical Abuse = 18% (42.8% in Vermont) Psychological abuse = 8.7% (0.4% in Vermont) 79.5% experienced neglect (3.5% in Vermont) 48.7% were males 50.91% were females These stats are of substantiated abuse. Keep in mind that many children are exposed to chronic stressors that result in experiencing complex trauma that are either never reported or if so, not substantiated according to Child Protective Services law. So, what is the impact of trauma on children’s development? Let’s talk a little bit about the brain. Source: US Department of Health and Human Services 2013 Child Maltreatment Report 10

Sources of Trauma Sexual abuse Physical abuse Emotional abuse Neglect
Domestic Violence Neighborhood violence Torture Bullying Prolonged exposure to traumatic stress Intrauterine stress Epigenetics Epigenetics – preconception stress impacts the microenvironment of DNA and impacts egg and sperm. Microchemical construction around cells are influenced by stress prior to conception. Gene expression is influenced by intra and extra uterine environment Genes cannot be read. Kids who experience complex trauma have 4 major genes that are shut off that repair brain injury (White matter tracts) so there is less white matter in your brain Reframe – instead of why did you do that, we like to ask, what happened to you 11

Impact Areas: Acts without thinking, interrupts
Overreacts to small issues Upset by changes/ transitions Overwhelmed, easily frustrated Resists change or tasks that are not interesting Does not notice the impact of their behavior Does not see their part in problems Easily over-stimulated, difficulty calming down Forgetful, loses things, disorganized Loses steam quickly, cannot sustain on challenging tasks

7 domains of impairment Biology and the brain
Attachment and relationship Cognition and learning Emotional regulation behavior dissociation Self-concept Biology and the brain. Some overlap of domains and functioning

The brain develops from the bottom up
Neocortex Limbic Diencephalon Brainstem The brain develops from the bottom up Cortex Limbic Diencephalon Brainstem Cerebral Cortex Prefrontal Cortex The brain begins to develop in utero. It is the only organ in the body that is incomplete at birth. By the second trimester, the brain stem if fully developed and the brain continues to develop throughout the gestation period. There is a four-year period of "potential" growth, which is the most critical period of human development. This time is from conception until about the third birthday. We have 10 billion neurons at birth. 85% of synaptic connections are made by 3 ½ The prefrontal cortex is not fully developed until a child is between 25 and 30. (Brandon) Adolescents lose 30,000 synapses per second resulting in 50% of the average number of synapses per cortical neuron before adolescence Show neuron slide Limbic Diencephalon and the inside out Brain Stem

Neocortex Limbic Diencephalon Brainstem Abstract thought
Concrete Thought Affiliation "Attachment" Sexual Behavior Emotional Reactivity "Arousal" Appetite/Satiety Blood Pressure Heart Rate Body Temperature Sleep Motor Regulation Bruce Perry is the architect of the NeuroSequential Model of Therapeutics which examines brain development and the impact of trauma. Different part of the brain are responsible for different functions Normal development of the neuronal systems and the functions they mediate requires specific patterns of activity—specific signals—at specific times during development. So what does that mean? Talk about holding a baby. Dyadic brain, serotonin and dopamine production, coo, smile, look ridiculous, – mirror neurons show still face experiment video. What if we don’t have a mirror or our mirror is hostile and negative? Our interactions help us learn to self-regulate. Baby pheromones suspend the emotional/feeling of disgust Dopaminergic reward related brain regions are activated and the reward center lights up when you make eye contact with a baby – they are simultaneously activated. Show brain builders video All rights reserved © Bruce D. Perry and The ChildTrauma Academy

The still face experiment
Mirror neurons – when mirror neurons fire, we do the same thing as what we are seeing. They also us to have theory of mind – thinking about what other people are thinking Ask audience – have you ever seen someone lose balance and you adjust your own balance in response? Babies need help with co-regulation Ask – what happens if we don’t have a mirror or if our mirror is hostile or negative -- what if we take same baby and express displeasure or ignore it Adverse experiences are remembered neuroanatomically Talk about language acquisition device – foreign language – specific patterns or signals as specific times

Impact of Neglect on the Brain
Hypofrontality Also corpus callosum which is the white matter tract that links the left and right brain hemispheres is smaller in children who have experienced complex trauma. Optimal development of more complex systems requires healthy development of less complex systems Bucharest experiment

Bottom up, Inside out Start talking about what we know about these kids Refer to handout of potential challenges Children with underdeveloped prefrontal cortex often present as disruptive and unsettling bx. They do no have the neurobiological structure necessary to self-regulate Many students with learning disabilities around language and processing Significant discrepancy b/w verbal and performance IQ They often have an impaired working memory – hard to put thoughts from mind to paper High resting heart rates

Stages of Sleep Kids who have experienced complex trauma break through the awake line during REM sleep – mind is most active, body is most at rest Sleep latency and sleep disruption. These kids are exhausted. Sleep helps us clean out toxins between cells in the brain Review – learning challenges not always detected during special ed process or they do not meet gates, high resting heart rates, poor sleep and we want them to learn.

Effects of Trauma on Brain Functioning
Thalamus Visual, auditory, olfactory, kinesthetic, gustatory Prefrontal Cortex (Integration and Planning) Amygdala (Intensity/significance) Hippocampus (cognitive map) We receive information visually, auditorally, etc., through the thalamus amygdala measures the intensity or evaluates the emotional meaning of the incoming stimuli (experience) h hippocampus maps the information or helps our brain evaluate and categorize it. It compares stimuli/experiences to others and sends the information to the prefrontal cortex which integrates the information and plans accordingly. Developmental trauma alters the anatomy and physiology of the hippocampus and the brain’s pleasure center. If the hippocampus is compromised, its activity is decreased and the event and significance gets “stuck” in the amygdala. High levels of amygdala stimulation interferes with hippocampus functioning and therefore the capacity evaluate and categorize information is inhibited. Brain is use dependent – the more a part of the brain is used, the “bigger it becomes” The more a neurobiological system is activated, the more the state (and the functions associated with it) become built in. For example, memorizing a poem, riding a bike, staying in a state of fear. State vs. Trait – state is easier to change, trait is harder Skiing example What do you think happens if you are in a constant state of arousal? Tired, depressed, agitated, irritable, etc. Kids struggle with stimulus discrimination and have a hard time focusing concentrating and can be difficult Good news – the brain is plastic --cortex most plastic, -- brain stem least plastic – Gabby Giffords

Building up from the base
Establish State Regulation -- Intensive School staff can be thinking about short, predictable, repetitive, patterned interactions throughout the day which would include: Touch Rhythmic activities (rocking) Eye contact drumming Respond to physiological cues. A child’s heart rate is a great indicator of levels of arousal (low end 80, high end 120). When interacting become an affective co-regulator for the child. Brainstem Blood pressure, heart rate, body temperature and sleep. REFLEXIVE – Intensive You will need a team to develop bx plans – some of which will need to include somatosensory interventions. Mental health involvement is critical here. In order to support regulation, you will have to provide interventions that replicate the body’s natural rhythms. Again, these are good for all kids, but you need to be more intentional with kids who are receiving tier 3 supports. Someone will need to coordinate this plan – very individualized. Comprehensive preference assessment as part of the FBA needs to be done to determine appropriate, rewarding interventions. BIP – Behavior Intervention Plans Family involvement!!!!! OT/PT – thorough evaluations! Be willing to do everything including letting go of your own agenda!!!! Premack principle – more spontaneous rewards – kids have impaired reward neurobiology Bruce Perry (2006)

Introduce Somato-Sensory Integration – targeted, intensive Diencephalon Large motor and fine motor Music and movement Sensory stimulation Predictable routines (eating, transitions, sleeping) Consider beginning the day with predictable, structured, patterned, rhythmic music and movement activities. Studies have indicated that children have increased self-regulation throughout the day when sensory integration occurs early. Remember that the brain fatigues after 7 minutes. Bruce Perry (2006) What is the cognition state? Reactive – Most likely intensive Motor regulation, appetite satiety, arousal, integration of multiple sensory inputs 50/50 rule of instruction – 50% teaching, 50% processing. These kids benefit considerably from movement to remember and learn. The earlier you introduce movement, the more likely they will be able to self-regulate and learn. Kids who have experienced complex trauma need it the most often.

Facilitate Socio-emotional Growth – targeted Limbic Turn-taking Team play Win & lose Sharing Consider that social development is a progression and the ability to form satisfying reciprocal interactions may depend on backing up and purposefully creating opportunities for parallel play or learning opportunities in a dyad with an adult and then a dyad with a peer before group play or group learning will be successful. Bruce Perry (2006) What is the cognition state? Concrete Emotional reactivity, sexual bx, attachment Consider backing things up here to promote parallel learning vs. competitive learning. These kids need control, so give it to them while learning –i.e., maybe they lead the class or activity.

Encourage Abstract Thought – Universal Humor Language Art Games Conflict resolution, problem solving Self-development and identity Self-esteem Children who have foundational skills will be able to utilize their prefrontal cortex successfully. However, for children with disrupted or traumatic early experiences, adults will need to emphasize the earlier skills. Remember, stage not age. Cortex Bruce Perry (2006) What is the cognition state? Abstract Abstract thought, affiliation, reward, socioemotional regulation The goal is to help kids strengthen the parts of their brains that were impaired by developmental insults so they can access their cortex more regularly to learn and they can benefit from universal interventions like their neurotypical peers. 50/50 rule – brains have limited working memory and need time to recycle proteins and glucose and to consolidate new learning at the synapse and create connections. Learning needs similarity, amount and strength

Potential Interventions: Think about brain regions
Music and Movement Yoga Somatosensory Parallel play/learning Touch Rhythmic Patterned Eye Contact Drumming Body-based

Do you use movement when working with students?
“Raise your hand” Do you use movement when working with students?

Attachment and relationship Cognition and learning Emotional regulation behavior dissociation Self-concept

4 Key Principles of Attachment
Build school staff capacity to manage affect Build school staff-child attunement Build consistency in school staff response to child behavior Build routines and rituals into classroom and school While attachment is critical to all tiers of support, we think of this most often with kids who are receiving intensive services. When pain is associated with human interactions, they have increased psychological distress during relational interactions. Co-regulation or co-disregulation – this is where the role of adults is critical – oxygen analogy and non-verbal communication Sitting, humming, rocking, proxemics Reward neurobiology – reward vacuum – need repetition Rewards last less time and has less intensity Coregulation (sometimes it is non-verbal Manage affect is how we respond to students Attunement is joining with students – mirror their affect to a certain degree.

Healthy Attachment Sequence
Physical or psychological need Security, trust, attachment, self-regulation, object constancy Relaxation (parasympathetic ANS) State of high arousal Baby crying registers close in brain where pain registers Nursing – pause and make eye contact, pauses become longer. Pauses stop if no eye contact is made. Attunement/satisfaction of need Beverly James

Unhealthy Attachment Sequence
Physical or psychological need Shame, mistrust, disregulation, disturbed mental blueprint Anxiety, rage, numbing State of high arousal Needs are disregarded/attunement disrupted Beverly James

Affect Management When caregivers modulate their own affect and emotional responses, they can create an emotionally safe environment in which children a can learn Change adult behavior to change children’s behavior – oxygen mask Co-regulation and disregulation are possible

Attunement Reading and responding to the cues of another
Synchronous and interactive Helps prevent mismatch between need and provision Reading the non-verbal, social-emotional “language” of another

Attunement

CONSISTENCY EVERY DAY EVERY GRADE EVERY BODY
Somatosensory interventions are those that address the body, affect and senses. Pbis builds consistency, routines and rituals. Every day, etc. is aligns with PBIS – we know that implementing with fidelity is key to efficacious results. We also know that we need to include all school staff including ancillary staff like bus drivers. Address thinking and body based approaches – top down and bottom up. Universal = top – cortex Targeted = both Intensive = bottom up and body based approaches Know when developmental insults occurred is best ways to tailor interventions. However, all somatosensory interventions can be helpful to all students and adults. If children have experienced very early developmental insults, interventions should be targeted toward the brain stem. For example rocking, yoga, horseback riding, massage, repetitive breathing activities, movements (Tai Chi, Marshal Arts), drumming, swimming, bilateral stimulation, animal assisted therapy– all interventions that help the body regulate and engage the para-sympathetic nervous system. Utilize during transitions, to start the day, consistent, consistent, consistent! Routine, routine, routine You want to match the nature and timing of the activities and techniques to the developmental stage and brain region. Good news is that when targeting the brain stem, you can do no wrong.

Routines and Rituals Routines increases predictability and the child’s ability to anticipate next steps. Establishing classroom and school-wide routines helps reduce trouble spots (transitions, substitute teachers, unstructured activities/days).

Targeting the Tiers, PBiS approaches
Intensive Brain stem/diencephalon Targeted Limbic In thinking about kids who are receiving tier 2 and 3 levels of support, it is helpful to conceptualize the parts of the brain that is most likely needing interventions to change responses. Remember, kids who are hyperaroused inhibit impulses with the limbic parts of their brain and automaticity is difficult due to working memory challenges, poor sleep, etc. Kids at universal level can cortically modulate Kids at targeted level need more assistance with co-regulation Kids at intensive level need assistance at the lower parts of the brain Let’s talk more about what to do? Cortex Universal

“No matter how exciting and meaningful and supported the learning experience is designed to be, a child cannot reap the cognitive benefits of it unless she feels calm enough to be curious.” (McMahon, 2011) Ask audience what images and words are conjured up when they think of the word curiosity? In brief executive functioning skills for life – harvard film Language acquisition device – neural connections and the funcitons they mediate need specific patterns of activity at specific times. Working memory is in limbic region of the brain Hard to cortically modulate when focusing on survival Black and white thinking (per Dave) Focused on survival vs. curiosity

Developmental Agenda Praxis is the ability to have an idea, plan for execution and execute idea. Dyspraxia is when the sequence breaks down. Kids who have experienced developmental trauma are often harshly punished for their praxia. Play is complicated – think about all you need to negotiate to play well Kids who have experienced DT are often harshly punished for their praxia. Skills needed for survival took precedence over some developmental skills like play Just as we learn from play we can heal from play – curiosity is key!

Do you have a morning, coffee routine?
“Raise your hand” Do you have a morning, coffee routine?

From Helping the Traumatized Child Learn
Sequential Thinking A child’s successful completion of many academic tasks depends on the ability to bring a linear order to the chaos of daily experience. Traumatic experience can limit this ability to organize material sequentially, leading to difficulty in reading, writing and communicating verbally. From Helping the Traumatized Child Learn IQ discrepancy Working memory is compromised Sequential thinking Think about trying to make a pot of coffee and the steps it takes. Now think about trying to do that when the toaster is also on fire. Where are you going to focus your attention? Universal interventions help put out fires. Kids will also need targeted and intensive supports but without a solid universal foundation, the other tiers will not work.

Competency 3 Key Principles
Build student executive functioning skills Target self-development and identity Target additional key developmental tasks The child develops an ability to evaluate situations, inhibit impulsive responses and actively make choices. Overarching goal is to build the foundational skills needed for healthy ongoing development and resiliency Doable tasks Islands of competency Sports Music Theatre Yoga Academics Marshall arts The child develops an ability to evaluate situations, inhibit impulsive responses and actively make choices.

MTSS FEW SOME ALL Anger Mgt. Math Science Adult Relationships
(Intensive) Math (Targeted) Science Adult Relationships Remind audience that all students have areas of competence and it is our job to notice it. If we manage our affect and attune to students, we can find and build on their competencies. Attendance (Universal) Reading Peer Interaction

Competing Demands Survival vs. learning
It is nearly impossible to dedicate your full attention and energy to survival and learning at the same time.

Potential interventions
General strategies Facilitating sequential thinking Multi-modal learning Regulate to educate Build on competencies Multiple motor breaks Brain breaks Differentiated instruction/Differentiated Discipline To do lists Visual schedules Repeat directions (tone of voice) Give notes None of these are radically different from any teaching method you might use, however, you must consider these interventions through a trauma informed lens.

Attachment and relationship Cognition and learning Emotional regulation behavior dissociation Self-concept Should call it affect regulation Affect is the presentation and emotion is the body or internal feeling

Normative Danger Responses Autonomic Nervous Response System
Fight Flight Freeze Flock The parasympathetic nervous system (PSNS) is one of the two main divisions of the autonomic nervous system (ANS). The ANS is responsible for regulation of internal organs and glands, which occurs unconsciously. The parasympathetic system specifically is responsible for stimulation of "rest-and-digest" activities that occur when the body is at rest – the brakes. Sympathetic is responsible for FFFF – the accelerator. Again, the more a neurobiological system becomes activated, the more the functions associated with it become built in. Traumatized children continue to show physical symptoms of fear in the absence of threatening stimuli and can be triggered by seemingly benign stimuli (take out your book). Relational Poverty – reward neurobiology is impaired for relationships and other rewards. Praise lasts less amount of time and has less intensity. Les sensitive to + affect and more responsive to neutral and negative affect. Developmental trauma interferes with the parasympathetic system’s capacity to function. Hard wired to see danger

Recognizing Affect – Emotional Identification
Masten, et al 2008

Facial Expression Recognition
Kids who experienced developmental trauma see scared and sad as angry – often misperceive non-verbal communication Perception is more important than reality They are constantly protecting themselves from danger and see non-verbal communication (interoceptive as well) before you know you have communicated.

As you move down the arousal continuum, you move down to more primitive parts of the brain
The first checkpoint for danger is the brain stem and then it moves to the cortex – hot stove example It is neurologically disrespectful to think these kids can think their way out of danger Use limbic regions to inhibit their impulses instead of cortically modulating It takes between 15 – 20 minutes to become calm after being hyperaroused. Sometimes external can appear calm but internal is not. Spider example? Three components of learning. Regulation is interdependent

Impact Areas It is often not the task or request that leads the child to misbehave… it is the feeling and negative thoughts that is evokes… Implicit memories

Potential Strategies Movement Mindfulness Non-verbal communication
Reflectively listen Validation Shhhhh Attunement Match affect without replication Do mindful eating Validation does not mean acceptance Hand-out reflective listening activity – good strategy to use and teach Have audience do reflective attunement activity with hand-out

What do you see and why? What are these kids doing? Why?
We all manipulate our environment to be safe.

Key Triggers Lack of power or control Unexpected change
Feeling threatened or attacked Feeling vulnerable or frightened Feeling shame And… Relationships – even positive ones Intense feelings of any kind When your template for adults is one where adults are unpredictable, dangerous and inconsistent, then you are likely to behave in ways that prevent adults from hurting you. Spider example.

Attention vs. Relationship

But…what about consequences?
Relational and relevant Restorative and reparative All actions have a consequence. Consequences tend to be viewed as punitive and needing to be punitive. Think about using relationship when imposing consequences. Be sure the consequence is relevant to the behavior or action. If there is property destruction, then consider having client repair the damage. If it is relational damage, consider restorative practices.

Potential interventions/considerations
Behavior is about survival Function AND feeling behind behavior Skill deficit Validation/attachment/comfort seeking vs. attention seeking or manipulative Focus on connection, not consequence Connect, rupture, repair Ritualize transitions (with movement) Evaluative process (even praise) can create defensiveness Remember where they are likely in their brain

Intervention strategies, continued.
Movement Routines and rituals Structure Supervision Small world Stage not age Push the pause button Somatosensory interventions Targeting the part of the brain that was impacted by developmental insults Neuroplasticity – brain stem is least plastic – Gabby giffords Marathon example – train vs. sports psychologist – you need to practice

More Intervention strategies
Incorporate body-based, multi-sense teaching Co-regulation activities Maintain a bond with child during discipline Focus on connection, not consequence Connect, rupture, repair Validation + empathy= Accountability Focus on choice and the function AND feeling of behavior Teach perspective taking and social skills Ritualize transitions (with movement) © NFI Vermont 2012

Repeat, Repeat, Repeat! Patterned Consistent More intensity Curiosity
Experience + Repetition = Learning/Memory “the country with many roads” analogy (Helgeson, 1997 Patterned, consistent interventions must be more intense that previous experiences in order for new learning to occur New learning interferes with old learning but takes time You must remain in a stance of curiosity and non judgment because kids do not know why they are responding in the way they do.

Helpful Reframes: Child Says: Student Believes:
“this is stupid” “I am stupid” “I can’t do this” “I am powerless” “You’re an ______ “ I am not safe” “why do you always…” “ I am to blame” “I’m outta here” “ I am overwhelmed” “I won’t do this” “ I can’t do this” “You can’t make me” “I need to protect myself”

Possible Collision Points at School
Schools focus on preparing children for and information related to the external world Students with DT focus on the present and internally to stay safe. Much of school is motivated by connection and participation with others Schools often use delayed gratification Students with DT are focused on the present to stay safe. Delaying gratification is dangerous and unpredictable. Teachers often set limits/goals for the common good Youth with DT don’t operate with a template that understands the common good.

Alignment: Trauma informed and PBIS
Consistency and predictability Repetition Attachment and attunement Affect management Regulate to educate Neurologically respectful Clinical differentiation Routines and Rituals 80% buy in, implementation with fidelity, common language (expectations) Practice in all settings, repetitive and patterned, teaching matrices, coaching support Repetition 6-8:1(again), rewiring (neurologically respectful), relational/attachment, creating safety (hostile attribution bias), CICO, TCCE Differentiating between major and minor behaviors, classroom management, avoiding emotionally laden praise, “The expectation is…” Predictability of PBIS allows for more flexibility, students and staff need to be regulated (attunement), non-verbal communication Precorrections, attunement (paying attention to the positive), multi-modal learning, transitions teaching Explicit teaching, multi-modal learning, tiers (building upon interventions depending on tiers) Acknowledgement system, celebrations (school-wide and classroom), teaching matrices, etc.

Questions????? 78

Presented By Kym Asam, LICSW, QMHP November 18, 2015

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