The participant will understand:
 Sources of potential trauma and complex trauma for individuals served by child serving systems.
 Impact of trauma on emotional and behavioral functioning
 Principles of trauma-informed systems.
 Ways to decrease the possibility that those seeking services and staff experience trauma.




“an emotional shock that creates significant and lasting damage to a person’s mental, physical and emotional growth.”
Traumatic experiences can significantly alter a person’s perception of themselves, their environment, and the people around them. In effect, trauma changes the way people view themselves, others and their world.
Can impact safety, well-being, permanence.

This is Anna at age one.
This is Anna years later – in a mental institution.
What happened?

 Over 90% of mental health clients have trauma histories
 In state hospitals, estimates range up to 95%
 90% or more of women in jails and prisons are victims of physical or sexual abuse
 Up to 2/3 of men and women in substance abuse treatment report childhood abuse or neglect
 Similar statistics exist for foster care, juvenile justice, homeless shelters, welfare programs, etc
 Boys who experience or witness violence are 1000 times more likely to commit violence

 Children & women
 American Indian/Alaska Native
 Veterans
 Refugees and immigrants
 People who are homeless
 People who are institutionalized in mental health or criminal justice systems




Annual Direct Costs: Hospitalization, Mental
Health Care System, Child Welfare Service
System, Law Enforcement = $33,101,302,133.
Annual Indirect Costs: Special Ed, Juvenile
Justice, Mental Health & Health Care, Criminal
Justice System, Lost Productivity =
$70,652,715,359.
Total Annual Cost: $124 billion.
Economic Impact Study. (September, 200
8
). Prevent Child Abuse America

 NOT a diagnostic category
 There is no universal definition of trauma. It is defined by the person who has had the experience.
 An experience or series of experiences that elicits feelings of terror, powerlessness, & out-of-control psychological arousal; result in survival driven behaviors, thoughts, emotions, & needs.

 Often misinterpreted & assigned as symptoms of disorders (depression, Bipolar
Disorder, ADHD, Oppositional Defiant
Disorder, Conduct Disorder, Attachment
Disorder, etc.)
 These diagnoses generally do not capture full extent of developmental impact of trauma.

Exposure to Trauma
Trauma can be:
• A single event
• A connected series of events
• Chronic lasting stress
Trauma is under-reported and under-diagnosed.
(NTAC, 2004)










Loss of a loved one
Abandonment
Accidents
Homelessness
Community/school violence
Bullying, including cyber-bullying
Domestic violence
Neglect
Frequent moves








Serious medical Illness
Physical abuse
Sexual abuse
Emotional/verbal abuse
Man-made or natural disasters
Witnessing violence
Terrorism
Refugee and War Zone trauma.

Types of Trauma
A single traumatic event that is limited in time.
Acute
Trauma
The experience of multiple traumatic events.
Chronic
Trauma
Complex
Trauma
Vicarious
Trauma
System
Induced
Trauma
Both exposure to chronic trauma, and the impact such exposure has on an individual .
The traumatic removal from home, admission to a detention or residential facility or multiple placements within a short time.

Trauma can occur at any age .
Trauma can impact anyone .

Bridging the gap between childhood trauma and negative consequences later in life.
50% of study participants reported at least one adverse childhood experience
25% reported at least two or more untreated trauma

4 or more traumatic experiences shorten life expectancy by 20 years
Immune
Diseases
Cancer
Heart
Disease
Adverse
Childhood
Experiences
Chronic
Lung
Disease
Liver
Disease
Diabetes

4 or more traumatic experiences shorten life expectancy by 20 years
Mental
Illness
Suicide
Relationship
Problems
Adverse
Childhood
Experiences
Substance
Abuse
Poor Self-
Esteem
Behavior
Problems

 Adults with ACE score >4 are 460% more likely to have lifetime history of depression.
 Adults with ACE score >5 are 16 times more likely to have lifetime history of alcoholism.
 Male child with ACE score of 6 has 4,600% increase in likelihood of later becoming IV drug user.

Can cause impairments in many areas of development & functioning, including:
 Attachment – Difficulty relating to & empathizing with others; believe the world to be uncertain & unpredictable
 Biology – problems with sensation & movement, including hypersensitivity to physical contact & insensitivity to pain; physical symptoms & increased medical problems

 Mood Regulation – difficulty identifying & controlling emotions & internal states
 Behavioral Control - poor impulse control, self-destructive behavior, aggression, risk taking behavior
 Dissociation – feeling detached, as if observing something happening to them that is not real

 Cognition – difficult focusing & completing tasks or anticipating future events; learning difficulties & problems with language development
 Self-concept – feeling shame/guilt; low self-esteem, disturbed body image
 Loss & Betrayal - loss of part(s) of their life; distrust of others
 Powerlessness – perceive self as victim; have no say in what happens to them; unable to control their lives, etc.




Has serious consequences for normal development of children’s brains, brain chemistry & nervous system.
Trauma-induced alterations in biological stress symptoms can adversely effect brain development, cognitive & academic skills, & language development.
Result in increased levels of stress hormones
(impacts response to future stress)

 Affects “cross-talk” between brain’s hemispheres, including parts that:
 regulate emotions
 manage fears, anxieties & aggression
 sustain attention for learning & problem solving
 control impulses & manage physical responses to danger
 allow realistic appraisal of danger & safety
 promote consideration of consequences of behavior
 allow ability to govern behavior & meet longer term goals




People of different cultural, national, linguistic, spiritual & ethnic backgrounds may define & describe “trauma” differently
Assessment of trauma history should always take into account cultural background & modes of communication of assessor and family
Strong cultural identify & community/family connections can contribute to strength & resilience or can increase risk for & experience of trauma.




Child traumatic stress reactions vary by developmental stage.
Children with traumatic experiences may spend much energy responding to, coping with, & coming to terms with the experience – results in delays in mastering age-appropriate developmental tasks – delayed development
The longer traumatic stress goes untreated, the farther children tend to stray from appropriate developmental pathways.

 The impact of a potentially traumatic event depend on
 Individual’s age & developmental level
 Individual’s perception of the danger faced
 Whether the individual was victim or perpetrator
 Individual’s relationship to victim or perpetrator
 Individual’s past experience with trauma
 Adversities the individual faces following the trauma
 Presence/availability of others who can offer help/support/protection

Seeing, feeling, hearing, smelling something that reminds us of past trauma
Activates the alarm system…
The response is as if there is current danger.
Thinking brain automatically shuts off in the face of triggers.
Past and present danger become confused.

We all have buttons that can be pushed…

Trigger
Non-
Trauma
Informed
Response
Negative
Outcome
Trigger
Trauma
Informed
Response
Positive
Outcome

Protective
Factors
• Parental/caregiver resilience
• Social connections
• Knowledge of parenting and child development
• Concrete support in times of need
• Nurturing and attachment/social and emotional competence of children

Karen Saakvitne

TRAUMA INFORMED PRACTICE
Trauma Informed
Recognition of high prevalence of trauma
Non-Trauma Informed
Lack of education on trauma prevalence & “universal” precautions
Recognition of primary and cooccurring trauma diagnoses
Assess for traumatic histories & symptoms
Over-diagnosis of Schizophrenia &
Bipolar D/O, Conduct D/O & singular addictions
Cursory or no trauma assessment
Recognition of culture and practices that are re-traumatizing
“Tradition of Toughness” valued as best care approach

TRAUMA INFORMED PRACTICE
Trauma Informed
Power/control minimized - constant attention to culture
Non-Trauma Informed
Keys, security uniforms, staff demeanor, tone of voice
Caregivers/supporters – collaboration
Address training needs of staff to improve knowledge & sensitivity
Rule enforcers – compliance
“Patient-blaming” as fallback position without training
Staff understand function of behavior (rage, repetitioncompulsion, self-injury)
Behavior seen as intentionally provocative

TRAUMA INFORMED PRACTICE
Trauma Informed
Objective, neutral language
Transparent systems open to outside parties
Non-Trauma Informed
Labeling language: manipulative, needy, “attention-seeking”
Closed system – advocates discouraged
( Fallot & Harris, 2002; Cook et al., 2002, Ford, 2003, Cusack et al., Jennings, 1998, Prescott, 2000)

Trauma Informed Systems
Presume that every person in a treatment setting has been exposed to abuse, violence, neglect, or other traumatic event(s).
“What has happened to you?”

Carl Bard

How people cope with trauma determined by:
 How they experience what they are exposed to
 Who they were exposed to in their traumatic past
 What they are exposed to in the present environment

Trauma-Informed Care provides a new paradigm under which the basic premise for organizing services is transformed from
“
What’s wrong with you?”
“
What happened to you?”
41

S
S
C
E
S
U
C

John is a 16 year old boy who, with his younger brother, was placed in DHHR custody at age 5 as a result of parental abuse/neglect. He has been in multiple placements, including numerous foster homes, residential care in all levels, psychiatric inpatient care on multiple occasions. He has been been kicked out of all levels of care for disruptive behavior. He was diagnosed with ADHD, conduct disorder, bipolar disorder, and substance abuse. He was placed in detention for physical aggression/ assault. He has been in outpatient care several times, and is now court ordered to outpatient care again. His intake assessment was being done by his previous outpatient therapist. He got angry during the intake and stormed out of the office and agency.

When an agency takes the step to become trauma-informed, every part of its organization, management & service delivery system is assessed & potentially modified to include a basic understanding of how trauma impacts the life of individuals seeking services.
45

Trauma-informed organizations, programs, & services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services & programs can be more supportive and avoid retraumatization.
46

Provides the foundation for a basic understanding of the psychological, neurological, biological, and social impact that trauma and violence have on many individuals.
Incorporates proven practices into current operations to deliver services that acknowledge the role that violence and victimization play in the lives of most of the individuals entering our systems.
47

 The provision of “trauma-informed care” is a seminal concept in emerging efforts to address trauma in the lives of children, youth and adults.
 In a trauma-informed system, trauma is viewed as “a defining and organizing experience that forms the core of an individual’s identity.”
Source: Harris, M. and Fallot, R.D. (Eds), 2001

 Understanding of Trauma
 Understanding of the Consumer/Survivor
 Understanding of Services
 Understanding of the Service Relationship

 Traumatic events are not rare ; experiences of life disruption are pervasive and common
 The impact of trauma is seen in multiple, apparently unrelated life domains
 Repeated trauma is viewed as a core life event around which subsequent development organizes
 Trauma begins a complex pattern of actions and reactions which have a continuing impact over the course of one’s life

 An integrated, whole person view of individuals and their problems and resources
 “Symptoms” are understood not as pathology but primarily as attempts to cope and survive ; what seem to be symptoms may more accurately be solutions
 A contextual, relational view of both problems and solutions
 Appropriate and collaborative responsibility allocation

 Primary goals are empowerment and recovery
 Survivors are survivors; their strengths need to be recognized
 Service priorities are prevention driven
 Service time limits are determined by survivor selfassessment and recovery/healing needs
 Risk to the consumer is considered along with risk to the system and the provider

 A collaborative relationship between the consumer and the provider of her or his choice
 Both the consumer and the provider are assumed to have valid and valuable knowledge bases
 The consumer is an active planner and participant in services
 The consumer’s safety must be guaranteed and trust must be developed over time

 Safety : Ensuring physical and emotional safety
 Trustworthiness : Maximizing trustworthiness, making tasks clear, and maintaining appropriate boundaries
 Choice : Prioritizing consumer choice and control


Collaboration : Maximizing collaboration and sharing of power with consumers
Empowerment : Prioritizing consumer empowerment and skill-building






Maximize one’s sense of security
Assist individual in reducing overwhelming emotion.
Help individual make new meaning of trauma history & current experiences.
Address impact of trauma & subsequent changes in one’s behavior, development & relationships.
Coordinate services with other agencies/systems.

 Utilize comprehensive assessment of trauma experiences & their impact on development & behavior to guide services
 Support & promote positive & stable relationships in the life of the individual.
 Provide support & guidance to the individual’s family & caregivers.
 Manage professional & personal stress.

Robert Frost

 Trauma-informed care refers not only to the recognition of the pervasiveness of trauma, but also to a commitment to identify and address it early, whenever possible.
 Numerous assessment/diagnostic issues complicate the identification & treatment of trauma.

Screening Assessment

 Questions about trauma should be part of the routine mental health intake, with parallel questions posed to a child’s parent or legal guardian.
 Screening and assessment for trauma should occur also in juvenile justice and out-of-home child protection settings as well.
 Assessment for trauma exposure and impact should be a routine part of psychiatric and psychological evaluations, and of all assessments that are face to face.
Hodas 2004

Three basic approaches to assessment of trauma and post-traumatic sequelae through tools and instruments:
 Instruments that directly measure traumatic experiences or reactions
 Broadly based diagnostic instruments that include PTSD subscales
 Instruments that assess symptoms not trauma specific but commonly associated symptoms of trauma
Wolpaw & Ford 2004




Identification of PTSD or sub-threshold PTSD symptoms is complicated by the fact that these symptoms mimic symptoms of anxiety and depression
Many individuals with PTSD also abuse alcohol and drugs
If trauma screening isn’t conducted, these individuals are usually treated as people with just depression, or just anxiety, or just AOD

Begin Initial Screening Process
Assess Through Clinical Interview & Standardized
Measures (Trauma History Crucial)
Integrate Assessment Information and
Form Unique Client Picture
Narrow Clinical Focus Select Symptom Domains &
Identify Treatment Priorities
Identify Appropriate Treatment

 Individual is exposed to traumatic event in which:
 They experienced, witnessed, or were confronted with event/events that involved actual or threatened death or serious injury to themselves or others
 Response to event included intense fear, helplessness, or horror
 Combat-related PTSD vs. non-combat related






Reexperiencing the traumatic event (nightmares, intrusive memories, flashbacks, etc.)
Intense psychological or physiological reactions to internal or external cues that symbolize or resemble some aspect of the original trauma
Avoidance of thoughts, feelings, places, 7/or people associated with the trauma
Emotional numbing (detachment, estrangement, loss of interest in activities, etc.)
Increased arousal (heightened startle response, sleep disturbance, irritability, etc.)

 Trauma Symptom Checklist for Children (TSCC)
 Trauma Symptom Checklist for Young Children
(TSCYC)
 Child Sexual Behavior Inventory (CSBI)
 UCLA PTSD Index for DSM-IV
 Chadwick Center Trauma History Checklist

 Trauma Assessment for Adults (TAA)
 PTSD Checklist for Adults (PCL-A)
 UCLA Adult PTSD Scale
 Traumatic Events Screening Inventory (TESI)

Is alcohol/substance abuse a desperate attempt at selfhealing?
(Felitti, et al, 1998)

Ste 1
Screening Questions for Mental Health
 Have you ever been worried about how you are thinking, feeling, or acting?
 Has anyone ever expressed concerns about how you were thinking, feeling, or acting?
 Have you ever harmed yourself or thought about harming yourself?
Screening Questions for Substance Abuse
 Have you ever had any problem related to your use of alcohol or other drugs?
 Has a relative, friend, physician, counselor, or other person been concerned about your drinking or other drug use or suggested that you cut down or stop drinking/using?
 Have you ever said to another person, “No, I don’t have an alcohol or drug problem,” when you questioned yourself and felt, maybe I do have a problem?
Screening Questions for Trauma
 Have you ever been hit, kicked, choked, or received a more serious punishment from a parent or other adult?
 Has anyone ever touched you in a sexual way or made you touch them when you did not want to?
 Have you had an experience that was so frightening, horrible, or upsetting that you have nightmares, upsetting thoughts or memories that come to your mind against your will or have bodily reactions (felt numb or detached from others/surroundings, been constantly on guard/watchful or easily startled, fast heartbeat, stomach churning, sweatiness, dizziness, etc.) when you are reminded of the event?

 Services designed specifically to address violence, trauma, and related symptoms and reactions.
 The intent of the activities is to increase skills and strategies that allow survivors to manage their symptoms and reactions with minimal disruption to their daily obligations and to their quality of life, and eventually to reduce or eliminate debilitating symptoms and to prevent further traumatization and violence.

 Characteristics of trauma-informed services
 Incorporate knowledge about trauma—prevalence, impact, and recovery—in all aspects of service delivery
 Hospitable and engaging for survivors
 Minimize re-victimization (particularly use of restraint & seclusion)
 Facilitate recovery and empowerment

 Trauma Focused Cognitive Behavioral
Therapy (TF-CBT)
 Dialectical Behavioral Therapy (DBT)
 Parent-Child Interaction Therapy (PCIT)
 Abuse-Focused Cognitive Behavioral Therapy
(AF-CBT)

 Make your environment, policies, procedures and interactions are empowering, collaborative, safe, and respectful.
 Include trauma survivors as evaluators, informants, and members of your team.
 Ensure that staff trauma is also a part of your plan.
74

Staff also experience symptoms of trauma.
 Use clinical supervision – consult with others about concerns/approaches


Peer support – not just for service recipients; find agency/peer trauma champions; let survivor be the champion on themselves
Be aware of burnout, compassion fatigue, secondary/vicarious trauma – contribute to non-trauma informed care





Conduct an organizational readiness assessment to evaluate specific criteria related to traumainformed care.
Include clients/consumers/patients in evaluation
& planning
Develop an organization plan that includes:
 Leadership buy-in
 Policy development
 Staff training/supervision/support
 Culture/environmental changes
Follow through on organization plan



Early screening & assessment process in place
Consumer/survivor driven care & service
 Encourage consumers to participate in their care

 Hire consumers/survivors in organization
 Implement continuous consumer feedback loop
Trauma-informed, educated & responsive workforce
 All staff trained in TIC & understand how their behaviors impact care received
 Provide & encourage staff to seek support




Provision of trauma-informed, EB & emerging best practices
 Trauma-focused/specific services
 Allow clients to explore their trauma in culturally & gender-specific way
Create safe & secure environment
 Environment, policies/practices established promote safe/secure environment & prevent re-traumatization
Engage in community outreach & partnership building
 Help community understand impact of trauma & that recovery is possible








Florida Dept. of Children & Families Children’s Mental Health,
Jane B. Streit, Ph.D., Sr. Psychologist, 2010.
National Child Traumatic Stress Network, Child Welfare Trauma
Training Toolkit, 2008.
http://www.cdc.gov/ace/prevalence.htm
. The ACES Experience.
Kerker & Dore (2006). Mental health needs and treatment of foster youth: Barriers and opportunities, American Journal of
Orthospychiatry, 76(1), 138-147.
Pynoos & al., Issues in the developmental neurobiology of traumatic stress. Annals of the New York Academy of Sciences, 821,
176-193.
Perry, B. (2003). The cost of caring: Secondary traumatic stress and
the impact of working with high-risk children and families. The Child
Trauma Academy.
Pecora et al., Assessing the effects of foster care: Early results from
the Casey National Alumni Study. Casey Family Programs.








Eyberg, S.M. (1988). Parent-child interaction therapy: Integration of traditional and behavioral concerns. Child and Family Therapy, 10, 33-46.
Complex Trauma in Children and Adolescents. Focal Point, Winter/2007, Vol.
21, No.1. www.rtc.pdx.edu
.
National Registry of Evidence-based Programs and Practices. http://www.nrepp.samhsa.gov
.
Models for Developing Trauma-Informed Behavioral Health Systems and
Trauma-Specific Services.-pdf, (2007) Update: Draft for Publication by
SAMHSA/CMHS Ann Jennings, Ph.D
Criteria for Building a Trauma-Informed Mental Health Service System .pdf.
Ann Jennings, Ph.D.
Blueprint for Action: Building Trauma-Informed Mental Health Service
Systems: State Accomplishments(pdf) , (2007) States’ Reports on Trauma-
Informed Activities Organized by Individual States, Ann Jennings, Ph.D.
Blueprint for Action: Building Trauma-Informed Mental Health Service
Systems: State Accomplishments(pdf). (2007) States' Reports on Trauma-
Informed Activities Organized to Trauma Informed Criteria. Anna Jennings,
PhD.