Transcript What Are ACEs? - Amazon Web Services

Invisible
Wounds
UNDERSTANDING AND
WORKING WITH THE
TRAUMATIZED STUDENT
JUNE 1, 2016
BEVERLY TOBIASON, PSYD
STACEY BRADY, JD
Do you work with students who…
Do you work with students who…
o Witness domestic violence?
o Are physically, emotionally or
sexually abused?
o Are neglected?
o Have family members serving in
the military?
o Have been in a serious accident?
o Have parents who have
divorced?
o Have family members
incarcerated?
o Live in homes with family
members who abuse alcohol or
other drugs?
o Live in homes with family
members with under or
untreated mental illness?
o Have lost a loved one?
o Lack consistent access to basic
necessities?
o Experienced school or
community violence
o Are homeless?
o Living in poverty?
o Are going though something bad,
but you don’t know what?
o Have experienced many of the
above?
Types of Trauma
o Acute Trauma (one-episode)
o
Results from a single, sudden, usually unexpected event, such as
rape, car accident, or witnessing violence
o Chronic Trauma (repeated)
o
Arises from long-standing, repeated events, such as abuse, neglect,
or contentious divorce
o Complex Trauma
o
o
Exposure to multiple or prolonged traumatic events and the impact it
has on a child’s development
Involved simultaneous or sequential occurrence of psychological
maltreatment, neglect, physical and sexual abuse, domestic violence
that are chronic and begin in childhood
National Child Traumatic Stress Network, 2008
Trauma Prevalence
o Research suggests that approximately 25% of U.S. children will
experience at least one traumatic event by age 16
o In a nationally represented U.S. survey, 39% of 12-17 year-olds
reported witnessing violence, 17% reported physical assault, and
8% reported sexual assault
o 100% of youth served in the child welfare system have a history
of substantiated abuse, neglect, or abandonment
o 75-93% of youth in the juvenile justice system are estimated to
have experienced some type of trauma
Healing Invisible Wounds: Why Investing in Trauma-Informed Care for Children Makes Sense, 2010
What Are ACEs?
Adverse Childhood Experiences
Traumatic experiences in
childhood
Sometimes referred to as “toxic
stress” or “childhood trauma”
“Turning Gold into Lead”
ACEs in the Classroom
o ACEs are the greatest single
predictor for health, attendance
and behavior.
o ACEs are the second strongest
predictor, after special education
status, for academic failure.
o The relationship between
academic achievement and health
status appears much less related
to income than to ACEs.
Study Participants
o 26,000 adults invited to participate;
o
17,337 accepted
o Solidly middle class
o Average age = 57
*Keep in mind there are ongoing
studies. This demographic information is
on the original study participants.
See www.cdcreport.com profiling 5 states
that have collected data.
Two Categories of ACEs
1)
Growing up (prior to age 18) in a
household with abuse:
o Recurrent physical abuse
o Recurrent emotional abuse
o Sexual abuse
o Emotional or physical neglect
Two Categories of ACEs
2) Growing up with Household Dysfunction:
o Alcohol or drug abuser
o Incarcerated household member
o Someone chronically depressed,
suicidal, institutionalized or mentally ill
o Mother being treated violently
o One or no parents
o
ACEs are Interrelated and Have
a Cumulative Stressor Effect
It is the number of
different categories,
not the
intensity/frequency of
the ACEs that
determine health
outcomes.
ACEs are Interrelated and Have a
Cumulative Stressor Effect
Without
interruption, ACEs
escalate across
generations.
ACEs are Highly Interrelated
Alcohol Abuse in the Home and the Risk of Other Household
Exposures During Childhood
45
40
35
30
25
20
15
10
5
0
0 alcohol abusers
1 alcohol abuser
2 or more
Mother
treated
violently
Mental illness
Drug use
Suicide
attempt
Member
imprisoned
Arizona Children 0 – 17 years
(2011/2012 Natl. Survey of Children's Health)
• 42.5 % - Zero ACEs
• 26.4 % - One ACE
• 31.1 % - 2 or more
ACEs
• National Average 22.6% - 2 or more
ACEs
“Children’s exposure to ACEs is the greatest
unaddressed public health threat of our time.” Dr.
Richard Block, former president, American Academy of Pediatrics
Children and Stress
o Biologically predisposed to more
physiologic stress
o Brain structures that modulate this
stress mature later
o Young children need safe, stable,
and nurturing relationships to
assist them in regulating their
stress
Toxic Stress
“Extreme, frequent or
extended activation of the
body’s stress response,
without the buffering
presence of a supportive
adult.”
Sara B. Johnson, et al., The science of early life toxic
stress for pediatric practice and advocacy, 131
PEDIATRICS 319 (2013), available at
http://pediatrics.aappublications.org/content/131/2/319.
full
Neurobiological Framework Linking Toxic Stress
in Childhood to Adult Health
Toxic stress early in development affects the
functioning of 3 highly integrated systems:
o
the immune system
o
the neuroendocrine system
o
the central nervous system
(Danese & McEwen, 2012)
Life Long Physical, Mental & Behavioral
Outcomes of ACEs
o Alcoholism & alcohol abuse
o Liver disease
o Chronic obstructive pulmonary o Obesity
disease and
o Sexually transmitted disease
ischemic heart disease
o Smoking
o Depression
o Suicide attempts
o Fetal death
o Unintended pregnancy
o High risk sexual activity
*The higher the ACE Score, the greater
o Illicit drug use
the incidence of co-occurring conditions
o Intimate partner violence
from this list.
Out of 100 People…
33%
Report No
ACEs
With 0 ACEs
1 in 16 smokes
1 in 69 are alcoholic
1 in 480 use IV drugs
1 in 14 has heart disease
1 in 96 attempts suicide
51%
Report 1-3
ACEs
16%
Report 4-10
ACEs
With 3 ACEs
With 7+ ACEs
1 in 9 smokes
1 in 9 are alcoholic
1 in 43 use IV drugs
1 in 7 has heart disease
1 in 10 attempts suicide
1 in 6 smokes
1 in 6 are alcoholic
1 in 30 use IV drugs
1 in 6 has heart disease
1 in 5 attempts suicide
Coping Solutions
What are conventionally
viewed as Public Health
problems are often personal
solutions to long concealed
adverse childhood
experiences.
Seeking to Cope
o Risk factors/behaviors
underlying adult
diseases are effective
coping devices.
o Dismissing these
coping devices as “bad
habits” or “self
destructive behavior”
misses their
functionality.
ACEs and Addiction
ACE findings suggest that
a major factor, if not the main
factor, underlying addiction is
ACEs that have not healed and
are concealed from awareness
by shame, secrecy, and
social taboo.
“It’s hard to get enough of something
that almost works.” - Dr. Vincent Filetti
ACEs are the
Pipeline to Prison
o 1 in 6 state male inmates reported being
physically or sexually abused before age
18, and many more witnessed
interpersonal violence.
o Over half of male inmates (56%) report
experiencing childhood physical trauma.
o Over one-quarter (1/4) of incarcerated
men report being abandoned during
childhood or adolescence
o Of the more than 93,000 children
currently incarcerated, between 75 and
93 percent have experienced at least one
traumatic experience.
Childhood and Adult Trauma Experiences
of Incarcerated Persons and Their
Relationship to Adult Behavioral Health
Problems and Treatment) Int Journal of
Environ Res Public Health. 2012 May;
9(5): 1908–1926. Published online 2012
May 18.
Healing Invisible Wounds: Why Investing
in Trauma-Informed Care for Children
Makes Sense,
% with Job Problems
ACE Score vs.
Serious Job Problems
18
16
14
12
10
8
6
4
2
0
0
1
2
ACE Score
3
4 or more
Complex Trauma
Early exposure to traumatic stress impairs multiple domains of a child’s being:
ATTACHMENT
o Uncertainty about the
o Interpersonal difficulties
reliability and
predictability of the world
o Boundary problems
o Distrust and
suspiciousness
o Social isolation
o Difficulties attuning to
(National Child Traumatic Stress Network, March 2008)
other’s emotional states
o Difficult with perspective
taking
o Difficulty enlisting others
as allies
Complex Trauma
Early exposure to traumatic stress impairs multiple domains of a child’s being:
BIOLOGY
o Sensorimotor development
problems
o Hypersensitivity to physical
contact
o Analgesia (absence of a
normal reaction to pain)
o Problems with coordination,
balance, body tone
(National Child Traumatic Stress Network, March 2008)
o Difficulty localizing skin
contact
o Somatization
o Increased medical
problems (e.g., pelvic
pain, asthma, skin
problems, autoimmune
disorders, pseudo
seizures)
Complex Trauma
Early exposure to traumatic stress impairs multiple domains of a child’s being:
AFFECT REGULATION
o Difficulty with emotional
o Problems knowing and
self-regulation
o Difficulty describing
feelings and internal
experiences
describing internal states
o Difficulty communicating
wishes and desires
(National Child Traumatic Stress Network, March 2008)
Complex Trauma
Early exposure to traumatic stress impairs multiple domains of a child’s being:
DISSOCIATION
o Alteration in states of
o Derealization
consciousness
o Amnesia
o Depersonalization
o Impaired memory for
(National Child Traumatic Stress Network, March 2008)
state-based events
Complex Trauma
Early exposure to traumatic stress impairs multiple domains of a child’s being:
BEHAVIORAL CONTROL
o Difficulty modulating impulses
o Excessive compliance
o Self-destructive behavior
o Oppositional behavior
o Aggression toward others
o Difficulty understanding and
o Pathological self-soothing
complying with rules
o Reenactment of trauma
through behavior and play (e.g.,
aggressive, sexual)
behaviors
o Sleep disturbances
o Eating disturbances
o Substance abuse
(National Child Traumatic Stress Network, March 2008)
Complex Trauma
Early exposure to traumatic stress impairs multiple domains of a child’s being:
COGNITION
o Difficulty in attention regulation
o
o
o
o
o
o
and executive functioning
Lack of sustained curiosity
Problems processing novel
information
Problems focusing on and
completing tasks
Problems with object constancy
Difficulty planning and anticipating
Difficulty understanding own
contribution to what happens to
them
o Learning difficulties
o Problems in language
development
o Problems with orientation in
time and space
o Acoustic and visual perceptual
problems
o Impaired comprehension of
complex visual-spatial patterns
(National Child Traumatic Stress Network, March 2008)
Complex Trauma
Early exposure to traumatic stress impairs multiple domains of a child’s being:
SELF CONCEPT
o Lack of continuous and
o Low self esteem
predictable sense of self
o Poor sense of
separateness
o Disturbed body image
o Shame
o Guilt
(National Child Traumatic Stress Network, March 2008)
Common Trauma Diagnoses
Current diagnostic classifications are inadequate in
describing the full range of difficulties that traumatized
children experience and present.
Most Common Diagnoses:
o Depression/Mood or Dysregulated Mood Disorder
o Anxiety Disorders (e.g., PTSD, GAD,
o
o
o
o
Separation Anxiety Disorder
Disruptive Behavior Disorders (e.g., ADHD, ODD,
Conduct Disorder)
Reactive Attachment disorder (RAD)
Learning Disorders
Communication Disorders
Trauma and Learning
Adversely affects ability to:







Organize narrative material
Understand cause and effect
Take another person’s
perspective
Attend to classroom instruction
Regulate emotions
Engage the curriculum
Utilize executive functions
Make plans
 Organize work
 Follow classroom rules

Trauma and School Performance
o Lower scores on standardized achievement tests
o Substantial decrements in IQ, reading achievement,
and language
o Two and a half times more likely to be retained
o Suspended and expelled more often
o Increased drop out
o More likely to have problems in receptive and
expressive language
(Delaney-Black et al, 2002; Goodman et al, 2011; Grevstad, 2007; Sanger et al, 2000; Shonk et al, 2001)
Signs and Symptoms of Trauma at All Ages
 Anxiety, fear, and worry about
safety (of self and others)
 Re-Experiencing the
Trauma/Event
 Fear of recurrence of violence
 Withdrawal
 Angry Outbursts/Aggression
 Hyperarousal
 Emotional Numbing
 Over/Under-Reacting (e.g. bells,
physical contact, sudden moves,
doors slamming, sirens)
 Change in Academic Performance

Concentration
 Avoidance Behaviors
 Increased Activity Level
Decreased Attention and/or

Absenteeism
Age-Specific Signs and Symptoms
Elementary
o
Increased distress
o
Whininess, irritability,
Middle
o Irritability with peers,
High School
o Increased risk of
teachers, events
substance abuse and
moodiness
o Somatic complaints
impulsive/risk-taking
o
Distrust of others
o Discomfort with
behaviors
o
Change in ability to interpret
and respond appropriately to
social cues
o
Somatic complaints
o
Difficulty with authority,
o
feelings
o Repeated discussion
of event
o Discussion of event and
reviewing details
o Negative impact on
perception of others
o Repetitive thoughts and
redirection, and criticism
comments regarding death
Statements/Questions about
and dying (including suicidal
death and dying
thoughts, writing, and art)
(NCTSN, 2008)
The kids who need the most
love will ask for it in the most
unloving ways…
How do we see these students?
Traditional View
Trauma-Informed View
o Anger management problems
o Difficulty regulating emotions
o ADHD
o Difficulty maintaining focus
o Volitional acting out
o Lacking necessary skills due to impacted
o Uncontrollable
o Destructive
o Non-responsive
Response:
Student needs consequences or
an ADHD evaluation.
neurobiology
o Difficulty trusting adults
o Trauma response was triggered
Response:
We need to understand and provide the
supports necessary for the student to
learn and succeed.
So, is this just the newest fad?
o Lawsuit filed against the Compton Unified School
District by 4 students and 3 teachers
o Contending the district failed to help students and
teachers in dealing with complex trauma
o Lawsuit is seeking class action certification
o Accuses the district of violating the federal Rehabilitation
Act and Americans with Disabilities Act
o Outcome?
OMG…
Now they want
us to be
therapists, too!
So you want us to be therapists?
Trauma-Specific Therapy vs. Trauma-Specific Education
School
Therapy
o Licensed clinical mental health
professionals
o Interventions occur in
o Licensed educators and student
services professionals with varied
mental health training
o Awareness, sensitivity, and
therapist’s office 1:1 or small
accommodations occur throughout
group settings
the school
o Focus on addressing trauma
reactions and reducing trauma
symptoms
o Focus is on students’ educational
success through emotional and physical
safety, empowerment, trust, choice,
and collaboration
The kids who are loved at home
come to school to learn.
Those who are not
come to school to be loved...
Healing from trauma
can only occur
within the context
of relationship…
Psychological First Aid
o Listen
o Protect
o Connect
Working with traumatized students…
What can I do?
o Increase your own awareness that a o Maintain a calm and respectful
student’s behavior may be secondary
to trauma (e.g. fight-flight-freeze)
demeanor
o Teach students self-care
o Understand that students may not be o Teach students the connection
able to express their suffering in ways
between their behavior and the
that adults can understand
consequences
o Make connections
o Work to ensure a sense of safety for
students
o Maintain a daily routine
o Monitor and reduce trauma
reminders
o Continue to teach students over and
over again, traumatized students will
not likely learn it the first, second, or
third time
o Involve family whenever possible
Working with traumatized students…
What can I do?
o Break down expectations into
o Focus on providing and/or
small information bits - repeat
advocating for community
these often
intervention (treatment works)
o Practice goal setting
o Keep things in perspective
o Nurture a positive self-view
o Reinforce healthy adult
relationships with the student
o Remember that it is not about you
o
Disrespect is an adaptive response to
trauma
o Reinforce a student’s protective
factors
o Believe in student and family
resiliency
o Give the student hope for their
future
Visual tool used by Principal Jim Sporleder to
help his students identify when they are ready
to talk or to learn.
Having a hard
time
with my feelings.
Calming down, but
not quite calm
enough yet.
I think I
am ready
to learn.
Ideas
o Greet every student daily at the front door, every classroom, and at the
end of the day
o Use of emotionally grounding rituals at high stress times (e.g.,
beginning of the day, before each class starts, before/after lunch, at the
end of each day)
o Eliminate intercom messages – messages walked to each classroom
o For the students with the most challenging behavior – assign one staff
to “adopt” that student
o Focus on teaching behavior rather than disciplining behavior
o Connecting before correcting
o The pencil and sand tray/rock garden
o Review of policies/practices that remove students from school (e.g.,
hall suspension)
o Dim classroom lights during transitions
o Put your hand up to get students attention
Trauma-Sensitive/Informed Schools
 National Leaders:
Washington
 6 Elementary schools
 Lincoln High School, Walla Walla
 “Paper Tigers”
 Massachusetts
 “Safe and Supportive Schools” signed into law
 2000 trauma grants
 ACE study
 Trauma-informed school movement
 EBP and TIC:
 Standardized School Discipline Guidelines
 Multi-tiered System of Support (MTSS)
 Positive Behavior Interventions and Support (PBIS)

PBIS and Trauma-Informed Care
What can I do today
that will make a
difference?
“If I could ask for anything,
it would be for you to
listen and be kind.”
- A Trauma Survivor
Resources
Trauma:
Child Trauma Toolkit for Educators
http://www.nctsnet.org/nctsn assets.pdfs/Child Trauma Toolkit Final.pdf
ACE Study:
http://www.acestudy.org
Trauma-informed schools:
Massachusetts Advocates for Children
http://traumasensitiveschools.org/tlpi-publications/
Washington State The Heart of Learning and Teaching
Http://k12.wa.us/CompassionateSchools/HeartofLearning.aspx
Resiliency:
Search Institute: Focuses on developmental assets research
http://www.search-institute.org/
Contact Information
Beverly Tobiason, PsyD
Clinical Director
Pima County Juvenile Court
[email protected]
520-724-2233
Stacey Brady, JD
Supervisor, Mediation Program
Children and Family Services
Pima County Juvenile Court
[email protected]
520-724-2274