Module I

Orientation to Child Trauma Assessment

Part IPart I

A Review of the Community Session A Review of the Community Session with CTACwith CTAC

Project GoalProject Goal

Introduce and embed trauma informed Introduce and embed trauma informed knowledge and practices knowledge and practices

• culturally competentculturally competent• evidence supported/basedevidence supported/based• responsive to the needs of traumatized responsive to the needs of traumatized

children and their familieschildren and their families

Changes Desired: Changes Desired:

•System changeSystem change

•Service deliveryService delivery

•Child & Family outcomes Child & Family outcomes

DHSCMH

SCHOOLS

COURTS

Resource

Parents

The Team

Cultural & Linguistic Competence

Yvette D. Hyter, Ph.D., CCC-SLPSpeech-Language PathologistWestern Michigan University

Children's Trauma Assessment Center

Why this information is important

World is becoming more global.

U. S. is becoming more diverse

U. S. counties are following the same trend

Image from Office of Languages, Canada

Culture is like an Iceberg

• What is visible?

• What is underneath the surface?

Photo courtesy of L. Hyter (1997) Ting-Toomey, 1999

Every Living Being has Culture

Degazon, C. E. (2008)

•Organizing structures includeChild rearing

practices

Religion

•Family structure

•Physical space

•Communication

Diversity within Cultures

Diversity includes– Immigrant status– Race– Ethnicity– Socioeconomic status

and it includes – Social class– Sexual orientation– Gender identity– Disability

Pathway to Cultural & Linguistic Competence

Awareness Sensitivity Reciprocity Competence

Open to others; learning about cultural histories, values, beliefs (Adams, 1995)

Aware of differences & similarities that have an effect on values and behavior; no value judgments (Stafford et al., 1997)

Coordinated behaviors, attitudes, and policies that allow effect service across multiple cultural & linguistic groups (Cross et al., 1989

Recognition underlying taken-for-granted assumptions, how they guide behaviors and affect those that do not hold them (Kalyanpur & Harry, 1999)

Reflect, Revise, Retry

Know Your Self and your group

Understand History

Learn from others

Eliminate ethnocentrism

Learn from mistakes made

Tear down barriers

Be accountable

Honor Uniqueness

Center other experiences

Hyter, 2009

The Brain-Behavior The Brain-Behavior ConnectionConnection

Neurobiological & Neurodevelopmental Neurobiological & Neurodevelopmental Impact of Impact of Traumatic Stress & Prenatal Traumatic Stress & Prenatal

Alcohol Exposure Alcohol Exposure

in Children & Adolescents: in Children & Adolescents:

Understanding Difficult BehaviorsUnderstanding Difficult Behaviors

Mark A. Sloane, DO, FACOP, FAAPMark A. Sloane, DO, FACOP, FAAPKalamazoo, MIKalamazoo, MI

18 February 200918 February 2009

Mind (Brain)-Boggling Mind (Brain)-Boggling NumbersNumbers

• 100 BILLION100 BILLION

• 10001000

• 100 TRILLION100 TRILLION

Neurons in the Neurons in the human brainhuman brain

Potential Potential connections for connections for single neuronsingle neuron

Total possible Total possible neuron connectionsneuron connections

Building the brainBuilding the brainFrom simple to complex:From simple to complex:

Hierarchy of brain functionHierarchy of brain function

Brain-stem

Diencephalon

Limbic

NeocortexAbstract ThoughtAbstract ThoughtConcrete ThoughtConcrete ThoughtExecutive FunctionExecutive Function

AttachmentAttachmentSexual BehaviorSexual Behavior

Emotional RegulationEmotional RegulationMotor RegulationMotor Regulation

MotivationMotivationArousalArousalSleepSleep

BP / Heart RateBP / Heart RateRespiratory DriveRespiratory DriveBody TemperatureBody TemperaturePerry 2006Perry 2006

All sensory input All sensory input enters hereenters here

The Delicate Balance:The Delicate Balance:Brain control of emotion / Brain control of emotion /

behaviorbehaviorTop-Down Top-Down ““BrakesBrakes”” (Prefrontal Cortex) (Prefrontal Cortex)

Bottom-Up Bottom-Up “Accelerator”“Accelerator” (Brainstem/Limbic System) (Brainstem/Limbic System)

So… now let’s talk about So… now let’s talk about the the

acceleratoraccelerator

Wake up!!!Wake up!!!

Let’s talk about arousal …

No energy / tired & sleepy (Eeyore)No energy / tired & sleepy (Eeyore)

Op

tim

al “

Gold

ilocks” A

rou

sal

Op

tim

al “

Gold

ilocks” A

rou

sal

Way too wound-up / “wild” (“Tigger - on Way too wound-up / “wild” (“Tigger - on crack”)crack”)

Arousal Genesis / RegulationArousal Genesis / Regulation

Too wound-up (Tigger)Too wound-up (Tigger)

Role of Anxiety & Panic Role of Anxiety & Panic in Mood / Emotion Generationin Mood / Emotion Generation

• Fight-Flight-Freeze conceptsFight-Flight-Freeze concepts

• Anxious boys and girls can look Anxious boys and girls can look differentdifferent

• Anxiety / Panic Anxiety / Panic Anger/explosiveness Anger/explosiveness

• Multiple causes for this in kidsMultiple causes for this in kids– Genetic Genetic – Environmental (traumatic stress)Environmental (traumatic stress)

Next, let’s talk about the… Next, let’s talk about the…

BRAKESBRAKES

The Prefrontal Cortex: The Prefrontal Cortex: The home ofThe home of Executive Executive

FunctionFunctionExecutive Function:

The The “brakes” “brakes” of the of the brainbrain

• Working memoryWorking memory

• Attention regulationAttention regulation

• Planning / organizingPlanning / organizing

• Impulse controlImpulse control

• Mental flexibilityMental flexibility

• Self-monitoringSelf-monitoring

Experience alters brain Experience alters brain structurestructure

• These sculpted changes are These sculpted changes are structural structural changeschanges seen in response to the seen in response to the specific environmentspecific environment

• Allow the child’s brain to become the Allow the child’s brain to become the best brain best brain for the given surroundingsfor the given surroundings– Implications for traumatic stressImplications for traumatic stress– Implications for foster care placementsImplications for foster care placements

Building (& Rebuilding) the Building (& Rebuilding) the BrainBrain

Neural systems can be changed / treatedNeural systems can be changed / treatedbut some systems are but some systems are easiereasier to change to change

Brain-stem

Diencephalon

Limbic

Neocortex

ComplexityComplexity Plasticity &Plasticity &Ease of changeEase of change

Child Traumatic Stress & Child Traumatic Stress & the Developing Brainthe Developing Brain

Traumatic Stress & the Traumatic Stress & the Child’s Developing BrainChild’s Developing Brain

• Research reveals a Research reveals a strong linkstrong link between all between all types of types of childchild abuse /neglectabuse /neglect and the and the subsequent development of subsequent development of psychiatric psychiatric illness in adulthoodillness in adulthood

• New findings link child traumatic stress with New findings link child traumatic stress with variety of variety of adult medical illness adult medical illness

VJ Felitti, MDVJ Felitti, MD

Traumatic Stress & the Traumatic Stress & the Child’s Developing BrainChild’s Developing Brain

•Early childhood traumatic stress to Early childhood traumatic stress to the developing brain results in: the developing brain results in:

– Physical “hard wired” brain changes that Physical “hard wired” brain changes that ::

•Cause abnormal functioning (including memory)Cause abnormal functioning (including memory)

•Contribute to problematic behaviors Contribute to problematic behaviors

•Contribute to developmental delaysContribute to developmental delays

•Result in child being unable to Result in child being unable to realize potentialrealize potential

So…what about neglect???So…what about neglect???

But…this

case only

involves

neglect!

Impact of Severe NeglectImpact of Severe Neglect

Complex Trauma: SummaryComplex Trauma: Summary

• Affects the Affects the structurestructure & & functionfunction of of the brain in ways that negatively affect the brain in ways that negatively affect allall stages of development: stages of development:

– Social Social

– Emotional Emotional

– Cognitive Cognitive

Complex Trauma Complex Trauma

AndAnd

Developmental Trauma Developmental Trauma DisorderDisorder

Connie Black-Pond MA, LMSW, LPCConnie Black-Pond MA, LMSW, LPC

Children who experienced complex trauma Children who experienced complex trauma have endured multiple interpersonal have endured multiple interpersonal traumatic events from a very young agetraumatic events from a very young age

The trauma was usually caused by adults The trauma was usually caused by adults who should have been caring for and who should have been caring for and protecting the childprotecting the child

What is Complex Trauma?What is Complex Trauma?

Sources: Cook et al. (2005). Psychiatry Ann,35(5):390-398; van Der Kolk & Courtois. (2005) J Trauma Stress, 18:385-388.

The term Complex trauma (or Developmental Trauma Disorder) describes exposure to chronic (repeated) trauma and the impact of such exposure (traumatic stress) on the child.

Domains Impacted by Domains Impacted by Complex TraumaComplex Trauma

BehavioralControl

Cognition

Attachment

Dissociation

Affect Regulation

BiologySelf Concept

Functional ImpairmentFunctional Impairment

ScholasticScholastic FamilialFamilial Peer Peer LegalLegal VocationalVocational

Generalized Expectancies Generalized Expectancies of the Traumatized Childof the Traumatized Child Negative self-attributeNegative self-attribute Loss of caregiverLoss of caregiver Loss of protectionLoss of protection Loss of trust in social systemLoss of trust in social system Lack of recourseLack of recourse Inevitability of future Inevitability of future

victimizationvictimization

What do we see?What do we see?

Disruptions of affect regulationDisruptions of affect regulation Disturbed attachment patternsDisturbed attachment patterns Rapid behavioral regressions and Rapid behavioral regressions and

shifts in emotional statesshifts in emotional states Loss of autonomous strivingsLoss of autonomous strivings Aggression towards self and/or othersAggression towards self and/or others Failure to achieve developmental Failure to achieve developmental

stridesstrides

Loss of bodily regulation: sleep, food Loss of bodily regulation: sleep, food and self careand self care

Negative working models of their worldNegative working models of their world Somatic problemsSomatic problems Anticipatory and traumatic reactionsAnticipatory and traumatic reactions Self hatred and self blameSelf hatred and self blame Chronic sense of Chronic sense of

ineffectiveness/helplessnessineffectiveness/helplessness

May suffer from distinct alterations May suffer from distinct alterations of states of consciousness:of states of consciousness: AmnesiaAmnesia Difficulties with attentionDifficulties with attention Disorientation in time and spaceDisorientation in time and space Unable to identify internal states - Unable to identify internal states -

alexythimiaalexythimia

The child’s age and developmental stageThe child’s age and developmental stage

The child’s perception of the danger facedThe child’s perception of the danger faced

Whether the child was the victim or a witnessWhether the child was the victim or a witness

The child’s relationship to the victim or perpetratorThe child’s relationship to the victim or perpetrator

The child’s past experience with traumaThe child’s past experience with trauma

The challenges the child faces following the traumaThe challenges the child faces following the trauma

The presence/availability of adults who can offer The presence/availability of adults who can offer help, reassurance, and protectionhelp, reassurance, and protection

Other factors that affect a child’s experience of a potentially traumatic event include:

If we don’t look for or If we don’t look for or acknowledge trauma in the acknowledge trauma in the

lives of children and lives of children and adolescents, we end up adolescents, we end up chasing behaviors and chasing behaviors and

limiting the possibilities for limiting the possibilities for change.change.

The behavioral and emotional The behavioral and emotional adaptations that maltreated adaptations that maltreated children make in order to children make in order to

survive are brilliant, survive are brilliant, creative solutions, and are creative solutions, and are

personally costly.personally costly.

If you don’t ask, If you don’t ask, they won’t tell.they won’t tell.

Traumatic Expectations of the Traumatic Expectations of the WorldWorld

How Children Respond to How Children Respond to TraumaTrauma

A strong relationship with a competent, caring adult

Feeling connected with positive role models/mentors

Being able to reach out to others for help

Having his or her talents/abilities recognized and appreciated

Having empathy and caring for other people

Good communication and social skills

A sense of humor

Factors that may help a child “bounce back” from traumatic events include:

Trauma = chaos,Trauma = chaos,

Structure = healingStructure = healing

Sensory Processing Disorder

Ben J. Atchison, PhD, OTR, FAOTA

Department of Occupational Therapy

Western Michigan University

Sensory Processing is..

Detection

Registration

Modulation

Response

Key Idea is:

ADAPTIVE RESPONSE

Meaningful

Purposeful

Organized

Sensory Processing Disorder (SPD)

Sensory Modulation Disorder Sensory-Based Motor Disorder Sensory Discrimination Disorder

SOR SUR SS

SOR=Sensory Over-reactivity-Low threshold

SUR=Sensory Under-reactivity-High Threshold

SS=Sensory Seeking/Craving-High Threshold

Miller, et al, (2007) , Mar.April AJOT

Dsypraxia Postural Disorders

Visual

Auditory

Tactile

Position/Mvt

Taste

Smell

Children with a trauma history demonstrate significant prevalence of sensory

modulation disorders

Atchison (2008)

This atypical responsiveness has a significant impact on the quality of lifefor these children and their families by

limiting their participation in home, school,and community activities

Cohn, Miller, & Tickle-Degnen, 2000; Dunn, 2001;Dunn & Westman, 1997; Miller, Reismann McIntosh, & Simon, 2001; Parham &

Mailloux, 1995) and countless parent testimony…

There are five key limitations or disabilities commonly demonstrated by

children with disturbances in sensory modulation

Parham and Mailloux (1995)

Including…

(1)Decreased social skills and participation in play

(2) Disturbances in self-confidence–self-esteem

(3) Difficulties with daily life skills and at school

(4) Anxiety, disturbances in attention, and disturbances in the ability to regulate reactions to others

(5) Disturbances in skill development

Social Communication

Yvette D. Hyter, Ph.D., CCC-SLPSpeech-Language PathologistWestern Michigan University

Children’s Trauma Assessment Center

Yvette.hyter@wmich.edu, 269-387-8025

“A new world of complex relationships and feelings opens up when the peer group takes its place along side the family as the emotional focus of the child’s life.

Greenspan, S. (1993) cited in Nelson, N. W.

Early Peer Relationships Contribute To:

• Work in groups

• Deal with disappointment

• Enjoy friendships

• Understand social relations

Greenspan, S. (1993) cited in Nelson, N. W.

Social Communication

The ability to and

Coggins, Timler, & Olswang, 2007

influence othersunderstand and interpret

social situations

Social Communication Framework

Higher Order Executive Functions Decision making and strategic planning processes

Social Communicative Behaviors

Social Communicative CompetenceUsing language in interpersonally appropriate ways to successfully influence people and interpret events

Coggins, T. E., Timler,G. R. & Olswang, L.. B. (2007).

Social CognitionUnderstanding why people act in certain ways and what they are likely to do next.

LanguageSentence Structure

Word meanings/relationshipsLanguage use

Benefits of Social Communication:

• Development of positive peer interactions

• Higher levels of prosocial behaviors

• Less aggression

• Boosts self esteem

• Supports positive mental health

• Supports interactions throughout the life span

Hey!.....Here’s a good idea!...Hey!.....Here’s a good idea!...Let’s finish with a group… Let’s finish with a group…

stress stress test!!!test!!!

Stress TestStress Test

• The next picture contains 2 identical dolphins. It has been The next picture contains 2 identical dolphins. It has been recently used in national stress research.recently used in national stress research.

• Notice the two dolphins jumping out of the water. The Notice the two dolphins jumping out of the water. The dolphins are identical. A closely monitored, scientific study dolphins are identical. A closely monitored, scientific study revealed that, in spite of the fact that the dolphins are revealed that, in spite of the fact that the dolphins are identical, a person identical, a person under stressunder stress would find would find differences differences in in the two dolphins. The more differences found between the the two dolphins. The more differences found between the dolphins, the more stress that person is experiencing.dolphins, the more stress that person is experiencing.

• Look closely at the photo and if you find more than one or Look closely at the photo and if you find more than one or two differences, you need to go on two differences, you need to go on vacation. vacation.

Are You Ready…For the Next Step?

Are You Ready for the Next Step?

You Are Ready….IF…

•Commitment

•Energy

•Passion

•Teaming

This presentation is part of a comprehensive professional education and training project created by the SW Michigan

Children’s Trauma Assessment Center funded by a grant from the Substance Abuse and Mental Health Services, Department of

Health and Human Services which funds the National Children’s Trauma Stress Network