TRAUMA INFORMED CARE FOR CHILDREN AND YOUTH

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TRAUMA INFORMED CARE FOR CHILDREN AND YOUTH
Gordon R. Hodas, M.D. W-55 Pennsylvania
Community Providers Association 2009 Annual
Meeting Thursday, October 8, 2009 Seven Springs,
Champion, PA
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INTRODUCTION

• DISCLOSURES
• No ties to pharmaceutical or other research
  companies.
• Statewide Child Psychiatric Consultant to PA
  Office of Mental Health Substance Abuse
  Services, 16 years.
• Child Adolescent Policy Consultant to Bucks
  County Behavioral Health System, 5 years.
• Direct care child adolescent psychiatrist at
  Wordsworth Academy school, 16 years.

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VIGNETTES INVOLVING TRAUMA

• A TALE OF TWO YOUTH

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VIGNETTES INVOLVING TRAUMA

• TWO TRAUMA STORIES
• Vignette 1 A violent act based primarily on
  prior individually based victimization.
• Vignette 2 A violent act based primarily on
  prior culturally based victimization.

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VIGNETTES INVOLVING TRAUMA

• THE PUBLIC HEALTH CHALLENGE
• Trauma due to individually based victimization
  (individually based trauma).
• Trauma due to culturally based socialization
  (culturally based trauma).
• Both types of trauma impact affected individuals
  and predispose toward further victimization of
  others.
• In reality, both individual and cultural trauma
  operate, in varying degrees, in sustaining
  violence in America.

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KEY DEFINITIONS CONCEPTS

• CHARACTERISTICS OF TRAUMA
• Traumatic event (per DSM IV) involves
  experiencing, witnessing, or being confronted by
  event or events that involved actual or
  threatened death or serious injury, or a threat
  to the integrity of self or others.
• The individuals response involved intense fear,
  helplessness, or horror (with children, may have
  disorganized or agitated behavior).
• Posttraumatic Stress Disorder re-experiencing,
  avoidance/numbing, hyperarousal.

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KEY DEFINITIONS CONCEPTS

• TYPES OF TRAUMA
• Neglect, and abuse physical, sexual, emotional.
• Witnessing domestic abuse or community violence.
• Bullying.
• Traumatic loss.
• Medical trauma.
• Natural disasters.
• War and terrorism.
• Refugee trauma.

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KEY DEFINITIONS CONCEPTS

• DETERMINANTS OF CHILDS RESPONSE TO TRAUMA
  RESULT OF 3 SETS OF VARIABLES
• Characteristics of the traumatic event(s) (sexual
  abuse, physical abuse, neglect, greatest
  impact, plus high frequency and severe harm).
• Characteristics of the environment (importance of
  first responders, family, and community).
• Characteristics of the individual child (age,
  strengths, intelligence, prior exposure)

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KEY DEFINITIONS CONCEPTS

• WHAT WE KNOW ABOUT CHILDHOOD TRAUMA
• There are many potential types of trauma.
• Single events disrupt the life of child and
  family, but often resolve without serious
  long-term damage.
• Severe, chronic, and/or recurring trauma disrupts
  development, creates anger, confusion,
  alienation, loss of trust, and can have
  serious, long-term consequences.
• These consequences can affect every aspect of a
  childs functioning, including mental and
  physical health, values beliefs, learning, and
  behavior.

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INDIVIDUAL TRAUMA

• INDIVIDUALLY BASED TRAUMA

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INDIVIDUAL TRAUMA

• ADVERSE CHILD EXPERIENCES (ACE) STUDY
• Kaiser Permanente, California, starting in 1995.
• Middle class population ongoing longitudinal
  study.
• Goal to determine relationship between adverse
  child experiences (exposures) childhood
  maltreatment family stress and later
  outcomes.
• Outcomes tracked for adults and youth.
• Notable 50 of adults surveyed reported at least
  1 exposure, and 25 reported two or more.

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INDIVIDUAL TRAUMA

• KEY FINDINGS OF THE ACE STUDY
• A graded relationship between number of
  categories of exposure (ACE score) and negative
  outcomes, as adult. Higher score more
  impairment.
• 10 adversities, so scores range from 0 10.
• Negative adult outcomes include health risk
  behaviors, poor health status with medical
  disorders, and psychiatric disorders.
• Graded relationship between number exposures
  health risk behaviors/outcomes during childhood
  adolescence (smoking, SUD, sex, suicide
  attempts).

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INDIVIDUAL TRAUMA

• THE ACE STUDY ACE SCORES RELATE TO DEPRESSION
  SUICIDALITY
• Adults with an ACE score of 0 less than 2
  attempted suicide.
• Adults with an ACE score of 4 or more 460 more
  likely to have depression, compared to score of
  0.
• Nearly 20 of adults with score of 4 made a SA.
• ACE score of 7 SA is 51x more likely, as youth.
• ACE score of 7 SA is 30x more likely, as adult.

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INDIVIDUAL TRAUMA

• FREQUENCY OF TRAUMA IN YOUTH
• Frequency very high in general population, and
  greater in poor communities, for both youth
  adults.
• Witnessing of domestic violence, including by
  young children, also high.
• Frequency especially high for youth involved in
  juvenile justice.

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INDIVIDUAL TRAUMA

• SOCIAL/EMOTIONAL CONSEQUENCES OF TRAUMA (1)
• Academic under-achievement, higher drop-out rate.
• Greater inappropriate risk-taking.
• Greater development of unhealthy life styles.
• Greater likelihood of depression and suicidality.
• Greater risk of bullying perpetration and
  victimization
• Greater rates of alcohol drug use/abuse.

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INDIVIDUAL TRAUMA

• SOCIAL/EMOTIONAL CONSEQUENCES OF TRAUMA (2)
• Higher rates of all psychiatric disorders.
• Greater under-employment or unemployment.
• Higher rates of divorce.
• Greater likelihood of arrest for any reason.
• Greater likelihood of arrest for violence
  perpetration.
• Greater likelihood of sexual victimization of
  females.

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INDIVIDUAL TRAUMA

• MEDICAL CONSEQUENCES
• Neurobiological changes impact on development.
• Physical inactivity, overeating, obesity.
• Use of substances, smoking, co-occurring
  disorders.
• Multiple sexual partners, STDs.
• Ischemia, chronic lung disease, skeletal
  fractures.
• Liver disease, autoimmune disorders, cancer.
• Shortened life span.

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INDIVIDUAL TRAUMA

• PTSD POSTTRAUMATIC STRESS DISORDER
• PTSD involves triad of hyperarousal, avoidance,
  and re-experiencing, thirty or more days after an
  event.
• Event or events involved actual or threatened
  death or serious injury, or threat to physical
  integrity.
• Response intense fear, helplessness, horror.
• In children, disorganized or agitated behavior.
• Emergence of PTSD reflects serious impact.
• PTSD construct not reflect full impact of
  trauma.

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INDIVIDUAL TRAUMA

• EFFECTS OF TRAUMA ON THE BRAIN NEUROBIOLOGICAL
  DYSFUNCTION
• Severe, prolonged childhood abuse damages the
  developing brain via 1) structural, 2)
  functional, and 3) neurochemical changes.
• These changes disrupt normal development.
• Most of these changes produce involuntary
  responses and reactions on the part of the
  student. In fact, most of the time, the student
  has little or no idea what is going on.

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INDIVIDUAL TRAUMA

• SPECIFIC STRUCTURAL CHANGES ASSOCIATED WITH
  SEVERE TRAUMA AND PTSD (DeBellis)
• Smaller brain volumes (decreased function)
• Overall brain size parts of brain connecting
  hemispheres.
• Intracranial growth occurs early 75 of adult
  brain volume by age 2, and 100 by age 10.
  (Carmichael, 1990).
• Larger volumes of ventricles (e.g., spaces).
• Reference Psychiatric Times, Vol. XVI, No. 9,
  1999.

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INDIVIDUAL TRAUMA

• CONCEPT OF NEUROBIOLOGICAL REGRESSION
  FUNCTIONAL CHANGES (PERRY)
• Retreat from cortex to less mature levels of
  brain functioning behavior, in response to
  trauma.
• Pathway of retreat cortex to limbic system to
  midbrain extreme terror brainstem.
• Frontal cortex bypassed. Self-regulation
  impaired.
• Global processes affected recognition response
  to danger, self-regulation, memory, attention,
  processing emotional information, impulse
  control, planning, learning from experience.

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INDIVIDUAL TRAUMA

• NEUROCHEMICAL CHANGES
• Hyperarousal the primary problem.
• Distortion of normal flight or fight response,
  such that catecholamines (adrenaline
  noradrenaline) are always high and easily
  triggered crisis mode.
• Individual also may dissociate (tune out) as
  another residual response to perceived danger.
• Result Lack of self-control and impaired
  capacity for self-regulation. Involuntary
  responses.

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INDIVIDUAL TRAUMA

• SUBJECTIVE EFFECTS OF TRAUMA
• Internal discomfort.
• Sense of impending doom, need for vigilance.
• Impaired daily functioning.
• Impaired learning problem solving.
• Impaired ability to trust and form relationships.
• Impaired ability to develop and display empathy.
• Impact on behavior, beliefs, values.

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INDIVIDUAL TRAUMA

• IMPACT OF TRAUMA ON YOUTHS BELIEFS
• The world is threatening and bewildering.
• The world is punitive, judgmental, and blaming.
• People are unpredictable.
• Very few are to be trusted.
• I dont have control over my life.
• My survival is uncertain.
• If I admit a mistake, things will be worse.
• When challenged, I must defend my honor
  self-respect.

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INDIVIDUAL TRAUMA

• COMMON PRESENTATION OF YOUTH (1)
• Lack of trust.
• Guardedness.
• Hyper-vigilance.
• Startle response.
• Dislike for being touched.
• Over-reaction.
• Urgency.
• Anger rage

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INDIVIDUAL TRAUMA

• COMMON PRESENTATION OF YOUTH (2)
• Impulsivity.
• Limited executive skills (analyze,
  problem-solve, self-regulation).
• Misperceptions.
• Limited capacity to verbalize, especially
  feelings.
• Reluctance to ask for help.
• Low frustration tolerance.
• Belief in need to resolve conflict through
  violence.

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INDIVIDUAL TRAUMA

• COMMON PRESENTATION OF YOUTH (3)
• Lack of future orientation.
• Materialistic concerns.
• Hypersensitivity to shame humiliation.
• Being dissed can provoke violence.
• Violence often a result of impulsivity.
• Risk of arrest and incarceration.
• Risk of death.

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INDIVIDUAL TRAUMA

• TRAUMA RESPONSE OFTEN MISUNDERSTOOD
• Typically, youth not understand own behavior.
• Adults misperceive youth, infer intentionality
  and malevolence. Responses exacerbate the
  problem.
• E.B Carlson
• aggressive behavior is less akin to the
  willful defiance of an obstinate (child) than the
  response of a frightened child to his or her
  experience of traumatic violence.

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INDIVIDUAL TRAUMA

• AN INDICATOR OF OUR ATTITUDES
• Consider a child with symptoms of a concussion
  (car accident), and another with symptoms of
  trauma.
• Are both sets of symptoms largely medical in
  nature?
• Might both affect the childs behavior and
  relating?
• Toward whom are we more sympathetic, and more
  accepting?

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CULTURAL TRAUMA

• CULTURALLY BASED TRAUMA

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CULTURAL TRAUMA

• FRAMEWORK OF CULTURAL TRAUMA
• Encompasses beliefs, values, expectations,
  practices embedded in our society and culture.
• Part of socialization of and informal
  prescription for children and adults through
  the lifespan.
• Cultural expectations predispose people toward
  certain typical responses to adversity and
  stress.
• Cultural expectations impact both males
  females. Primary focus here involves impact on
  males.

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CULTURAL TRAUMA

• QUESTION TO CONSIDER
• What are the most admired male characteristics
  and traits, as reflected in movies, television,
  and elsewhere, in our culture?

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CULTURAL TRAUMA

• CULTURALLY BASED TRAUMA
  CONSEQUENCE OF MALE SOCIALIZATION COMMON
  VIEW OF MASCULINITY

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CULTURAL TRAUMA

• GEOFFREY CANADA PERSONAL REFLECTIONS
• (1995 FistStickKnifeGun A Personal History of
  Growing Up in America. Boston Beacon Press)
• Canada grew up on Union Street, in South Bronx.
• The big issue among the boys was whether or not
  you had heart. Having heart meant that you
  were unafraid, that you would fight even if you
  couldnt beat the other boy.
• The codes of conduct on the streets of our slums
  have always been hard, cold, and unforgiving.

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CULTURAL TRAUMA

• CANADA PERSONAL REFLECTIONS (2)
• The rules of the street defined manhood
• The thing about the South Bronx was that you
  could never relax. Anything might happen at any
  given time.
• The first rules I learned on Union Avenue...were
  simple and straightforward Dont cry. Dont act
  afraid. Dont tell your mother. Take it like a
  man. Dont let no one take your manhood.
• Escaping the rules was difficult
• It was an art form to saunter away without
  looking as if you were trying to avoid anything.

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CULTURAL TRAUMA

• THE CRITIQUE OF GEOFFREY CANADA (1)
• (1998 Reaching Up for Manhood Transforming the
  Lives of Boys in America. Boston Beacon Press)
• Current male socialization glorifies violence and
  sets males up to perpetrate be victimized by
  violence.
• Society promotes denial of vulnerable feelings
• Boys are conditioned not to let on that it
  hurts, never to say, Im still scaredIve come
  to see that in teaching boys to deny their own
  pain we inadvertently teach them to deny the pain
  in others.

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CULTURAL TRAUMA

• CANADA, DISTORTED MALE SOCIALIZATION (2)
• More and more I have become concerned with what
  boys think they should be, with what they believe
  it means to be a man. Our beliefs about
  maleness, the mythology that surrounds being
  male, have led many boys to ruin. The image of
  male as strong is mixed with the image of male as
  violent. Male as virile gets confused with male
  as promiscuous. Male as adventurous equals male
  as reckless (pp. vii-viii).

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CULTURAL TRAUMA

• THE CRITIQUE OF JOE EHRMANN (1)
• (2003 Season of Life A Football Star, Boy,
  Journey to Manhood. New York Simon Schuster)
• From Pro-Bowl football good old boy to minister
  with concern about destructive male
  socialization.
• Concern about traditional masculinity, which
  Ehrmann calls false masculinity
• We compare, we compete. Thats all we ever do.
  It leaves most men feeling isolated and alone.
  And it destroys the concept of community (p. 73).

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CULTURAL TRAUMA

• THE CRITIQUE OF JOE EHRMANN (2)
• Elements of false masculinity include athletic
  success, sexual conquest, and economic success.
• Consequence of false masculinity is a sense of
  emptiness
• It ends up putting you in a situation where
  youre always hiding. Youre always hiding who
  and what you really are. If youre hiding that,
  then you cant be comfortable with anyoneif
  youre not in any kind of community and youre
  never sharing who and what you are, then I think
  that keeps you in a state of brokenness (pp.
  74-75).

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CULTURAL TRAUMA

• THE CRITIQUE OF JAMES GILLIGAN (1)
• (2001 Preventing Violence. New York Thames and
  Hudson)
• Central role of shame disrespect in violence
• The purpose of violence is to force respect from
  other people.
• Differences in traditional gender roles make it
  possible for men to ward off, or undo, feelings
  of shame, disgrace, or dishonor by means of
  violence, whereas that is significantly less true
  for women.

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CULTURAL TRAUMA

• THE CRITIQUE OF JAMES GILLIGAN (2)
• To feel shamed is to perceive oneself as being
  disrespected, and the most direct and rapid way
  to make others respect you is to make them afraid
  of you.
• men can prove their manlinesswhen it has been
  called into question by an insult or a sign of
  disrespect, by means of violence and their
  failure or unwillingness to engage in violence
  can throw their manliness into doubt, and expose
  them to shame.

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CULTURAL TRAUMA

• THE CRITIQUE OF ELIJAH ANDERSON (1)
• (1999, Code of the Street Decency, Violence, and
  Moral Life of the Inner City. New York Norton).
• The need for manhood and respect is increased due
  to lack of social standing and societal
  protection (e.g. social capital)
• The code of the street involves a set of
  prescriptions and proscriptions, or informal
  rules, of behavior organized around a desperate
  search for respect that governs public social
  relations, especially violence, among so many men
  and women.

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CULTURAL TRAUMA

• THE CRITIQUE OF ELIJAH ANDERSON (2)
• Code of the street is a cultural adaptation to
  danger
• The code of the street is actually a cultural
  adaptation to profound lack of faith in the
  police and the judicial system and in others
  who would champion ones personal security.
• Many of the forms dissing can take seem petty to
  middle-class peoplebut to those invested in the
  street code, these actions, a virtual slap in the
  face, become serious indications of the other
  persons intentions.
• respect on the street may be viewed as a form of
  social capital that is very valuable, especially
  when various other forms of capital have been
  denied or are unavailable.

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CULTURAL TRAUMA

• SAD IRONY OF THE CODE OF THE STREET
• An intended cultural adaptation to danger,
  similar to the bodys physiological,
  fight-or-flight adaptation to danger, gets out of
  balance, becoming a source of danger even
  death, not a protection from danger.
• Code of the street morality not limited to
  urban ghettos, arises from core gender
  stereotypes in our culture.
• Particularly applicable to males with low
  self-esteem, who become overly sensitive to
  shaming by others.

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TRAUMA INFORMED CARE

• HOW TRAUMA INFORMED CARE CAN HELP

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TRAUMA INFORMED CARE

• TRAUMA INFORMED CARE (1)
• Trauma informed care involves a commitment to
  relationships, programs, and interventions that
  seek to mitigate the effects of past traumatic
  experiences, and to prevent traumatizing and
  re-traumatizing experiences, for youth and
  others. Trauma informed care thus involves both
  individual interactions with youth and a public
  health approach that supports safe, non-violent
  relationships and settings.

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TRAUMA INFORMED CARE

• TRAUMA INFORMED CARE (2)
• When used in treatment and care settings, TIC
  involves the provision of interventions informed
  by an understanding of the pervasiveness of
  trauma and its consequences, and also addresses
  the symptoms and core deficits related to past
  trauma and promotes the youths self-awareness,
  self-regulation, healthy functioning.

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TRAUMA INFORMED CARE

• ELABORATION OF TRAUMA INFORMED SERVICES (Ann
  Jennings, 2004)
• Trauma informed services are not specifically
  designed to treat symptoms or syndromes related
  to sexual or physical abuse or other trauma, but
  they are informed about, and sensitive to,
  trauma-related issues present in survivors.

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TRAUMA INFORMED CARE

• TIC AS VIEWED WITHIN PUBLIC HEALTH MODEL
• Public health, per Institute of Medicine, 1988
  What we, as a society, do collectively to assure
  the conditions in which people can be healthy.
• Three levels of prevention
• Universal TIC efforts to prevent trauma and
  victimization, for everyone.
• Selective TIC for those in high risk situations
  e.g., inner city youth, refugees, youth
  displaying externalized behavior.
• Indicated TIC for those with significant trauma
  history, in community or care settings, including
  those with PTSD.

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TRAUMA INFORMED CARE

• COMMON STRENGTHS OF YOUTH WITH TRAUMA
• Very aware of how treated.
• In search of personal control and mastery.
• Strong survival skills.
• Strong concept of fairness and justice.
• Passion common.
• Typically responsive to respectful adults.
• Capable of loyalty.
• Importance of determining specific strengths
  profile.

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TRAUMA INFORMED CARE

• PRINCIPLE OF UNIVERSAL PRECAUTIONS, AS APPLIED
  TO TIC (Hodas 2005)
• Need to presume that each person, regardless of
  setting or specific needs, should receive TIC
• Principle based on near-universal prevalence of
  trauma within the population, and
• The commitment to prevent trauma and
  re-traumatization.
• TIC creates relationships and contexts that
  support safety and positive psychosocial
  development.

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TRAUMA INFORMED CARE

• TRAUMA INFORMED BELIEFS ABOUT YOUTH (1)
• Youth are more than the sum of their behaviors,
  and need to be understood in terms of their life
  to date.
• Youth generally do the best they can under their
  current circumstances, and want to do well.
• Negative behavior by youth is most likely not
  intentional, but a result of limitations
  challenges.
• Youth are still developing emotionally, and their
  development can be influenced positively by
  others.

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TRAUMA INFORMED CARE

• TRAUMA INFORMED BELIEFS ABOUT YOUTH (2)
• Youth often feel out of control, but dont say
  it.
• Youth listen even when they appear not to be.
• Youth observe adults recognize genuineness.
• Most youth seek adult support and want to trust.
• Youth need to be respected spoken to with
  respect
• Adults need to collaborate with youth, not
  dictate.
• The core consideration for adults involves
  avoidance of shame and humiliation.

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TRAUMA INFORMED CARE

• OTHER TRAUMA INFORMED BELIEFS
• TIC for youth includes partnering with the
  family.
• TIC for youth involves collaboration by all
  involved adults and systems.
• TIC for youth involves creating a bond among
  peers.
• TIC involves both youth accountability for
  behavior and adult responsibility to promote
  youth wellbeing.
• Safety must be addressed youth cannot give up
  trauma defenses when dangers continue.

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TRAUMA INFORMED CARE

• CORE TRAUMA INFORMED PRACTICES
• Program level
• Welcoming environment positive culture.
• Informed committed leadership and staff.
• Commitment to avoid restraint, other coercive
  practices.
• Other core elements data collection, involvement
  of youth and families, debriefment process.
• Individual level
• Trauma history and risk assessments.
• Safety plan.

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TRAUMA INFORMED CARE

• SKILL AND HEALTH-BUILDING 10 AREAS
• Self-knowledge (re. life experience, effect of
  trauma).
• Self-awareness (triggers, internal warning signs,
  what helps, what doesnt).
• Self-expression (being able to socialize, asking
  for help, expressing gratitude).
• Self-advocacy (standing up for rights dignity
  in determined, respectful way).

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TRAUMA INFORMED CARE

• SKILL AND HEALTH-BUILDING 10 AREAS
• Affiliation and attachment (becoming connected
  being able to trust others).
• Negotiation compromise (avoiding all-or-nothing
  thinking learning to be flexible).
• Conflict resolution, without resort to violence
  (daily living no longer a life-and-death matter).
  
• Self-regulation (the basis for all other
  changes).
• Wellness (promotes more satisfying quality of
  life).

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TRAUMA INFORMED CARE

• NEED FOR A TIC MODEL
• Good intentions and efforts by single individuals
  not enough to guarantee TIC.
• The system involved with the youth must be TI.
• A TI system requires core principles to guide its
  operations.
• Bloom (Sanctuary) and Fallot offer valuable
  models.
• Main focus on Fallots model (Community
  Connections).

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TRAUMA INFORMED CARE

• BLOOMS SANCTUARY MODEL
• Concept of sanctuary and need to create and
  maintain safety, non-violence, justice.
• Commitment to organizational change as well as to
  trauma informed care for youth.
• The SELF components (safety, emotions, loss,
  future).
• Specific tools to promote Sanctuary practices.

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TRAUMA INFORMED CARE

• FALLOTS 5 CORE PRINCIPLES OF A TI SYSTEM
• Safety physical and emotional.
• Trustworthiness built on respect
  transparency.
• Choice prioritizing opportunities to make
  decisions and experience a sense of control.
• Collaboration working together and sharing
  power.
• Empowerment prioritizing competency and
  skill-building.

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TRAUMA INFORMED CARE

• IMPLICATIONS OF FALLOTS MODEL (1)
• Applicable to all youth, whether in treatment,
  care, or a community program.
• Entire program and its staff must follow.
• Within service setting, involves more than just
  the direct care providers
• Includes administrators, supervisors, support
  staff.
• Involves all aspects of a program, not just
  services program setting, atmosphere,
  relationships.
• Model leads to a new culture new way of doing
  business.

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TRAUMA INFORMED CARE

• IMPLICATIONS OF FALLOTS TI MODEL (2)
• TI system must follow TI principles in daily
  operations.
• Staff feel safe empowered, are not
  traumatized.
• Youth are not intimidated or coerced.
• Youth are encouraged to take initiative, not just
  obey rules and be compliant.
• Youth are encouraged to express self and
  advocate, which is understood as developmentally
  appropriate.

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SPECIFIC TI APPLICATIONS

• APPLICATIONS OF TIC IN MULTIPLE CONTEXTS

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TRAUMA INFORMED CARE

• ANY TREATMENT OR CARE SETTING (1)
• Residential and/or community settings.
• Staff are welcoming, engaging, non-intimating.
• Staff listen to youth, and promote dialogue.
• Staff model attitudes behaviors expected of
  youth.
• Staff develop trusting relationships.
• Staff provide encouragement, not shame or
  threats.
• What you went through, not whats wrong with
  you.

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TRAUMA INFORMED CARE

• ANY TREATMENT OR CARE SETTING (2)
• Appropriate screening, assessment, clinical
  treatment provided.
• Youth helped to understand their trauma history,
  symptoms behaviors, impact on their life.
• Youth helped to learn to recognize control
  triggers.
• Youth advocacy self-expression is promoted.
• Social skills, coping, wellness are promoted.
• Failure reframed as opportunity for new
  learning.

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TRAUMA INFORMED CARE

• RESIDENTIAL TREATMENT AND CARE
• Commitment to use restraint only as emergency
  safety intervention of last resort.
• Use of group process to create a sense of
  community, with mutual support TI practices.
• Youth screened for trauma and signs of PTSD, and
  for suicidality, homicidality, substance abuse,
  contraindications to restraint.
• Use of safety plan, early staff intervention.

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TRAUMA INFORMED CARE

• POSITIVE IMPACT OF TIC ON YOUTH
• Safety enables youth to be less vigilant, trust
  more easily, and be less aggressive.
• Relationships offer new models of how to be a
  good citizen and lead a meaningful life.
• Education leads to recognition of role of trauma
  in life and reassessment of personal goals.
• Social skills lead to sense of competence.
• All of above promotes renewal of hope.

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TRAUMA INFORMED CARE

• APPLICATIONS WITHIN THE COMMUNITY CHANGING
  CULTURE PROVIDING OPPORTUNITY

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TRAUMA INFORMED CARE

• THE CRITIQUE OF GEOFFREY CANADA (1)
• Need to counter traditional male socialization
• Boys find themselves pulled and tugged by forces
  beyond their control as they make the perilous
  trip to manhood. Some lose their wayWe must
  spend more time trying to understand what happens
  to boys and how we can help shape them into
  better men.
• Boys need a sense of self that is developed
  though personal accomplishments and hard work. A
  sense of self that includes the desire to grow
  into men who are kind, disciplined, and caring.

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TRAUMA INFORMED CARE

• THE CRITIQUE OF GEOFFREY CANADA (2)
• Creating a trauma informed school at Rheedlen
• (At Rheedlen), we make sure our programs have
  mature and caring men in them, both young and
  oldOur boys see men holding childrens hands,
  wiping their tears away, reading them
  stories(The boys) grow up knowing how normal it
  is for men to show concern, love, and tenderness
  for children..

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TRAUMA INFORMED CARE

• THE CRITIQUE OF JOE EHRMANN
• Redefining essence of masculinity from
  aggression self-preoccupation to a man built
  for others.
• Emphasis on service to others, caring, kindness
  and empathy, with de-emphasis on power,
  competition, vengeance.
• Coaching as vehicle for promoting youth
  leadership and development
• I expect greatness out of you. And the way we
  measure greatness is the impact you make on other
  peoples lives.

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TRAUMA INFORMED CARE

• JOE EHRMANNS RITUAL WITH HIS FOOTBALL TEAM CAN
  YOU BELIEVE THIS?
• 1) Joe Ehrmann to Gilman HS football team
• What is our job?
• Most of the boys To love us.
• 2) Ehrmann back to football team
• And what is your job?
• The boys To love each other.

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TRAUMA INFORMED CARE

• THE CRITIQUE OF JAMES GILLIGAN
• ...the first steps toward preventing violence
  consist of not shaming people (as by
  disrespecting them), and not depriving them of
  access to the tools they need in order to attain
  and maintain their self-respect even when they
  are disrespected by others.
• A related principle for preventing violence is
  this always give people a chance to talk,
  remembering that the only alternative to action
  including violent action is words.

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TRAUMA INFORMED CARE

• THE CRITIQUE OF ELIJAH ANDERSON (1)
• How inner city youth can survive in a positive
  way
• Crucial to resolving the dilemma of being decent
  in a street-oriented environment is the ability
  to code-switchA decent youthtends to have a
  wide array of styles from which to choose how to
  act
• The need for early and ongoing intervention
• (There is) a need both for early
  interventionbefore the opposition culture has
  had a chance even to begin developing in the
  child, and for continuing intervention with
  preadolescents and adolescents.

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TRAUMA INFORMED CARE

• THE CRITIQUE OF ELIJAH ANDERSON (2)
• Need for genuine opportunities for youth to
  achieve mainstream success
• the credible promise of opportunity nurtures in
  young people a more positive outlook and a
  hopeful sense of the future, while at the same
  time building a social framework for civility,
  law-abidingness, social peace, and a positive
  outlook.

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TRAUMA INFORMED CARE

• TRAUMA INFORMED TEACHERS
• TI teachers offer a pedagogy of kindness,
  teach with love.
• TI teachers offer consistent structure, but also
  are apostles of serendipity, drawing on
  teachable moments.
• TI teachers inhabit the world of their
  students, so they know each ones needs.

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TRAUMA INFORMED CARE

• TRAUMA INFORMED PARENTING
• Core concepts being a teacher, supportive coach,
  mentor, validator role model.
• Safety predictability, using teachable
  moments.
• Setting limits consequences instructively,
  without anger loss of control, so message is
  heard.
• Discarding humiliation shaming as motivational
  tools.
• Avoiding responses that elicit or exacerbate
  activation of childs hyperarousal system.

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TRAUMA INFORMED CARE

• THE PARADOX OF MOTIVATION
• Change depends on believing you can change, even
  if this is only partially true.
• We encourage good choices, knowing that some
  youth, at current point in life, might not be
  able to.
• Our response needs to combine accountability with
  acceptance, with ongoing teaching and mentoring
  essential.

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CONCLUSION

• SELF-HEALING POST-TRAUMATIC GROWTH
• The capacity for self-healing resides within us
  we have natural processes of self-healing
  (Mollica)
• Healing begins with a choice. Survivors of
  extreme violence must decide which reality to
  live in their old, broken world or a new one.
• Post-traumatic growth Some people grow after
  trauma, becoming kinder, enlightened, committed
  to good deeds altruism helping others.
• We need to learn more about how this works.

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CONCLUSION

• TIC CAN PROMOTE NEURAL DEVELOPMENT
• Brain growth/differentiation through mid-20s.
• Replace use it or lose it with choose it and
  use it.
• Positive life experiences relationships promote
  brain development.
• This occurs through mirror neurons and creation
  of new cognitive, emotional, neural pathways.
• Relationships more neural circuits
  adaptability.
• Thus, recovery of the brain can be part of
  recovery.

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CONCLUSION

• CORE ELEMENTS OF TRAUMA INFORMED CARE
• Caring at the individual level, with respect,
  collaboration, and mentoring as the core
  relational elements.
• Culture, with cultural transformation involving
  gender socialization and values that reinforce
  violence.
• Capital, with opportunity for mainstream success
  available and an enduring commitment to social
  justice.
• Together, these three elements can promote
  enduring trauma informed care.

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ADDITIONAL REFERENCES

• SUGGESTED CHILDHOOD TRAUMA REFERENCES
• - Hodas, G (2006) Responding to childhood
  trauma The promise and practice of trauma
  informed care. National Association of State
  Mental Health Program Directors (NASMHPD).
• Easy access via web search Hodas with
  NASMHPD
• Multiple references identified in above
  paper.
• - National Child Traumatic Stress Network,
  SAMHSA www.nctsn.org

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REFERENCES

• TRAUMA SCREENING
• Strand, V., Sarmiento, T., Pasquale, L. (2005)
• Assessment and screening tools for trauma in
  children adolescents A review. Trauma,
  Violence, and Abuse, Vol. 6, No. 1, January 2005,
  55-78.

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REFERENCES

• OTHER BOOKS OF INTEREST
• Garbarino, J. (1999) Lost Boys Why Our Sons
  Turn Violent and How We Can Save Them. New York
  Free Press.
• Iacoboni. M. (2008) Mirroring People The New
  Science of How We Connect With Others. New York
  Farrar, Straus, and Giroux.
• Mollica, R, (2006) Healing Invisible Wounds
  Paths to Hope and Recovery in a Violent World.
  Orlando, FL Harcourt.