Recognizing and Responding to Child Traumatic Stress in Schoolage Children

1
Recognizing and Responding toChild
Traumatic Stress in School-age Children

• Douglas W. Walker, PhD
• Clinical Director - Mercy Family Center
• Project Director - Project Fleur-de-Lis
• New Orleans, Louisiana
• USA

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Background
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Learning Objectives

• Participants will appreciate the body of
  literature supporting the impact of trauma on
  child development and learning.
• Participants will be able to recognize the signs
  and symptoms of CTS in their everyday lives as
  parents, educators and administrators.
• Participants will be given a CTS response tool
  kit to use when assisting children and their
  families who have undergone extremely stressful
  or traumatic events

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Overview

• Impact of Trauma on Youth
• Introduction to Trauma Informed Systems
• Why a trauma program in schools?
• Third Culture Students Stress Trauma
• Your toolkit to manage stress and trauma Support
  for Students Exposed to Trauma (SSET)
• Small group/Individual Consultation

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Impact of Trauma on Youth
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Consequences of trauma exposure Traditional
Concept of PTSD

• Re-experiencing
• Numbing/Avoidance
• Hyperarousal

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Evolving Understanding of Trauma and Youth
PTSD
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Evolving Understanding of Trauma and Youth
Traumatic Stress
PTSD
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Defining Trauma

• Not an event itself but rather a response to a
  stressful experience in which a persons ability
  to cope is dramatically undermined
• Traumatic events cause overwhelming anxiety or
  distress and include experiencing, witnessing, or
  being confronted with physical, verbal, and
  emotional abuse, or another event that involved
  actual or threatened death or serious injury to
  oneself or someone else

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Defining Trauma Traumatic Stress

• Traumatic events overwhelm the ordinary human
  adaptations to lifethey confront human beings
  with the extremities of helplessness and terror
• Judith Herman

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Child Traumatic Stress
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Individual
Family
Trauma
School
Community
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Trauma TypesNational Child Traumatic Stress
Network

• Physical Abuse Neglect
• Sexual Abuse
• Traumatic Grief
• Domestic Violence
• Community / School Violence
• Complex Trauma
• Medical Trauma

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Trauma TypesNational Child Traumatic Stress
Network

• Refugee Trauma
• Natural Disasters
• Hurricane
• Epidemics
• Floods
• Fires
• Earthquakes

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Trauma TypesNational Child Traumatic Stress
Network

• Terrorism
• Biological
• Chemical
• Radiological

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Trauma TypesNational Child Traumatic Stress
Network

• Physical Abuse and Neglect
• Causing physical pain or injury (physical abuse
  or maltreatment)
• Failing to give a child the care it needs
  according to its age (child neglect)
• Causing psychological injury (psychological
  maltreatment)

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Trauma TypesNational Child Traumatic Stress
Network

• Sexual Abuse
• Wide range of sexual behaviors that take place
  between a child and an older person. May also
  include non-contact abuse which includes genital
  exposure, verbal pressure for sex, and
  exploitation via prostitution and pornography

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Trauma TypesNational Child Traumatic Stress
Network

• Traumatic Grief
• Occurs following the death of a loved one when
  the child objectively or subjectively perceives
  the experience as traumatic

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Trauma TypesNational Child Traumatic Stress
Network

• Domestic Violence
• Actual or threatened physical or sexual violence
  or emotional abuse between adults that occurs in
  a childs home environment

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Trauma TypesNational Child Traumatic Stress
Network

• Community and School Violence
• Predatory violence and violence that comes from
  personal conflicts between people who are not
  family members.
• Robbery
• Shootings
• Rapes
• Stabbings
• Beatings

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Trauma TypesNational Child Traumatic Stress
Network

• Complex Trauma
• The cumulative problem of a childs exposure to
  multiple or prolonged traumatic events and the
  impact of this exposure on their development
• Usually begins in early childhood and occurs
  within the primary care-giving environment

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Trauma TypesNational Child Traumatic Stress
Network

• Medical Trauma
• Associated with injury or accident, chronic or
  life-threatening illness, or painful or invasive
  medical procedures

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Trauma TypesNational Child Traumatic Stress
Network

• Refugee and War Zone Trauma
• Exposure to war, political violence or torture
• Can also occur from living in a region affected
  by bombing, shooting or looting, as well as
  forced displacement due to political reasons

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Trauma TypesNational Child Traumatic Stress
Network

• Natural Disasters
• Any natural catastrophe that causes enough damage
  that local, state or federal agencies and
  disaster relief organizations are called into
  action

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Trauma TypesNational Child Traumatic Stress
Network

• Terrorism
• Intent to inflict psychological damage on an
  adversary
• US Department of Defense the calculated use of
  violence or the threat of violence to inculcate
  fear, intended to coerce or to intimidate
  governments or societies in the pursuit of goals
  that are generally political, religious, or
  ideological

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Child Traumatic Stress

• Children and Adolescents experience trauma as a
  result of two unique types of situations
• Acute Traumatic Events
• Chronic Traumatic Environments

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Acute Traumatic Events

• These types of trauma include
• When a child experiences a serious injury to
  themselves or witnesses a serious injury or death
  of someone else
• When children are faced with imminent threats of
  serious injury or death for themselves or others
• When children experience a significant violation
  of personal physical integrity.

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Acute Traumatic Events

• Specific Examples
• School shootings
• Gang-related violence in the childs neighborhood
• Terrorist attacks
• Natural Disasters (Tsunami, hurricane,
  earthquake)
• Serious accidents (motor vehicle)
• Sudden and/or violent loss of loved one
• Physical or sexual assault

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Chronic Traumatic Environs

• Exposure to trauma occurs repeatedly over long
  periods of time.
• This exposure to the toxic environment can bring
  about a large range of emotional responses
  including fear, mistrust, compromised feelings of
  safety, guilt and shame.

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Chronic Traumatic Environs

• Specific Examples
• Some types of physical abuse
• Long-term sexual abuse
• Domestic violence
• Wars and other forms of political violence and
  unrest

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Child Traumatic Stress

• The dynamic nature of child development causes
  children to respond to traumatic stress in
  different ways

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Child Traumatic StressChildren Under Age Three

• Change in their personality that involves being
  clingy, irritable or tearful
• Loss of energy or interest in play
• Regression or change in daily routines of eating,
  sleeping or toileting

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Child Traumatic StressPreschool Age Children

• Fear of being alone
• Nightmares, fear of the dark
• Clinginess
• Changes in speech (baby talk or stuttering)
• Defiance

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Child Traumatic StressSchool-Age Children

• Irritable, whiney
• Aggression toward peers
• School avoidance
• Headaches or other physical complaints
• Disturbances in sleeping or eating habits

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Child Traumatic StressTeenagers

• Headaches or other physical complaints
• Disturbances in sleeping or eating habits
• Withdrawal from family and/or friends

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Child Traumatic Stress Outcomes

• Many children recover naturally and completely on
  their own after experiencing Child Traumatic
  Stress
• Other children may go on to develop such
  psychiatric conditions as posttraumatic stress
  disorder, depression, and anxiety

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Child Traumatic Stress Outcomes

• Significant disruption of child or adolescent
  development
• Repeated exposure to traumatic events are
  associated with
• Atypical brain and nervous system development
• Increase risk of poor academic performance
• Engaging in high-risk behaviors
• Compromised peer and family relationships

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Child Traumatic Stress Outcomes

• Repeated exposure to traumatic events are
  associated with
• Increased use of health mental health services
• Increase involvement with the child welfare and
  juvenile justice system
• Adult survivors may experience difficulty in
  establishing intimate relationships and healthy
  employment histories

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Consequences of Trauma Exposure

• Posttraumatic Stress Disorder (PTSD)
• Re-experiencing
• Numbing/Avoidance
• Hyperarousal

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Consequences of Trauma Exposure

• Posttraumatic Stress Disorder (PTSD)
• Prevalence in adolescents
• 4 of boys
• 6 of girls
• 75 of those with PTSD have additional mental
  health problems
• Breslau et al., 1991 Kilpatrick 2003, Horowitz,
  Weine Jekel, 1995

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Consequences of Trauma Exposure

• Depression
• Anxiety
• Substance Abuse
• Behavioral Problems
• Poor School Performance

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How can Child Traumatic Stress impair childs
ability to learn?

• Single exposure to traumatic events may cause
• Jumpiness
• Intrusive thoughts
• Interrupted sleep nightmares
• Anger and moodiness
• Social withdrawal
• Concentration and memory difficulties

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Chronic exposure to traumatic events

• Especially during a childs early years
• Brain changes that impact attention, memory and
  cognition
• The overdevelopment of certain regions involved
  in anxiety and fear responses which result in the
  underdevelopment of other regions of the brain
  necessary for complex thought and learning
• Reduction in a students ability to focus,
  organize, and process information
• Difficulty with effective problem solving

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Impact of trauma on learning

• Decreased IQ and reading ability
  (Delaney-Black et al., 2003)
• Lower grade-point average (Hurt et al., 2001)
• More days of school absence (Hurt et al., 2001)
• Decreased rates of high school graduation
  (Grogger, 1997)
• Increased expulsions and suspensions (LAUSD
  Survey)
• Students and Trauma DVD

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Introduction to Trauma Informed Systems
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The Trauma Lens

• A shift in perspective from
• Whats wrong with you?
• to
• What happened to you?

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Attempts to cope may lead to behaviors that
undermine healthy relationships

• Aggressive or sexualized behaviors
• Sleeping, eating, elimination problems
• High activity level, irritability, acting out
• Emotional detachment, unresponsiveness, distance,
  or numbness
• Hyper-vigilance or feeling that danger is
  present, even when it isnt
• Under/over controlled behavior

(Developmental Trauma Disorder)
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High-risk or destructive behaviors as an attempt
to cope

• Aggressive or disruptive behavior
• Sleep disturbances
• Drug and alcohol as a coping mechanism to deal
  with stress
• Over-or under-estimation of danger
• Expectations of maltreatment or abandonment
• Difficulties with trust
• Leading to an increased risk of re-victimization

(Developmental Trauma Disorder)
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Protective Factors that Increase Resilency

• Caring supportive relationships
• High expectations for success
• Opportunities for meaningful participation
• Clear and consistent boundaries
• Life Skills (e.g., identifying internal states)

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Resilience and Recovery from Trauma

• Resilience describes the phenomenon that most
  children adolescents can bounce back from
  family or community problems or losses if the
  right combination of internal and external
  protective factors are in place.
• Most youth recover over time, yet 25-30 will
  withdraw from teachers, friends family or act
  out with increased negative behavior.

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Resilience and Recovery from Trauma

• These youth are in need of more specialized
  support from a Mental Health Professional.

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Why a trauma program in schools?
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Trauma School DVD
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Trauma Screening Activity
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Why a program for traumatized students?

• One night several years ago, I saw men shooting
  at each other, people running to hide. I was
  scared and I thought I was going to die. After
  this happened, I started to have nightmares. I
  felt scared all the time. I couldnt concentrate
  in class like before. I had thoughts that
  something bad could happen to me. I started to
  get in a lot of fights at school and with my
  siblings.
• Martin, 6th grader

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Why a program for traumatized students?

• While walking we saw people crying because they
  had no food and water. We saw bodies in the
  street. They had an old man dead in a chair. I
  was so scared I thought I was going to die. We
  were walking on the bridge, and the army men
  started to shoot in the air, and I just started
  to cry I was so scared. It started to rain and
  everyone started to cry, saying, I hope another
  hurricane dont pass by.
• Keoka, 10th grade

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Why a program for traumatized students?

• More and more youth are experiencing traumatic
  events
• Community violence
• Natural and technological disasters
• Terrorism
• Family and interpersonal violence
• Most youth with mental health needs do not seek
  treatment
• Many internalizing disorders in children go
  undetected

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Events of the Generation That Have Changed
Education

• 1990-2009 School Shootings 600
• 1995-Oklahoma City
• 2001-9/11 Terrorist Attacks NYC/DC
• 2001-Present The War on Terrorism
• Iraq War/Afghanistan/Middle East
• 2005 Hurricanes Katrina / Rita

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Traumatic Events in Society

• Child abuse and maltreatment
• Domestic violence
• Community violence
• Criminal victimization
• Medical trauma
• Traumatic loss
• Accidents and fires
• Natural Disasters (hurricanes, earthquakes,
  tornados, sunamis, wildfires)

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Traumatic Events in Schools

• School related violence
• Bullying
• Gang violence and threat
• Internet sources of information, values,
  instruction

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LAUSD 6th Grade StudentsPrevalence of Past Year
Violence, 2004
Gun or knife violence (40)
Non-weapon related violence(54)
No violence (6)
(N28,882)
No Violence (6)
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National Survey of Adolescents Prevalence of
Violence History
Assault Witness (23)
Witness Only (48)
No violence (27)
(N1,245 Kilpatrick et al, 1995)
Direct Assault Only (2)
(N28,882)
No Violence (6)
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Evidence-Based Practice A Dynamic Interplay
Best Clinical Experience
Best Research Evidence
EBP
Consistent with Family / Client Values
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Bringing Evidence-Based Treatment to Schools

• Kids are in schools (removes obstacles such as
  transportation, stigma, etc.)
• CBT in school setting
• Acceptable
• Feasible
• Amenable to group structure
• Focus on building skill
• Empowering

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Gaining support from school community

• Liaison with teachers and administration
• Find ideal time for group
• Present education about trauma and respond to any
  concerns about program
• Students and Trauma DVD
• Trauma Awareness Powerpoint Slides
• Trauma Factsheets for Educators
• Outreach to parents
• Depending on community and school issues,
  consider working with parent leaders to engage
  parents in process
• Develop parent component depending on needs of
  parents

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Third Culture Students Stress Trauma
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Third Culture Students Stress Trauma
Stress
Trauma
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Third Culture Students Stress Trauma
Not an event itself but rather a response to a
stressful experience in which a persons ability
to cope is dramatically undermined
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Third Culture Students Stress Trauma
Open Agenda Discussion
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Overview of AISA Trauma Response Program
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Children of War DVD
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Your toolkit to manage stress and trauma
Support for Students Exposed to Trauma (SSET)
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• Who implements SSET?
• teachers,
• school counselors
• school social workers

• What age group benefits from SSET?
• designed for middle school children/ grades
  4th-9th

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Goals of the SSET Program

• Reduce symptoms of PTSD and other related
  problems
• Build resilience
• Build peer and parent support

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Theory behind SSET
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Getting Started

• Screening
• Permission from parents
• Space
• Time of day
• Time of year (10 continuous weeks are optimal)
• of kids 6-10, gender mixed usually
• Group schedule

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Lesson One

• Introduction

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Goals and Objectives

• Build trust and group cohesion.
• Cover expectations of group.
• Students will verbalize why they are
  participating in group.
• Increase students comfort level within group.

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Materials

• Bag of MMs or other multicolored candy.
• Confidentiality statement to be signed by group
  members.
• Index cards
• Copies of the Why I am Here worksheet.
• Copies of the Goals worksheet.
• Copies of the Letters to Parents with leaders
  name and contact information.
• Return to Class slips.

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Leader Preparation

• Interview each student privately to confirm
  trauma and desire to attend group.
• Obtain permission slips.
• Discuss with each student on how he or she will
  present trauma have permission to present for
  student if it is to hard for them.
• Locate place and time to hold group sessions.

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Preparation cont

• Review Disclosure by Group Members.
• Troubleshoot Why we are here exercise.
• Review the Dos and Donts of the MM game.
• Have introductory questions on index cards and
  ready for MM game.
• Personalize the Letter to Parents.

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Session

• Welcome students and review agenda for the
  meeting.
• Review group schedules and hand out written
  copies for students to have.
• Discuss importance of being on time, showing
  respect and completing between-lesson activities.
• Review and discuss Confidentiality.

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Activities

• Play the MM game.
• Explanation of SSET.
• Go over Stress/Trauma/Violence Triangle.
• Have group members share stories.
• Go over at home assignment with students.
• Troubleshoot problems they might have in
  practice.
• Review what happened in group.

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Parent Calls

• Call parents to introduce yourself and provide
  information on group expectations.
• Letters are sent home after session one in case
  phone calls are not possible.

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Lesson Two Common Reactions to Trauma and
Strategies for Relaxation
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Goals and Objectives

• Teach students about normal or common problems
  that we have after a traumatic experience.
• Teach relaxation exercise to calm anxiety.
• Students increase understanding about negative
  thoughts ,feelings, and actions that result from
  trauma.
• Students feel more normal as result of
  understanding.
• Students feel a sense of support form peers in
  group.

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Goals and Objectives cont

• Students establish a sense of hope that the group
  will help reduce negative thoughts, feelings and
  actions associated to their experience.
• Children experience increased communication and
  support from parents.
• Students learn how to relax their bodies.

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Materials

• Copies of the List of Problems People have After
  Stress worksheet.
• Copies of the Information About Common
  Reactions to Stress or Trauma worksheet.
• Copies of the Activities worksheet.
• Highlighters
• Return to Class slips.

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Session

• Introduce agenda for session.
• Review practice from previous session.
• Education about common reactions to Trauma.
• Relaxation training to combat anxiety.
• Homework assignment.
• Review session

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Education on common reactions to trauma

• Deliver information and lead discussion on
  traumatic stress.
• Normalize problems.
• Explain how group can offer support.
• Build support among group members.

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Relaxation

• Have group members decline in chairs or lie on
  floor.
• Encourage focus and silence during activity
• Lead students in guided imagery and relaxation
  activity.

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Lesson Three Thoughts and Feelings
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Goals and Objectives

• Teach students a common language to describe
  feelings.
• Teach students that thoughts directly effect
  feelings.
• Introduce skill that challenges unrealistic
  thoughts.
• Students observe and increase ability to
  challenge thoughts.
• Students begin experiencing less anxiety by
  decreasing negative thoughts.

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Overview

• Introduce Agenda for session
• Review homework.
• Introduce fear Thermometer.
• Examples of thoughts affecting feelings.
• Linkage between thoughts and feelings.
• Assign homework.
• Review session.

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Materials

• Copies of fear thermometers worksheet.
• Comic strips, video clips or other examples that
  demonstrate how thoughts affect feelings.
• Copies of the Noticing Your Thoughts and
  Feelings worksheet.
• Return to class slips.

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Fear Thermometer

• Introduce fear thermometer concept for students
  to talk about how anxious or nervous they feel.
• Give examples to demonstrate different levels of
  feelings.
• Distribute blank thermometers, allow children to
  think of different situations and provide fear
  rankings using the fear thermometer.

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Linkage between thoughts and feelings

• This lesson shows that thoughts can cause and
  fuel feelings.
• Make certain group members understand the way
  that thoughts and feelings are linked.
• Engagement activity use example from group to
  demonstrate concept.

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Lesson Four Helpful Thinking
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Goals and Objectives

• Teach students to challenge their negative
  thoughts and replace them with more-helpful
  thoughts.
• Increase ability to challenge thoughts
• Increase ability to generate helpful thoughts.
• Students experience less anxiety as a result of
  mastering these skills.

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Overview

• Agenda for session.
• Review of previous homework.
• Hot Seat Check the Facts.
• Hot Seat activity
• Homework assignment
• review

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Materials

• Chair for Hot Seat activity.
• Copies of Questions you can use to argue
  against negative thoughts worksheet.
• Copies of Hot Seat Exercise worksheet.
• Return to Class slips.

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Hot Seat Activity

• Teach students to challenge negative thoughts
  and replace with positive thoughts.

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Lesson Five Facing your Fears
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Goals and objectives

• Introduce concept of avoidance.
• Students will be able to identify trauma-related
  avoidance.
• Decrease anxiety and increase confidence by
  facing fears.
• Increase skills by coping with anxiety.

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Materials and Leader Preparation

• Copies of Steps toward Facing your Fears,
  instruction worksheet, Facing your fears and
  Hot Seat Exercise
• Copies of Letter to Parents.
• Return to Class slips
• Review students individual experience and
  progress.

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Overview and Lesson

• Review homework from previous session.
• Introduction to facing your fears.
• Working with students on fear.
• Steps toward facing your fears.
• Go over coping strategies
• Assign homework.
• Review of session.

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Introduction to facing fears

• Explain that avoidance is a form of coping with
  anxiety.
• Avoidance often creates more problems than it
  solves.
• Pick a safe fear for student to work on.
• Work on steps to facing fears.

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Other Coping Strategies

• Introduce other ways of dealing with stress.
• Thought stopping
• Distraction
• Positive Imagery

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Lesson 6 Trauma Narrative Part 1

• Overall Goal
• Help students begin to process their traumatic
  experience through writing about it and sharing
  their story with the group
• Materials
• Writing a Newspaper Story worksheet
• A Newspaper Picture worksheet
• Facing Your Fears and Hot Seat Exercise
  Worksheets
• Return to Class slips filled out
• Leader Preparation
• Review each students traumatic event
• Review table 4, Common Misconceptions About
  Processing Trauma

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Sharing their Stories

• Confidentiality
• Support
• Paying attention
• Positive feedback

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Plan for Independent Practice

• Handout the Newspaper Picture Worksheet
• Ask students to draw a picture to accompany their
  news story
• Explain Drawing a picture is another way of
  digesting what happened
• Assignments
• Facing your Fears
• Hot Seat Exercise

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Lesson Eight Problem Solving
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Goals and Objectives

• Teach students skills to problem solve.
• Students learn the link between thoughts an
  actions.
• Students learn to brainstorm solutions.
• Students learn to evaluate pros and cons to
  solutions.
• Students learn to apply skills to problems in
  their own lives.

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Materials and Leader Preparation

• Copies of worksheets
• Problem Solving
• Facing Your Fears
• Hot Seat Exercise
• List of real-life problems faced by students in
  group
• Return to class slips.

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Overview

• Introduction
• Review of homework from previous session
• Social problem solving
• Brainstorming Solutions
• Decision Making
• Homework assignment
• Review

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Social Problem Solving

• Introduce that problem solving with others takes
  practice.
• Teach students how thoughts influence behavior
  with family and friends.

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Parts of a Problem

• Physical
• How others think and act
• How you think
• How you act or what you do

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Brainstorming and Decision Making

• Generate real-life solutions to real-life
  problems.
• Seek social support
• Try to get as much information about problem.
• Decision making pros and cons
• Evaluate possible actions

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Lesson Nine Practice with Social Problems and
the Hot Seat
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Goals and Objectives

• Increase students competence in challenging
  negative thoughts.
• Increase students ability to handle real-life
  problems.

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Materials and Leader preparation

• Evaluation forms
• Return to class slips
• Check in with students to assess continuing
  problems and symptoms.
• Consult with supervisor about referrals that will
  be made to outside services.

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Overview

• Introduce agenda
• Review homework
• Continued practice with problem solving and hot
  seat.
• Review key concepts that students have learned in
  group.
• Hand out evaluations
• Review session

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Lesson 10Planning for the Future and Graduation
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Goals and Objectives

• Help students review and celebrate their progress
  and consolidate skills they have learned.
• Students will identify positive change/progress
  made during the group
• Students will anticipate possible future
  challenges and consider ways of applying skills
  to future situations
• Students will celebrate graduation from SSET

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Materials

• Copies of Note to Self
• Copies of Certificate of Achievement
• Special snacks, gifts, treats and/or party
  supplies

130
Leader Preparation

• Review Ending the Group
• Review Individual students progress and have at
  least one genuine positive statement in mind
  regarding his/her involvement in the group
• Have students verbalize positive feedback to each
  other or have them right these down on slips of
  paper to be read to the group
• Make phone call to parents (optional)

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Overview

• Introduce agenda
• New Group Member Game
• Planning for the Future
• Graduation Ceremony and Individual Appreciation
• Wrap-up and Goodbyes

132
SummaryRecognizing and
Responding toChild Traumatic Stress in
School-age Children
133
Small group/Individual Consultation
134
Recognizing and Responding toChild
Traumatic Stress in School-age Children

• Douglas W. Walker, PhD
• Clinical Director - Mercy Family Center
• Project Director - Project Fleur-de-Lis
• dwallacewalker_at_yahoo.com