Feb 25, 2013 — In addition to aggressive behaviors, these children are As a best practice for trauma informed care, it is.

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echappellTDMHSASResearchTeam 02/25/2013 Page | 46 TDMHSAS BEST PRACTICE GUIDELINES Trauma-Informed Care Introduction What is Trauma? According to the Diagnostic and Statistical Manual (DSM-IV-TR, 2000), trauma is defined as, the experience of a real or perceived threat to life or bodily injury OR the life or bodily injury of a loved one AND causes an overwhelming sense of terror, horror, helplessness and fear. (Note: The DSM-5 will include a new chapter titled fiTrauma- and Stressor-Related Disordersfl. However, it is not available in either print or electronic format at the time of this publication.) Types of trauma. Psychological trauma may include medical issues such as surgeries, living in combat zones, accidents, natural disasters, relational trauma, abuse, neglect, enduring deprivation, and urban violence, all of which involve major losses for children who rely on adults to meet their physical and emotional needs, including connection, safety, support, and soothing (Giller, 1999).The National Child Tr aumatic Stress Network (NCTSN, n.d.e) divides trauma into the following categories: Community and School Violence Complex Trauma Domestic Violence Early Childhood Trauma Medical Trauma Natural Disasters Neglect Workgroup Members: Kristin Dean, PhD, Univerisity of Tennessee-Cherokee Health Systems Center of Excellence Œ Chairperson; Bonnie Beneke, LSCW, Tennessee Chapter of Children™s Advocacy Centers; Crystal Crosby, MA, LPC- MHSP, NCC, Fortwood Center; Donald Jordan, LMSW, Pathways of Jackson; Elizabeth Power, MEd, EPower & Associat es; Ann Kelley, PhD, Omni Visions; Kathy A. Benedetto, SPE, LPC, LMFT, Frontier Health; Patti van Eys, PhD, Volunteer State Health Plan; Lori Myers , LCSW, RPT, Sexual Assault Center; Robert Edmonds, MA, LPE, Volunteer Behavioral Health Œ Cookeville; and Mary Katsikas, MAFP, Helen Ross McNabb Center.

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echappellTDMHSASResearchTeam 02/25/2013 Page | 47 Physical Abuse Sexual Abuse Refugee and War Zone Trauma Terrorism Traumatic Grief What is Child Traumatic Stress? Blaustein (2010), co-developer of the Attachme nt, Self-Regulation, and Competency (ARC) treatment model, offers that fitraumatic expe riences are those that are overwhelming, invoke intense negative affect and involve some degree of loss of contro l and/or vulnerability.fl Child traumatic stress takes place when children and adol escents are put in view of traumatic events or traumatic situations, and when this situation overp owers their skills to cope with what they have gone through (NCTSN, n.d.c). What is Trauma-Informed Care? The Substance Abuse and Mental Health Services Administ ration (SAMHSA, n.d.) National Center for Trauma-Informed Care defines trau ma-informed care as fian approach to engaging people with histories of trauma that rec ognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their livesfl (SAMHSA/NCTIC web site, n.d.). Trauma-informed care focuses on the provision of developmentally appropriate, gender-specific care through the lens of research and evidence of effective practice for children and youth who have experienced events that are psychologically overwhelming (Jennings, 2008). Impact of Trauma Prevalence Trauma exposure prevalence rates vary widely, depending on the community and type of trauma. For example, more than 6 in 10 U.S. youth have b een exposed to violence within the past year, including witnessing a violent act, assault with a weapon, sexual victimization, child maltreatment, and dating violence. Nearly 1 in 10 was injured (Finkelhor et al., 2009; SAMHSA, 2009). Nationally, an estimated 772,000 children were victims of maltreatment in 2008 (U.S. Department of Health and Human Services, 2010). Violence exposure rates in urban settings have been well-documented (Stein, Jaycox, Kataoka, Rhodes, & Vesta, 2003), but rural communities are also reporting higher rates of violence exposure (Dean, Wiens, Liss, & Stein, 2007). In a longitudinal general population study of children and adolescents 9-16 years old in western North Carolina, researchers found that one quarter had experienced at least one potentially traumatic event in their lifetime, and 6 percent within the past three months (Costello, Erkanli, Fairbank, & Angold, 2002). In a continuation of the North Carolina study, Copeland and colleagues (2002) found that more than 68 percent of children and adolescents had experienced a potentially traumatic event by the age of 16. Full- blown PTSD was rare, occurring in less than

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echappellTDMHSASResearchTeam 02/25/2013 Page | 48 one half of one percent of children studied. Other impairmentsŠincluding school problems, emotional difficulties, and physical problemsŠoccurr ed in more than 20 percent of children who had been traumatized. In those who had experience d more than one traumatic event, the rate was nearly 50%. Traumatic stress rates also vary and are dependent on a number of variables, including proximity to the event, the number of previous stressors or trauma exposures, trauma reminders or triggers, support system, and resources (La Grecca, Silv erman, Vernberg, & Prinstein, 1996). A recent review of research on children exposed to specific traumas found wi de ranges in rates of PTSD: 20 percent to 63 percent in survivors of child maltreatment. 12 percent to 53 percent in the medically ill. 5 percent to 95 percent in disaster survivors (Gabbay, Oatis, Silva, & Hirsch, 2004). These numbers do not reflect the multitude of othe r consequences of trauma exposure, including physical health issues and other behavioral health consequences. Adverse childhood experiences (e.g., physical, emotional, and sexual abuse; fam ily dysfunction) are associated with mental illness, suicidality, and substance abuse in youth, and with many of the leading causes of death in adulthood (Felitti et al, 1998). Trauma and Development Children respond differently to stressors, including traumatic stressors, depending on a number of factors such as: 1) Characteristics related to the individual child (e.g., temperament, cognitive abilities), 2) Characteristics related to the trauma exposure (e.g ., proximity, fidosefl of trauma), and 3) Post-trauma factors (e.g., s upportive caregivers). A critical and ubiquitous factor in how children experience traumatic events and express their subsequent distress, however, depends in large part on the child™s age and developmen tal level. The following paragraphs outline developmental information that can be used as a general guide when providing care for children from a trauma-informed pers pective (Adams, 2010; Hodas, 2006; NCTSN, n.d.a, Schwartz& Perry, 1994). In response to trauma: Infants might – Become irregular in their biological pa tterns such as sleeping, eating, and voiding Become more fussy OR become di sengaged (shut down, dissociated) Become more difficult to soothe Become less adaptive to changes in routine Show bodily symptoms (e.g., vomiting, looser stools or constipation)

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echappellTDMHSASResearchTeam 02/25/2013 Page | 49 Preschoolers and young school-age children often– Experience feelings of helplessness Are uncertain regarding the possibility of continued danger Experience generalized fear that extends beyond the specific trauma Show their distress through behaviors rather than through words Lose (temporarily) previously acquired developmental skills such as toileting and speech Generally regressive behaviors such as clinging, thumb-sucking or bedwetting Display sleep disturbance (e.g., fear of going to sleep, nightmares, frequent wakening) Display separation anxiety and a fear of doing things they once did freely (e.g., playing outside in the yard without a caregiver with them) Engage in traumatic play (e.g., repetitious play that is less imaginative than their normal play and may represent the child™s continued focus on the trauma) Tend to react more to the reaction of the primary caregiver in relation to the trauma than to the trauma itself School-age children might – Develop a persistent concern regarding their own safety and the safety of others close to them and may show sign s of separation anxiety Become preoccupied with their own actions dur ing the traumatic event, experiencing shame or guilt regarding what they did or did not do Experience sleep disturbances Experience trouble with concentration and learning in school Complain of headaches, stomachaches, or other somatic problems that appear to have no medical basis Engage in constant retelling of the traumatic event Describe feeling overwhelmed by fe elings of fear and/or sadness Become more irritabl e and/or aggressive Become withdrawn Adolescents might – Experience heightened anxiety and fear sometimes with flashbacks/intrusive thoughts Experience vulnerability that could: lead to behaviors of acting out (aggressive) to gain a sense of control/power or lead to avoidance behaviors such as staying at home inst ead of going to school or out with friends Have concern over being labeled fidiffe rentfl or fiabnormalfl from their peers Withdraw/actively avoid reminders of trauma Experience sleep disturbance Experience feelings of shame and guilt regarding the trauma vis-à-vis what they either did or did not do during the trauma Engage in revenge fantasies Have depressive symptoms including suicidal ideation

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echappellTDMHSASResearchTeam 02/25/2013 Page | 50 Experience school/vocational decline Have a radical shift in their world-view (e.g., fiNowhere is safefl) Engage in self-destructive or accident-prone behaviors Complex Trauma In contrast to the earlier belief that early trauma had little impact on the child, it is now recognized that early trauma has the greates t potential impact, by altering fundamental neurobiological processes, which in turn can affect the growth, structure, and functioning of the brain. When trauma occurs in a chronic, persistent manner in the context of the young developing brain, the negative effects of such ficomplexfl or fidev elopmentalfl trauma have been shown to be cumulative, with damage from one stage of development a ffecting the successful navigation of developmental task s at the next stage (e.g., van der Kolk, 2003). The majority of brain development is completed during the first five years of life, with the most critical development occurring within the first two year s. Brain structures responsible for regulating emotion, memory, relationship secu rity (e.g., attachment) and behavior develop rapidly in the first few years of life and are very sensitive to da mage from the effects of emotional or physical stress, including neglect (e.g., Ford, 2009; Nelson, Zeanah, Fox, Marshall, Smyke, & Guthrie, 2007; Perry, Pollard, Blakeley, Baker, & Vigiliante, 1995; Teicher, Anderson, Polcari, Anderson, Navalta, & Kim, 2003). Thus, when thinking deve lopmentally about a child™s symptoms across social, emotional, behavioral, somatic, and cognitiv e domains, it is important to learn as much as possible about the early history of the child with an eye toward traumatic experiences, losses, and most importantly, the early car egiving environment. It is im portant to ask, fiDid the child experience early, multiple, or persistent overwhelmi ng events that might have altered the actual neurochemistry and structure of the developing br ain?fl If the answer is fiyesfl, the child may have symptoms of complex trauma that will re quire a more comprehensive treatment approach. Subtle Psychological Effects of Trauma on Children While only a minority of traumatized children shows signs of Complex Trauma, many children manifest signs of pervasive subtle effects of trauma, and these signs may be missed without careful assessment . Consider the followi ng from Hodas (2006): [Youngsters] fiwho are required to a dapt to dangerous and frightening circumstances, especially within the context of poverty, tend to develop subtle changes in their thinking, beliefs, and values. Such changes lead to attitudes and behaviors that are seen by adults as pathological, even though they may have been adaptive in the past, or in some cases continue being adaptive in the community environment. The subtle psyc hological effects of trauma on children represent yet another manifestation of the pervasive impact of trauma. These internal changes and consequent behavioral manifestations, while appearing maladaptive to mainstream adults and child-serving professionals, actually have often been of adaptive benefit to the child, given the need for survival.

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echappellTDMHSASResearchTeam 02/25/2013 Page | 51 Professionals working with children who have been exposed to trauma often encounter highly guarded individuals, who appear unresponsive to adult efforts to help. Not uncommonly, the trauma goes unrecognized and the child enters, or is at risk of entry into, the juvenile just ice system. Many similar children are in Special Education as well. In addition to aggressive behaviors, these children are also at risk of self-injurious behaviors and suicide attempts–fl(pp. 24-25). Resilience Children who experience trauma display num erous responses, reactions and symptomology. Originally, researchers believed children to be resilient if they posse ssed a defined list of protective factors and were asymptomatic fo llowing a trauma. Recently, the definition has expanded to encompass certain characteristics within each child and his/her environment. Bonanno (2004) suggests resilient individuals are people who remain stable throughout the process of trauma. Resilience continues to be defined finot as immunity or imperviousness to trauma but rather the ability to recover from adverse experiencesfl (Truffino, 2010, p. 146). Multiple researchers define resilience as a cluster of personal characteristics and/or environmental strengths (Bensimon, 2012; Knight, 2007; Perry, 2006; Truffino, 2012). Agaibi and Wilson (2005) noted th e characteristics of fihardiness, optimism, self enhancement, repressive coping, positive affect and a sense of coherencefl as the personal characteristics seen in resilient individuals. Perry (2006) published an article defining four key areas that affect a child™s capacity for resilience, child temperamen t, attuned caregiving, healthy attachments and opportunities for practice. This view of resilien ce as a personal cluster of symptoms and environmental characteristics fits with what re searchers know of development and trauma in children. These clusters explain children growing up in adverse situations being resilient and asymptomatic following a traumatic event. As a be st practice for trauma informed care, it is imperative that clinicians assess for and streng then the resilient characteristics and qualities within families and children. This poses a framework to fisupport children and families by fostering coping skills that empower them a nd become protective resourcesfl (Knight, 2007, p. 543). Assessment Why Screen for Trauma? As indicated in previous sections, childhood traumas vary from the sudden loss of parents, siblings, and other loved ones, life-threatening illness, natural disasters, physical and sexual abuse, to community and domestic violence . Though children are resilient, they are also profoundly affected by these experiences. With e ffective responses from caregivers and the community, they recover and thrive. Without it, trauma™s effects can derail childhood and reverberate into adult life. Yet child traumatic stress remains one of our most under recognized public health problems(www.nctsn.org; www.acest udy.org). Youth impacted by trauma often do not receive appropriate mental h ealth care, particularly children who internalize their experience and do not engage in fiacting outfl behavior. Alternatively, children who engage in disruptive

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echappellTDMHSASResearchTeam 02/25/2013 Page | 53 Assessing Other Psychiatric Disorders Children™s Depression Inventory (CDI: Kovacs, 1992) Revised Child Manifest Anxiety Scale (RCMAS: Reynolds & Richmond, 2008) Child Behavioral Checklist (CBCL: Achenbach, 2001) Teacher Report Form (TRF: Achenbach, 2001) Diagnostic Interview Schedule for Children (DISC: Shaffer, 2000) Diagnostic Interview for Children and Adolescents- Revised (DICA-R: Reich, 1991) Parenting Stress Index Short Form (PSI: Abidin, 1995) Assessing Caregiver Traumatic Stress Assessing trauma issues in parents is also critic al to engaging and tailoring the intervention for the caregiver. Caregivers who are overwhelmed, or for whom traumatic experiences are part of their own history, may have deficits in their ab ility to manage and modulate strong feelings; in creating, accessing and using strong positive connectio ns when stressed; and in feeling worthy of life. The experience of having a child who has been traumatized often brings with it anger, shame, and embarrassment coupled with feelings of inadequacy. In many cases, access and support for change may be challenges (NCTSN, n.d.b). Systems Approach to Trauma Informed Care Overview Trauma-informed care (TIC) is a systems-focused frame of reference and operating model appropriate in the care of all children and youth. TIC impacts: Organizational culture Staff practices and approach Policy and processes Technology (record keeping) Screening and assessment Staff learning and development in each component of care. TIC also impacts interfaces among systems. For exam ple, if an educator is not trauma-informed, the tendency to view disruptive behavior from a punitive perspective is stronger. If that educator engages with a trauma-informed behavioral prov ider, the differences in world views can be challenging. In one community, helping teachers shift their understandi ng of student behavior reduced suspensions by 85 percent (Stevens, 2012). Infusing systems of care with trauma-informed knowledge and practice has dramatic results. Systems that become trauma-responsive reduce re sponses such as seclusions and restraints,

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echappellTDMHSASResearchTeam 02/25/2013 Page | 54 model the post-system responses hoped for in clients, reduce the inevitable secondary or vicarious traumatization of st aff, and distribute the respons ibility among everyone involved rather than relegating it to mental health st aff. Because the impact of trauma can undermine successful intervention, trauma-infor med systems that address this impact are more likely to see treatment success. Why TIC is Critical to Care: Incidence of Trauma We are increasingly recognizi ng the importance of implementing trauma-informed care. Williamson, Dutch, & Clawson (2010) offer the follo wing description of why TIC is critical to care: Trauma-informed services are a crucial part of a victim™s recovery (Clawson, Salomon, & Grace, 2008). In trauma-informed care, treatment is guided by practitioners™ understanding of trauma and trauma-related issues that can present themselves in victims. Trauma-informed care plays an important role in service delivery by providing a framework for accommodating the vulnerability of trauma victims. It is not, however, designed to treat specific symptoms or syndromes (Office of Mental Health and Addiction Services, 2008). The treatment of specific mental health symptoms and syndromes requires evidence-based ther apeutic and sometimes pharmacological approaches (pp. 3-4). Trauma is strongly associated with mental and substance use disorders (SAMHSA, 2009). Mueser and colleagues (1998) reported that 90 percent of public mental health clients have been exposed to multiple experiences of trauma. In response, trauma-informed services recognize and avoid coercive interventions that traumati ze children, youth, and those who care for them. Organizations providing the new gold standard of care collaborate with those who receive services focusing on the present, identifying and enhancing strengths rather than working only on symptom management. They assume that servic e recipients do the best they can at every moment, and work to create authentic reconnecti on, reparation, and healing in the areas impacted (Fallot & Harris, 2006). Another response to the prevalence of trauma and its contex t is the awareness that trauma- informed care is inherently re lational aware of the impact of the work on all involved. As a result, a key focal point in trauma-informed care is the management of vicarious trauma and self- care for those who receive and provide servi ces to optimize trauma-informed services. Finally, evidence-informed or evidence-based trau ma-specific treatments can be delivered in any operating model, whether traditional, medical or trauma-informe d. However, the delivery of a trauma-specific treatment in an environment that is not trauma-informed may foster cognitive dissonance and confusion for those receiving serv ices because of the dissonance between the environment and the intervention.

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echappellTDMHSASResearchTeam 02/25/2013 Page | 55 Foundational Principles in Trauma-Informed Care for Systems These principles were identified on the basis of knowledge about trauma and its impact, findings of the Co-Occurring Disorders and Violence Pr oject (Moses, Reed, Mazelis, & D’Ambrosio, 2003), literature on therapeutic communities (C ampling, 2001), and others (Harris & Fallot, 2001; Fallot & Harris, 2002; Saakvitne, Gamble, Pearlman, & Lev, 2000; Bloom & Sreedhar, 2008). Principles of trauma-informed care in systems include: Understanding Trauma and its Impact. Trauma impacts body, brain, judgment, frame of reference, beliefs, the ability manage fee lings, experience healthy connection, and feel worthy of life; problematic behaviors (symptoms) in the present are adaptive responses to past traumatic experiences ( Saakvitne et al., 2000). Promoting Safety. In trauma-sensitive organizations , provider responses are respectful, consistent, and predictable. The environment pa ys attention to physical and emotional safety, and to reducing barriers to access. Ensuring Cultural Competence. This includes understanding how cultural context influences perception of and response to traumatic events and the recovery process; respecting diversity within the program, providing opportunities to engage in cultural rituals, and using interventions respectful of and specific to cultural backgrounds. Supporting Control, Choice and Autonomy. Systems of care that are trauma-informed help children and youth (1) regain a sense of choice in their daily lives, (2) develop practical skills in managing feelings, developing intern al connections, and feeling worthy of life, correct cognitive errors and develop autonomy (3)provide opportunities for them to make daily decisions and participate in the creation of personal goals, and (4) maintain awareness and respect for basic human rights and freedom. Sharing Power and Governance. Trauma-informed systems promote equalization of the power differentials. Persons who receive services and in the case of children and youth, their caregivers, are active fully empowered particip ants in advisory and board capacities. Integrating Care. Integrating systems of care across body, mind, and spirit is a hallmark of trauma-informed care. For example, a recent re search study testing Risking Connection™s key principles in low-income healthcare clinic s noted improved communication between patients and providers. Sidran Institute has partne red with faith-based communities to support adoption of a trauma-informed rather than stigmatizing perspec tive in responding to congregants in Jewish, Muslim and Christia n congregations. Trauma happens to the body, and the use of interventions such as yoga and mindfulness practices have been used in re- regulation of the brain and body. Healing Happens in Relationship. Trauma often occurs in relationship. The recovery from all trauma involves relationships, and TIC inco rporates establishing safe, authentic, and

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echappellTDMHSASResearchTeam 02/25/2013 Page | 56 positive relationships can be corrective and restorative to survivors of trauma. Recovery occurs. Understanding that recovery is possible for everyone regardless of how vulnerable they may appear; instilling hope by providing opportunities for involvement at all levels of the system, facilitating support from a broad social network, focusing on strength and resiliency, and establishing future-oriented goals are key characteristics in TIC. A general compare and contrast model for non-tr auma informed and trauma informed systems follows (Gillece, n.d.): Trauma-informed Non-trauma informed Recognizing high prevalence of trauma Lack of education on trauma prevalence & fiuniversalfl flprecautions Recognizing primary and co -occurring trauma diagnoses Over-diagnosis of schizophrenia, bipolar disorder, conduct disorder & singular addictions Assessing for traumatic histories & symptoms Cursory or no trauma assessment Recognizing culture and practices that are retraumatizing fiTradition of Toughnessflflvalued as best care approach Minimizing power/control – -constant attention to culture Keys, security uniforms, staff demeanor, tone of voice Caregivers/supportersŒŒcollaboration Rule enforcers ŒŒcompliance Addressing training needs of staff to improve knowledge & sensitivity fiPatient-blamingfl flas fallback position without training Objective, neutral language Labeling language: manipulative, needy, fiattention-seekingfl Transparent systems open to outside parties Closed system – advocates discouraged Specific policy recommendations ex ist for agencies interested in implementing trauma-informed care, but that is beyond the scope of these guidelines. For more information, please visit the National Center for Trauma-Informed Care website at http://www.samhsa.gov/nctic/default.asp . For a full report of recognized, effective TIC models, see Jennings (2008).

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