Trauma Informed training continues

The APA explains that traumatic events include ‘the direct threat of death, severe bodily harm or psychological injury that a person finds intensely distressing- such as those involved in natural disasters, life-threatening incidents -such as molestation, rape, combat experience, physical assault or abuse, or the personal experience of interpersonal violence. Psychological manifestations related to trauma experience include mood and anxiety disorders, behavioral disorders, identity disorders- eating and substance abuse, or co-occurring disorders.’

One of the central issues of trauma-informed care is that ‘traumatic life experiences are often shrouded in secrecy and denial’ and the ‘concept doesn’t fit well in traditional medical model with its focus on the biological causes of illness.’ So say Kevin Huckshorn and Janice L. Lebel in Chapter 5 on Trauma Informed Care in the book Modern Community Mental Health: An Interdisciplinary Approach ed. By Kenneth “Yeager, David Cutler, Dales Svendsen, and Grayce M. Sills.

There are challenging days/times for teens and staff alike in any setting. It’s true of the family dynamic also. Vicarious trauma is often called compassion fatigue or sometimes referred to as the ‘cost of caring for others’. The experience of empathy wires us for ‘sharing’ distress. ‘There are four categories of symptoms which may be associated with experiencing vicarious trauma: behavioral, interpersonal, those affecting personal values/beliefs, and job performance,’ explained Pomegranate’s Phoebe Kellerman, LISW-S in the August All-Staff meetings. ‘Symptoms might manifest in a sense of isolation, staff conflict, impatience, avoidance behaviors, low motivation, increased errors, or perfectionism.’ (See American Counseling Association Traumatic Interest Network) Kellerman said there are personal strategies to cope with the stresses of constant, intense caregiving. These include seeking escape- physically, mentally- such as provided by a walk or run; rest- time with no goals or ‘to-do’ lists; and play- which lightens the spirit through laughter and other activities. Agency strategies might include additional benefits, time off, supervision/supervisory input, team building, and trainings.

Edward, one of the senior mentors of Pomegranate’s youth said it was helpful to him to remind himself, ‘It’s not me; it’s them’ [they’re having a ‘bad hair day’; something may have triggered a traumatic memory] and to ‘go to where they’re at’; to ‘walk the extra mile in understanding a teen who is struggling with an emotion or behavior.’ This brought agreement from several other teen coaches. Kellerman showed slides that trauma victims are especially triggered by use of seclusion and restraint. Clinical Director Demetra Taylor added that this is the primary reason Pomegranate does not use either. To prevent re-traumatization, there are four coping mechanisms: try to de-escalate a situation/event; utilize crisis plans, identify triggers that remind or initiate a state of anxiety or agitation, and stay calm. Key principles of trauma informed care include: 1) awareness, 2) emphasis on safety, 3) opportunity to rebuild control and 4) a strength-based approach.

As authors Huckshorn and Lebel explain, ‘PTSD sufferers often re-experience an event through flashbacks, nightmares, or intrusive memories. They may engage in avoidance or numbing behaviors, disassociate, or withdraw. They could experience hyper-arousal and fearfulness. There are neuro-biological markers as dysregulation occurs via the hypothalamic pituitary adrenal axis. There is a different response in PTSD from other mood and anxiety disorders. PTSD adversely impacts the hippocampus, learning and memory and the frontal limbic system which regulates responses to stress and fear.’ (adapted from Harris & Fallot 2001 and NASMHPD 2010; also see Van der Kolk 2001).

With research, and new discoveries brought about through advances in technology, we can legitimately say that mental illness is “not just in someone’s head”, but can be experienced through-out one’s entire being, influencing body, mind, spirit, relationships, career, and life. PTSD is one example of this. ‘Because of the sequential nature of childhood development, trauma can stop or slow a child in his/her tracks physically, emotionally, mentally and genetically-in teen or earlier stages of childhood, and therefore, must be taken seriously,’ concluded Kellerman and Taylor.

[photo credit: Wikimedia Commons Creative Commons 2.0. Author Ness Kerton from The Dept. Foreign Affairs & Trade at Point Moresby General Hospital Susa Mama Health Clinic, in Papua New Guinea]

Biology and response of the developing brain

Franklin County Family and Children First (with funding provided by Ohio Children’s Trust Fund and OACCA) presented several workshops by Bruce D. Perry, M.D., PhD, through the Building Better Lives: Changing the Cycle of Child Abuse and Family Violence initiative last week. Perry is the Senior Fellow of The Child Trauma Academy which is a not-for-profit organization in Houston, Texas. He is also adjunct Professor in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine at Northwestern University in Chicago. His bio is impressive, outlining his work in psychiatry and neuroscience, academic appointments, hundreds of articles, engagements and media appearances. Most importantly, his work with developmental neuro-science, and neuro-biology-informed approach to clinical work (NMT) and education (NME) is being integrated into programs in public and non-profit organizations for children and families who have suffered trauma and/or are at risk. The Pomegranate Health Systems clinical team is in the process of becoming certified in NMT, Neuro-sequential model of therapeutics.

Perry explained that there are 100 billion neurons in the brain with sophisticated connections and pattern of activity of firing. The brain is not a democracy; some neurons are more important. “The brain allows us to absorb the accumulated and distilled experiences of thousands of previous generations in a single lifetime,” he said. Adverse experiences disrupt development, health and growth. A body is dys-regulated by interrupted, inconsistent, unpredictable patterns of regulation/activation. The baseline systems over-react. Everything that happens forms the basis for future development and these developmental stages are sequential. “Children with more than four adverse childhood experiences have a greater risk of heart disease than smoking two packs of cigarettes a day.” ACES info at http://www.cdc.gov/ace/findings.htm

The brain does different things in one state versus another and there is a shift that takes place when the stress response gets activated. Almost all feelings/behaviors are elicited in the somato-sensory part of the brain before they get to the cognitive or ‘smart part’ he explained. There were many slides of not only the brain, but visual representations how neurons fire, how development takes place, how emotions/response are processed and the arousal response from a calm state to alert, progressing to terror –which can occur as a response to abuse. Some children will dis-associate. Responses are physiological, psychological, emotional, hormonal and neurological.

‘Human interactions are physiological events,” he said. Most successful interventions are done within a rich network of people you can go to; something which is less likely to happen when you only revisit in appointments of 45 minutes once a week. (At this point, he shared several examples.) ‘Relational environments are good for you. In our culture you have two caregivers, often only one- with multiple kids. This does a dis-service not only to the child, but the parent who is supposed to provide every -and all- skills and services in parenting,’ he said. In the natural world there are many healthy older members. (Think tribe or clan). A hunter-gatherer function with a clan of caregivers offer multiple skills. The ratio is more like 4:1 (four parent figures to 1 kid). ‘With the ratio reversed- one caregiver to four kids, there is a greater possibility of emotional impoverishment,’ he noted.

With traumatized children he has worked with, intervention/s are likely to happen in sporadic sessions of a few minutes here or there as the child is able; not one steady forty five minute session once a week. Often, the way many interventions are done in a child protective framework, the child is removed totally from his/her familiar network. For example, by removing an abused girl from home, she does not have the comfort of her sister, familiar school, girl-scout troop, church, grandma, or familiar setting-own bedroom. She has lost the network she knows and which can be supportive, even if the primary one is not. The girl is then placed for example, into a suburban foster home in a far Northwest suburb. If she AWOLs, she is then placed in a locked facility, rather than remove the father who abused her. These are the systems which are being re-examined and re-imagined for the knowledge we now have.

Perry addressed chronological versus developmental age. Because the brain develops in a use- dependent way, you might have a very young parent with the skills and social development of a five year old, and should not be surprised if they spend the rent money on a DVD player. Typical teaching in the school system is based on chronological age, not developmental age. This can set many kids up to fail. After an explanation of adaptive response, and response patterns, Perry went into a discussion of the chronological timeline when adverse events took place, and whether a condition was developed at the genetic level, epigenetic level, intrauterine, up through each year of early childhood into pre-school and kindergarten. He explored core principles of NMT and showed several visual representation ‘maps’ which assess adverse risk events at different stages in a child’s life to help in understanding and creating better outcomes with safe, developmentally appropriate repetitive experience and education.

He said we need ‘new ways to deal with these children; a treatment coalition of different skill sets. In many cases treatment programs are designed around us and our needs, and this is not helping the kids.”

For “Tips for Parents & Caregivers of Children who have Experienced Trauma” by Bruce D. Perry, M.D. PhD, or more information, visit: http://www.ChildTrauma.org. All course material is copyrighted by Bruce D Perry, MD, PhD 2010; for more information visit the website.

Attendees were treated to a copy of Dr. Perry and Maia Szalavitz book, ‘The Boy Who Was Raised As A Dog: And Other Stories from a Child Psychiatrist’s Notebook by Basic Books, New York, 2007; or ‘Born for Love: Why Empathy Is Essential and Endangered’ by Harper Collins, New York, 2010.

He is also writing: ‘Maltreated Children: Experience, Brain Development and the Next Generation’, Norton, New York, which is in preparation.

Link to ACES Adverse Childhood Experiences Information:
http://www.cdc.gov/ace/prevalence.htm#ACED
http://www.cdc.gov/ace/findings.htm

[photo credit: Wikimedia Commons. NARA. Edison, Kern County California. Children of young migratory parents, originally lived in Texas].