Trauma informed care: Teaching not treating INFORMED CARE: TEACHING NOT TREATING. ... brain Neocortex /subcortex Subcortex/ limbic Limbic/mid ... If this shift is …

TRAUMA INFORMED CARE: TEACHING NOT TREATING.A BRIEF OVERVIEW OF THE TRANSFORMING CARE TRAINING PACKAGE

Sharon Atkin, Diana Boswell, Sue Kitchener, Brenda Boustead & Valerie Picot.

12/5/2008

Thomas Wright Institute

OVERVIEW

12/5/2008Thomas Wright Institute

Goal & objectives of Transforming Care trainingImpact of complex trauma on brain developmentImplicationsRelevance across diagnosesContexts for learningRelevance across culturesSummary

Goal of TC Training


Developed through the Thomas Wright InstituteGoal

To positively transform the way care providers understand and respond to the children in their care.

To enhance understanding & promote ways of respondingDevelop practice

Learning objectives of TC Training


ObjectivesTo provide information about underpinning theoriesOutline key principles of brain developmentIntroduce concept of pain based behaviour and responsesDescribe the 3 central intervention principles Introduce a sample set of practice skills based on the 3 key principles

Theories


The training aims to create a framework that links trauma, developmental, attachment theories and neuroscience

Defining Trauma


Trauma as “a psychologically distressing event that is outside the range of usual human experience, often involving a sense of intense fear, terror or helplessness”(Bruce Perry, 2002)

Simple trauma (acute trauma; type 1)- one off event

Complex trauma (relational trauma; developmental trauma; type 2)

Complex Trauma


“Complex trauma describes the experience of multiple, chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature (e.g. sexual or physical abuse, war, community violence) and early life onset”(van der Kolk, 2005)

“At the core of traumatic stress is a breakdown in the capacity to regulate internal states like fear, anger, and sexual impulses” Bessel van der Kolk

“The most significant consequence of early relational trauma is the loss of the ability to regulate the intensity and duration of affects” Allan Schore

Trauma and Pain

Trauma leads to the repeated

involuntarytriggering of the stress reaction with feelings of overwhelming

fear and helplessness.

“States of autonomic hyperarousal are subjectively experienced as pain…”

(Schore, 2003, p. 68).


The organisation of behaviour

• If young people have learned to be in a constant state of hyperarousal & constantly vigilant for danger or threat?

•What behaviours would we expect to see? •Impulsive responses: Anger; fear; aggression; disorganisede.g. change of plans

Behaviours that make sense given the context

Trauma, Attachment & Brain Development


AttachmentAttunement (draw upon external (carer) means of regulating emotion whilst learning and developing self regulation)Emotion regulation development

Central challenge is to engage in the world (learn from novel experience) yet maintain a degree of emotional regulation (Shroufe et al, 2005)

Attachment & development


Ability to learn and develop compromised when can’t explore the world in the context of responsive care giving (secure attachment base)

Behaviour as organised


Infant developing in tandem with carer (relationship with carer)

Infant behaviours as organised to achieve safety – genetically wired to seek care giver to ensure safety.

Secure attachment


Mother behaviour Infant behaviour Purpose/ utility

Knowledge & understanding of needs; responsive to child’s needs and timing of needs; affectionate

Protest when separated show delight when mum returns.

Easily settled.

Explores with reference to carer for security.

Behaviour organised for safety and learning:

Facilitates exploration and learning/ development

Anxious/ambivalent


Mother behaviour Infant behaviour Purpose/utilityLack of knowledge & understanding of infant needs; unresponsive; not attuned to timing or needs

Not easily settled; May be angry; may fuss; clingy; push away after seeking to be held;

Behaviour organised for safety:

learn to maximise expression of attachment (intensity in face of slightest threat) so as to ensure proximity of carer should this be crucial(inhibits exploration/ learning)

Avoidant/ Resistant Attachment


Mother behaviour Infant behaviour Purpose/utility

Physical rejection; lack of affection; lack of interest; negative feelings about motherhood

Fail to seek out or establish contact; may ignore care-giver;

Behaviour organised for safety:

learn to minimise expression of attachment behaviours so as to not alienate carer more so may be there when crucial

(inhibits exploration/learning)

Disorganised Attachment


Mother behaviour Infant behaviour Purpose/ utilityMay be incoherent; confusing or frightening (addiction; mental health; own prior trauma)

Intrusive/ interfering

May be abusive (carer as a source of threat)

Crucial to survival that infant be able to depend on care-giver when under threat

Contradictory behaviours

Negative & overwhelmed reactions

May consist of trance like behaviour; stereotypic motions e.g. rocking; head banging

Behaviour not organised

Irresolvable paradox (Shroufe et. al, 2005)

Can’t minimise and maximise attachment behaviours at the same time

Serious compromise to infants ability to organise behaviour; to explore, learn, develop

Principles of Brain Development


The brain develops in an experience dependent manner

Neurons that fire together wire together

Use it or lose it

The brain develops from back to front


The triune brain (McLean, 1990)

Survival Brain

Emotional Brain

Logical Brain

The Primary Function

“The primary function of parents can be thought of as helping children modulate their own arousal by …teaching them skills that will gradually help them modulate their own arousal” van der Kolk, 2005

What then is the primary function of teachers, & care workers in programs for troubled kids?

Outcomes


Pervasive impact across contextsParticular concern re integration of brain functionsCompromises child’s ability to make sense of the world- connections between stimulus or event & emotional reactions strong whilst connections between emotion and reasoning & logic weakStress response & cortisol level; noise & focus (hyperactivity)Dissociation or tuning out (attention deficit)

Paradigm shift

Specific diagnosis

Behaviour problem

Fixing the child

Lists symptoms e.g. Indicates low achievement

Focus on the deficits of the child

Holistic: integration of emotions, cognition & behaviour

Learning problem

Teaching the child

Causation – why the children struggle

Focus on the ‘life space’

FROM TO

The question is not “What is wrong with you?” …but“What has

happened to you?”

Sandra Bloom

The ‘life space’ of the childHow do we help not harm?


“dealing with…primary pain without unnecessarily inflicting secondary pain experiences on the residents through punitive or controlling reactions”

(Anglin, 2002, p. 55)

Cook 2005 – Pervasive effect on adaptation

Attachment – tend not to ‘belong’ to school, to class, to peer group, not to relate to teacher -Biological – often sleep deprived and stress related illnesses – low tolerance for stress -behaviourAffect regulation – explosive, overreact -suspension Dissociation – attention, focus – academic failure/suspensionBehaviour – disruptive - suspensionCognition – language, logic – academic failureSelf concept

Xavier –from Zero to 100 in a split secondIn response to being asked to go to the reading

specialist Xavier ran to the school bathroom, kicked the pipes and screamed that he was going to break something.

The principal who worries that even minimal performance demands can put Xavier over the edge describes him as going from 0-100 in a split second, his frustration climbing with accelerating speed

Sticky kid

Xaviers parents describe him as a sticky kid who gets fixated on an activity and consequently has a hard time changing gears.

According to his parents and teachers Xavier’s aggressive behaviours especially punching and kicking are typically precipitated by his being asked to end a favourite activity or engage in an activity that he dislikes. He is often remorseful and feels bad after he has hit another child or family member. Nevertheless his parents and teachers agree that their attempts to use rewards and punishments to modify these behaviour have been,

Most Frequent DSM diagnoses

given to chronically abused children

1. Separation Anxiety2. Oppositional Defiant

Disorder3. Phobic Disorders 4. Post Traumatic

Stress Disorder5. Attention Deficit

Hyperactivity Disorder Ackerman and colleagues

Hodgepodge of labels

In the absence of a diagnosis that accurately captures the pervasive nature of disturbances

related to early childhood trauma, children tend to receive a hodgepodge of labels for any number of symptoms that are treated as separate conditions

Approaching any of these problems piecemeal rather than as expressions of a vast system of internal disorganisation, runs the risk of losing sight of the forest in favor of one tree

van der Kolk

WHERE IS THE BASE LINE SET?(from Perry)

AGES 30-15 15-8 8-3 3-1 1-0

DEVELOPMENTAL

Adult/adolescent

Adolescent/child

Child/toddler

Toddler/infant

Infant/newborn

Primary/secondary brain

Neocortex/subcortex

Subcortex/limbic

Limbic/midbrain

Midbrain/brainstem

Brainstem/autonomic

Cognition Abstract Concrete Emotional Reactive reflexive

Mental state

Calm Aroused Alarm Fear terror

Brainstem drivenbehaviour

During school, if any emotionally charged content is present the child’s state will shift.If this shift is dramatic enough the person will essentially be so anxious and regressed that ‘brainstem driven’

Don’t behave like a baby!It’s like he’s fighting for his life!He’s OK on 1:1

BRAINSTEM DRIVEN BEHAVIOUR

his or her functioning will be

Turn to the person next to you and discuss a child you know

Look at the list of thinking difficulties associated with éxplosive’ childrenDo you recognise any as relating to a child you know who is experiencing difficulty being included at school?What does the child’s BEHAVIOUR MANAGEMENT plan look like?

Characteristics of students from a trauma background

Characteristics of traditional classroom environments

Difficulty organising time, tasks, materials Students expected to start, complete and turn in work with appropriate independence

Concrete black and white thinker Emphasis on conceptual themes

“lost” in class, class clown, ME ME ME Group learning activities, group rules

Impaired understanding of other’s non verbal

Teacher/peer intentions communicated through emotional expression, tone of voice, gestures

Impairment in complex auditory comprehension

Emphasis on teaching through talk

Reduced control over outbursts Outbursts seen as intentionally disruptive and punished

Limited understanding of own and other’s emotional responses

Teacher uses social-emotional reasoning “how would you feel?”

Difficulty considering likely outcomes of actions

Impulsive behaviour interpreted as deliberate rule breaking because he ‘knows’

Difficulty considering a range of solutions Language of “choice” – you have made a bad choice

Calmer Classrooms. A guide to working with traumatised children

Teachers who understand the effects of trauma on children’s education, who are able to develop teaching practices to help them, and who are able to participate actively and collaboratively (with carers) ..will not only improve their educational outcomes but will assist in their healing and recovery.

Child Safety Commissioner, Victoria

BRAIN BASED TEACHINGSurrogate frontal lobe –

I will do the thinking for a child who right now cannot do it for themselves

•MANAGE the situation

•REDUCE explosivity

•TEACH problem solving skills

Ritchie


Were Richie’s developmental needs for SAFETY being met?What was he saying that he needed?Did the adults at home/school LISTEN? Why not?Did his mother CO-REGULATE his emotional arousal? Why not?Were Richie and his mother CONNECTED? Is love enough?

Questions to ask ourselves


Help teach carers HOW to LISTENHelp teach carers HOW to SELF REGULATE

HOW to CO-REGULATEHelp teach carers HOW to help the child USE

FRONTAL LOBE thinking skills to meet normal

developmental goals for INDEPENDENCE and

Transforming Care – skills base


Collaborative Problem-Solving

The Three ‘Plans

Plan A – When the adults will must prevailPlan B – A format for negotiating issues that canbe negotiatedPlan C – Issues that can be deferred

Worker/carer perspective of the training – Val Picot


Transforming Care training beneficial for me as a worker

Training is primarily in relation to children and young people in careUnderstanding the impact trauma has on a child/yp in careparticularly ‘the brain and it development’section, how its functions and explains why children/yp have difficulty in learning and many other challenges they faceThe second part of TC module, a lot more interaction with other participants which made training interesting but also gives a realistic experience of how a child/yp is feeling

Worker/carer perspective


Cultural perspectiveModule 2 beings with the three pillars of intervention: Safety, Connection and Emotion ManagementFirst Piller of Intervention: SafetyIf children are anxious and fearful most of the time they cannot focus on other areas of development

Builds resilience, short story

Worker/carer perspective


Carer perspectiveTC training beneficial as a carer to understand what trauma is and how it affects children/yp in care

Behaviour management, behaviour strategiesAs carer helps me to respond positively to behaviourAble to recognise behaviors’ linked to trauma

Indigenous perspective


Bargumar & KIPA- Sue KitchenerIFACSS- Brenda Boustead

–Recognised Entities

The of the REEnsuring child placement principles are upheld; provided cultural & family advice throughout the decision making processes

KIPA


Funding from Department of Child SafetyCaboolture AreaRedcliffe AreaPine Rivers Area

KIPA


Foster & kinship care team leader

Provide responsive, diverse care environments

Culturally appropriate

Safe

Indigenous Family And Child Support Service


IFACSS


Alternative CareRecruitment

Working with Carers:Training and AssessmentCarer Support Approvals and RenewalsLocating culturally appropriate placements (S83)Attend relevant meetingsPlacement Referrals/RespiteCultural SupportAdvocacy ReferralsPlacement AgreementsCarer Agreements

Recognised EntitySCAN CoordinatorS6 Child Protection Act 1999S83 Child Placement PrincipleCourt and Court ReportsSCANI & A’sFGMCultural SupportLiaisonReferralsCase Discussions and ReviewsPlacement Support



Trauma of Indigenous childrenHistoricalContextual (reasons came into care)Non-indigenous placement

Many Aboriginal and/or Torres Strait Islander children do not like to express/share their feelings to the non-Indigenous or wider community.Assuming body language and facial expressions can often be mistaken for sadness, disrespect, lack of understanding



Relevance of Transforming Care Training

Provides greater awareness of how children suffer traumaProvides opportunity to develop greater flexibilityTeaching not trying to manage behaviours

Mirroring is common with Aboriginal and/or Torres Strait Islander children as this is traditionally the way of learning/teaching e.g. through Dance, Art/drawings/symbols, Storytelling and Music/Song.

Practicing the skills from the Transforming Care Course will especially benefit Aboriginal and/or Torres Strait Islander children and young people to become more confident about themselves and in control of their own decisions and choices.

Usefulness of the training from an Indigenous perspective


Carers know first hand the struggles with children when we don’t understand the behaviourSkills

ListeningLearning about co-regulationConcrete ideas about collaborative problem solving which encourages working with rather on children

Usefulness of the training from an Indigenous perspective


Fit with Indigenous culturePromotes notion of needing multiple carers/ significant adults input

Develops resilience

Promotion of positive self esteem through cultural awareness and pride

Implications


Expectations of children don’t necessarily fit with child’s skills.They can at times intellectually reason out good responses; however their ability to connect with this reasoning in times of stress is compromised.Adults response can lead to more confusion & shame; child does not know why they react the way they do at times

Delivery


Broken down into smaller trainings of about 3 hoursEach section to be presented with a skill or practice tool e.g. When training refers to how putting words to feelings can assist traumatised young people include straight after listening skills training & practiceLots of poster around to reinforceFollow up learning by support person

Learning through role plays


Skills practice- collaborative problem solving as one approachCreative delivery Special thanks to Shirlene Boyd, Judy Scorinis, Tracy Gray & Amanda Schroder from Cairns & Atherton Alt care teams for the clips of role playsScenario What might the adults expectation be

Why e.g. consistent; following through

Plan A- adult’s will prevails


Plan B; negotiation


What’s happened?


Engaged by Policy & Practice Development Branch; Policy & Programs Division to present train the trainer programs across a number of regions

North Brisbane - NudgeeSouth Brisbane – Beenleigh; RuncornToowoomba/Ipswich - ToowoombaTownsville Cairns

Train the trainer participants


96 participants across a number of organisations

Department of Child SafetyKIPAIFACSSLife Without BarriersTRACCMercy Family ServicesIntegrated Family & Youth ServicePartners in Foster CarePathways

Feedback


94 of the 96 train the trainer participants provided feedback

Of those 94 – 96% indicated a belief that the training would be very useful for those interacting with children & young people in the care system; 4% indicated the training as useful

Summary


Transforming care training aims to provide information for direct care providers that links knowledge and provides a climate in which the paradigm shift from fixing behaviour to teaching skills can occurTo provide the basis of necessary tools to address the skills deficits

Trauma informed care: Teaching not treating INFORMED CARE: TEACHING NOT TREATING. ... brain Neocortex /subcortex Subcortex/ limbic Limbic/mid ... If this shift is …

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