TRAUMA-INFORMED PRACTICE: ASSESSING & TREATING CHILDREN FOLLOWING A DISASTER Karen Rice, PhD, LSW, ACSW Marc Felizzi, PhD, LCSW Assistant Professors Department of Social Work Millersville University

TRAUMA A Psychophysical reaction to an event which is experienced as overwhelming An event that arouses a strong emotional reaction in those exposed to it (Rothschild, 2000)

Symptoms of trauma Hyper-arousal: state of alertness, expecting the danger to recur, feels as if danger is still present Intrusion: Trauma interrupts daily life (e.g. flashbacks, re-enacting the traumatic event) Emotional constriction: Feeling numb, dissociating, feeling a disconnect between events and their meanings. Feelings of “unreality” Avoidance behavior: A means of preventing a confrontation with danger (Briere & Scott, 2006)

TRAUMA TYPES According to the National Child Traumatic Stress Network (NCTSN) there are 12 types of trauma children might experience Community and school violence Complex trauma Domestic violence Early childhood trauma Medical trauma Natural disasters Neglect Physical abuse Refugee and war zone trauma Sexual abuse Terrorism Traumatic grief Community violence: predatory violence (robbery, theft, rape, beatings, shootings) School violence: threats, injuries, fights Complex trauma: multiple or prolonged exposure to traumatic events (i.e., abuse, DV, neglect) that often leads to repeated trauma in adolescents/adulthood Domestic violence: 3 to 10 million of children in US are exposed to DV annually and most are under the age of 8 years Early children trauma: any trauma that occurs to children between 0-6 years Medical trauma: reactions children have to pain, injury, serious illness, medical procedures, or treatments Natural disasters: natural catastrophe or fire, flood, or explosion child experiences Neglect: not receiving basic needs Physical abuse: causing or attempting to cause physical pain or injury Refugee and war zone trauma: exposure to war, political violence, or torture Sexual abuse: wide range of sexual behaviors (involving and not involving contact) between child and older person Terrorism: intent to inflict psychological damage on adversary Traumatic grief: grief following death of person who is important to child and when child perceives the experience as traumatic

Trauma and the brain The brain responds to external influences Brain controls the nervous system & is linked to other parts of body During a traumatic event or flashback, amygdala becomes activated, and hippocampus shuts down, which interferes with the ability to “make sense” of event (Rothschild, 2000) Triune Brain

Trauma and the brain Systems of the brain process experiences by receiving & responding to perception of stress (flight/ fight/ freeze) -Amygdala: stores emotions & reactions to traumatic events; present at birth (implicit memory; experienced in body or senses) -Hippocampus: processes data as a narrative, makes sense out of experiences, matures about age 3 (Explicit memory; linguistic) (Rothschild, 2000) Freezing: Can be the body’s response to stress “playing dead” Dissociation: Not sure why it occurs, may be related to the brain’s response to trauma to allow one to not fully experience a horrible event Memories created through: Encoding: Etching the event into your brain Storage- Hippocampus store event, gives time & place context Retrieval- Recalling the memories as you remember them

Trauma and the brain Limbic system produces cortisol, which is used to return body to equilibrium after stress/ trauma Increased cortisol levels seen in trauma victims (Rothschild, 2000)

TRAUMA AND CHILDREN Developmental Trauma Attachment Biology Mood regulation Dissociation Behavioral control Cognition Self-concept (Child Welfare Committee, 2008; NCTSN; van der Kolk, 1996) Attachment - difficulty relating to and empathizing with others Biology – hypersensitivity to physical contact, insensitive to pain, unexplained physical symptoms, increased medical problems, Mood regulation – difficulty regulating emotions, difficulty knowing and describing feelings Dissociation – may withdraw from outside world and demonstrate amnesia-like states Behavioral control – poor impulse control, self-destructive behaviors, aggression against others Cognition – difficulty focusing on and completing school tasks, learning difficulties and problems with language development Self-concept – disturbance of body image, low self-esteem, shame, guilt Inability to regulate moods, which places at increased risk for further abuse Impairs ability to describe event Lack of trust results in inaccurate or incomplete information about event Dull affect may make professionals question child’s statements Altered world view may result in destructive behaviors 2. Inability to regulate mood may result in threatened stable placement Lack of trust may lead to rejection of caregiver or superficial attachments Early experiences with attachment may lead to lack of empathy toward others New family may inadvertently trigger reminders to trauma 3. Impacts cognition and ability to learn, focus, and succeed in school Ability to regulate emotions can impact ability to function within family, in regular classroom, and with peers Guilt and self-blame may lead to sense of hopelessness, which impairs motivation to succeed in social and educational settings Due to lack of trust, child may isolate self from family, peer, social, and emotional supports Lack of positive coping strategies may lead to high-risk, destructive behaviors

Children’s cognitive reactions Confusion, disorientation Fear of separation from family/ pets Recurring dreams or nightmares Preoccupation with disaster Trouble concentrating or remembering things (schoolwork) Difficulty making decisions Questioning spiritual beliefs (Rothschild, 2000)

Children’s behavioral reactions to trauma Sleep problems Crying easily Avoiding reminders of disaster Excessive activity level Increased conflicts with family Hyper-vigilance, startle reactions Isolation or social withdrawal Focus on disaster/ worry another will occur Lack of interest in usual activities, even playing with friends Returning to earlier behaviors, such as baby talk, bedwetting, or tantrums Increase in teens' risky behaviors, such as drinking alcohol, using substances, harming themselves, or engaging in dangerous activities (Rothschild, 2000)

Children’s physical reactions to trauma Fatigue, exhaustion Gastrointestinal distress Appetite change Tightening in throat, chest, or stomach Worsening of existing medical conditions Somatic complaints (Rothschild, 2000)

approaches to treatment of traumatized children Counseling Psychodynamic-Trauma-Focused Therapy Cognitive Behavioral Trauma-Focused Therapy (CB-TFT) Trauma Focused Therapy Psychotropic Medication Exposure Therapy Relaxation Therapy Creative Arts Therapy

Goal when working with children who experienced trauma Establish sense of safety Regulate affect Reestablish attachment Enhance brain’s executive function Reframe and integrate traumatic experience (Malchiodi, 2008)

Establish sense of safety Where do you feel safe? Sense of safety essential to resolving trauma experience Ask questions to assess: “Where do you fee the safest?” “Who do you feel the safest with?” “What do you do to feel safe?” (Malchiodi, 2008) Can use expressive arts therapy to process these questions---ask to draw picture of “safe place;” ask to show on body outline what safety “feels like;” make an image or image those people with whom feel safest Visual----using soda bottle, shake to demonstrate the pressure individuals under following a traumatic experience; goal is to teach how to release that pressure without creating “mess”; this is done by slowly releasing content and then “putting on the breaks”

Regulate affect Important to address body’s response to trauma Trauma prevents normal expression of cognitive processes Goal is to empower individuals to regulate reactions to stressful events Questions to ask: “How big or small is your hurt?” “If your hurt could talk, what do you think it would say?” “If your hurt could listen, what would you say to it?” (Malchiodi, 2008) What is body’s physiological response to the trauma? Children and adolescent have problems with attention, comprehension, and overall learning Teaching children how to be observers of their body’s sensations and learn what they can do with their bodies and minds to react in less stressful manger when trauma-inducing situations occur Activities: relaxation, mindfulness, drawing on body outline where “feel” trauma “Magic Box”---helps children regulate their emotions/feelings. Each child in group places an item in the “magic box” from his/her life he/she would like to get rid of. The box is then closed, locked, and packed away. This allows youth to place something traumatizing from his/her life in a safe place.

Reestablish attachment Identifying institutions to foster supportive relationships is essential Foster and build supportive networks Strengthen friendships and peer support (Malchiodi, 2008) Immediate response efforts should emphasize teaching effective coping strategies, fostering supportive relationships, and helping children understand the disaster event. Schools and other community, state, federal organizations can play an important role in this process of providing stable, familiar environment Children’s relationships with others/peers can offer ways to cope with adversity and can decrease isolation---in cases where families were relocated due to disaster, it is important for children to develop supportive relationships with their teachers and classmates. One way to enhance those relationships is to have children work in small groups asking them to cooperate on completing task.

Enhance brain’s functioning Provide youth with opportunity to discuss disaster-related events Promote positive coping and problem-solving skills Emphasize strengthening resiliency to Take decisive actions; do not avoid Avoid blowing event out of proportion (Malchiodi, 2008) When teaching problem-solving skills be sure they encourage children to develop realistic and positive methods of coping that increase ability to manage their anxiety and to identify which strategies fit with each situation Resiliency is behavior that can be learned (comprises behaviors, thoughts, and actions that can be learned and developed in anyone). When focusing on strengthening resiliency, ask youth what they did in the past that helped them cope when they were frightened or upset. Share how other communities experienced disasters and then recovered.

Reframe and integrate traumatic experience Telling one’s story gives trauma survivors a voice Stories link past, present, and future Reparative nature to “restory” one’s life (Malchiodi, 2008) Video---Smallest Wonders We tell stories because we hope to find or create significant connections between things…link past, present, and future in way that tells us where we have been, where we are, and where we are going. They give meaning to life and provide guidance and wisdom….”restorying” our life is reparative. Focus on the strengths rather than weaknesses. Exercise….Sadako and the Thousand Paper Cranes…works well when working with group of youth who experienced group trauma (community violence, terrorism, war, disaster) as allows them to identify memorial project to create that commemorates those lost yet provides outlet for individual healing. This project allows for group work and processing and reinforces community building

Issues associated with specific disaster: fires Emotional and physical exhaustion Survivor guilt Fear and anxiety Lingering distress (Malchiodi, Steele, & Kuban, 2008) Survivor guilt can occur if someone’s home unharmed while others destroyed Greater symptomatology associated with more frightening experiences during fire and with great levels of damage to community and homes Sights, sounds, and smells of fire often generate fear and anxiety Same sensations can generate distress in months following disaster

Focus of treatment-specific to fires Provide perceptions of safety and security Provide opportunity to discuss feelings and concerns to correct misperceptions and to offer reassurance Provide predictable activities and normal routines Provide and maintain interpersonal connections Encourage healthy behaviors Educate and encourage parents/caregivers to model positive coping skills Reduce exposure to events that increase stress Encourage participation in less stressful events Develop response plan that addresses psychological impact (Malchiodi, Steele, & Kuban, 2008) Normal routines enhances safety and security Friendships and social activities help maintain interpersonal connections Healthy behaviors include sleep, exercise, and proper nutrition Positive coping skills include nurturing behaviors, consistency, and clear limits---help children practice these skills Reduce exposure to repeated viewing of images of disaster and encourage participation in games, reading, creative expression, or athletics Disaster response plans should address psychological impact of trauma on individuals and how will respond immediately following event as well as in long-term

Questions “Trauma stays with us even though the trigger may appear to be out of sight” (Rothschild, 2000)