1. 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

2. 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)

3. 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)

4. 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

5. 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

6. 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

7. 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)

8. 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

9. 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)

10. 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)

11. 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)

12. 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

13. 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)

14. 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”

15. 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.

16. 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.

17. 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.

18. 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

19. 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

20. 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

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