1. An Over-view Colette Ryan Nurse Educator MHAID Service Southern DHB
Trauma Informed Care
An Over-view
Colette Ryan
Nurse Educator
MHAID Service Southern DHB

2. Over-view Definitions Prevalence Impact of Trauma Trauma Informed Care
Resiliency
References
Resources

3. What is trauma
A traumatic event is one in which a person experiences (witnesses or is confronted with):
Actual or threatened death
Serious injury
Threat to the physical integrity of self or another

4. What is trauma
“Prolonged exposure to repetitive or severe events such as child abuse, is likely to cause the most severe and lasting effects.”
“Traumatisation can also occur from neglect, which is the absence of essential physical or emotional care, soothing and restorative experiences from significant others, particularly in children.”
(International society for the study of Trauma and Dissociation, 2009)

5. Responses to a traumatic event may include
Intense fear
Helplessness
Horror
Attachment

7. Interpersonal trauma?
Interpersonal violence tends to be more traumatic than natural disasters because it is more disruptive to our fundamental sense of trust and attachment, and is typically experienced as intentional rather than as “an accident of nature.”
(International society for the study of trauma and dissociation, 2009)

8. Attachment Genes have little to do with Attachment
Temperament and attachment are independent!
Attachment patterns are solely built by experience
L. Alan Sroufe, et al “The Development of the
Person,” 2005.
In every culture, healthy relationships are contingent on relational interactions

10. ACE Study (Adverse Childhood Events) 2010
CDC and Kaiser Permanente Collaboration (USA).
Over a decade long. 17,000 people involved.
Looked at effects of adverse childhood experiences over the lifespan.
Largest study ever done on this subject

11. HMO Members in ACE Study
80% White, including Hispanic
10% Black
10% Asian
About 50% men, 50% women
74% had attended college
62% age 50 or older
The 17,000 HMO members who were interviewed for the ACE study were middle class people with jobs and medical insurance – not likely to have been exposed to street violence, extreme poverty, malnutrition, dislocation, homelessness, natural catastrophes or war terror. So they can’t be dismissed as atypical, aberrant, or “not in my practice”. They can’t be categorized as “at risk” populations. “They” are “us”.
Of these HMO members: 80% were white including hispanic, 10% black, 10% Asian; About half were men, half were women; 74% had attended college; 62% were 50 or older. 11 11

12. Adverse Childhood Experience* ACE Categories (Birth to 18)
Abuse of Child
Emotional abuse
Physical abuse
Contact Sexual abuse
Trauma in Child’s Household
Environment
Alcohol and/or Drug User
Chronically depressed, emotionally
disturbed or suicidal household
member
Mother treated violently
Imprisoned household member
Not raised by both biological
parents
(Loss of parent – best by death
unless suicide, - Worst by
abandonment)
Neglect of Child
Physical neglect
Emotional neglect
* Above types of ACEs are the “heavy end” of abuse. *1 type = ACE score of 1
Impact of Trauma and Health Risk Behaviors to Ease the Pain
Neurobiologic Effects of Trauma
Disrupted neuro-development
Difficulty controlling anger-rage
Hallucinations
Depression - other MH Disorders
Panic reactions
Anxiety
Multiple (6+) somatic problems
Sleep problems
Impaired memory
Flashbacks
Dissociation
Health Risk Behaviors
Smoking
Severe obesity
Physical inactivity
Suicide attempts
Alcoholism
Drug abuse
50+ sex partners
Repetition of original trauma
Self Injury
Eating disorders
Perpetrate interpersonal violence
Long-Term Consequences of Unaddressed Trauma (ACEs)
Disease and Disability
Ischemic heart disease
Cancer
Chronic lung disease
Chronic emphysema
Asthma
Liver disease
Skeletal fractures
Poor self rated health
Sexually transmitted disease
HIV/AIDS
Serious Social Problems
Homelessness
Prostitution
Delinquency, violence, criminal
Inability to sustain employment
Re-victimization: rape, DV, bullying
Compromised ability to parent
Negative alterations in self percep-
tions and relationships with others
Altered systems of meaning
Intergenerational trauma
Long-term use of multiple human
service systems
This is an overview of the ACE Study. You have this chart as one of your handouts. It captures the essence of the ACE study in one page.
In column one are listed 10 categories of adverse childhood experiences or ACEs. All 17,000 participants answered specific questions to determine which of these 10 types of potentially traumatic events they had experienced. (Abuse of Child: Emotional abuse; Physical abuse; Contact sexual abuse. Trauma in Household: Alcohol/Drug use; Depressed, emotional disturbed or suicidal household member; Mother treated violently; Imprisoned household member; Loss of parent thru divorce, separation, death, suicide, abandonment. Neglect of Child: (Physical and/or Emotional)
A person’s ACE Score is based on the number of CATEGORIES of adverse childhood experiences they identified in their childhood. So if as a child you were physically abused – that counts as ONE ACE – no matter how many times the physical abuse occurred.
Column Two lists the impacts of these adverse childhood experiences on the brain or nervous system and identifies health risk behaviors that are developed to cope with and ease the pain caused by the emotional and neurological impacts of childhood trauma
. Neurobiologic Effects of Trauma: disrupted neuro-development, difficulty controlling anger-rage; hallucinations; depression; panic reactions; anxiety; multiple somatic problems; sleep problems; impaired memory; flashbacks; dissociation.
Health Risk Behaviors are understood by the ACE study as attempts to cope with, get release from or lessen the pain caused by childhood traumas NOT as symptoms, bad habits, self-destructive behavior, or public health problems. These behaviors include smoking, severe obesity; physical inactivity; suicide attempts; alcoholism; drug abuse; multiple sex partners (50+); repetition of original trauma; self injury; eating disorders; perpetration of interpersonal violence.
In the third column are listed some of the long-term consequences of unaddressed childhood trauma. Disease and Disability: Ischemic heart disease; cancer; chronic lung disease; chronic emphysema; asthma; liver disease; skeletal fractures; poor self rated health; sexually transmitted disease; HIV/AIDS.
Serious Social Problems: Homelessness, prostitution; delinquency violence criminal behavior; inability to sustain employment; re-victimization by rape, DV; compromised ability to parent; Negative alterations in self-perception and relationships with others; Alterations in Systems of Meaning; intergenerational transmission of abuse; and longterm use of health, behavioral health, correctional, and social services. 12 12

13. Adverse Childhood Experiences ACE Categories (Birth – 18)
Abuse of Child
Emotional Abuse
Physical Abuse
Contact Sexual Abuse
Neglect of Child
Physical Neglect
Emotional Neglect
Trauma in Child’s Household/Environment
Alcohol and/or Drug user
Chronically depressed, emotionally disturbed or suicidal household member
Mother treated violently
Not raised by both biological parents. (Loss of parent – best by death, unless suicide. – Worst by abandonment)

14. Adverse Childhood Experiences are Common
Of the 17,000 HMO Members:
1 in 4 exposed to 2 categories of ACEs
1 in 16 was exposed to 4 categories.
22% were sexually abused as children.
66% of the women experienced abuse, violence or family strife in childhood.
Women were 50% more likely than men to have experienced 5 or more ACEs
Among this middle class HMO population, Adverse Childhood Experiences were found to be common.
1 in 4 were exposed to 2 categories of ACE’s –which would equate to 1/4th of this audience
1 in 16 were exposed to 4 categories
22% were sexually abused as children. That’s over 20% of this audience. Over one in every 5 of us. Applies to men and women.
66% of the women reported abuse, violence or family strife in childhood. (That’s two out of every 3 women in this audience)
And women were found to be 50% more likely than men to have ACE scores of 5 or more. 14 14

15. ACE Study Findings
Childhood experiences are powerful determinants of who we become as adults.

16. Impact of Trauma and Health Risk Behaviours to Ease the Pain
Neurobiologic Effects of Trauma
Disrupted neuro-development
Difficulty controlling anger-rage
Hallucinations
Depression – other MH disorders
Panic reactions
Anxiety
Multiple (6 +) somatic problems
Sleep problems
Impaired memory Flashbacks
Dissociation
Health Risk Behaviours
Smoking
Severe obesity
Physical inactivity
Suicide attempts
Alcoholism
Drug abuse
50 + sex partners
Repetition of original trauma
Self injury

17. Long-term Consequences of Unaddressed Trauma (ACEs)_
Disease and disability
Ischemic heart disease
Cancer
Chronic lung disease
Chronic emphysema
Asthma
Liver disease
Skeletal Fracture
Poor self rated health
Sexually transmitted disease
HIV/AIDS
Serious Social Problems
Homelessness
Prostitution
Delinquency, violence, criminal
Inability to sustain employment
Re-victimisation: rape, violence
Compromised ability to parent
Negative alterations in self perceptions and relationships with others
Altered systems of meaning

18. The higher the ACE Score, the greater the likelihood of :
Severe and persistent emotional problems
Health risk behaviors
Serious social problems
Adult disease and disability
High health, behavioral health, correctional and social service costs
Poor life expectancy
The higher a persons ACE score (the more TYPES of adverse childhood experiences he or she reported) – the more likely he or she was to develop
Serious emotional problems
Health risk behaviors
Serious social problems
Adult disease and disability
Cumulative childhood traumas also led to -
Higher health and human service costs from long term use of multiple services.
And resulted in:
Poor life expectancy or early death. For example: 18 18

19. Health Consequences of Early Life Trauma Vincent Felitti, M.D.,
Health in all domains is related to
childhood experience
Health risks:
Stroke
Heart disease
Depression and suicide
Substance abuse
Smoking

20. Childhood Experiences vs. Adult Alcoholism4+ 3 2 1

21. Childhood Experiences Underlie Chronic Depression

22. Childhood Experiences Underlie Suicide4+ 3 2 1

23. Emotional Problems Childhood experiences underlie Chronic depression
Childhood experiences underlie suicide
2/3rd (67%) of all suicide attempts
64% of adult suicide attempts
80% of child/adolescent suicide attempts
Are attributable to Childhood Adverse Experiences

24. Positive Stress Moderate, short-lived physiological response
Increased heart rate, higher blood pressure
Mild elevation of stress hormone, cortisol , levels
Activated by:
Dealing with frustration, meeting new people
(National Scientific Council on the Developing Brain, Harvard University 2006)

25. Tolerable Stress
Physiological responses large enough to disrupt brain architecture
Relieved by supportive relationships:
that facilitate coping,
restore heart rate and stress hormone levels
reduce child’s sense of being overwhelmed
Activated by:
Death of loved one, divorce, natural disasters
(National Scientific Council on the Developing Brain, Harvard University 2006)

26. Toxic Stress
Strong & prolonged activation of stress response systems in the absence of buffering protection of adult support
Recurrent abuse, neglect, severe maternal depression, substance abuse, family violence
Increased susceptibility to cardiovascular disease, hypertension, obesity, diabetes and mental health problems

27. Institutionalization and Neglect of Young
Children Disrupts Their Body Chemistry
35%
Percent of Children with Abnormal Stress Hormone Levels
30%
25%
20%
15%
10% 5%
Middle Class US Toddlers in Birth Families
Neglected/Maltreated Toddlers Arriving from Orphanages Overseas
Source: Gunnar & Fisher (2006)

28. PTSD
PTSD is the only diagnostic category in the DSM that is based on etiology.
In order for a person to be diagnosed with PTSD, there had to be a traumatic event.
Because most diagnoses are descriptive and not explanatory they focus on symptoms or behaviours without a context: they do not explain how or why a person may have developed those behaviours (e.g. to COPE with traumatic stress).

29. TRAUMA
For the purposes of identifying trauma and its adaptive symptoms, it is much more useful to ask “What HAPPENED to this person” rather than “What is WRONG with this person”.

30. Types of Trauma: Acute Trauma
Acute trauma is a single traumatic event that is limited in time. Examples include:
Serious accidents
Community violence
Natural disasters (earthquakes, wildfires, floods)
Sudden or violent loss of a loved one
Physical or sexual assault (e.g., being shot or raped)
During an acute event, people go through a variety of feelings, thoughts, and physical reactions that are frightening in and of themselves and contribute to a sense of being overwhelmed.

31. Acute Response To Trauma
Terror
Vulnerable
few supports
Fear
Normal
with supports
Alarm
Vulnerable “with supports”
Dissociation or
Resilient
Vigilance
Calm
Traumatic Event

32. Types of Trauma: Chronic
Chronic trauma refers to the experience of multiple traumatic events.
These may be multiple and varied events—such as a child who is exposed to domestic violence, is involved in a serious car accident, and then becomes a victim of community violence—or longstanding trauma such as physical abuse, neglect, or war.
The effects of chronic trauma are often cumulative, as each event serves to remind the child of prior trauma and reinforce its negative impact.

33. Types of Trauma: Complex
Complex trauma describes both exposure to chronic trauma—usually caused by adults entrusted with the child’s care—and the impact of such exposure on the child.
Children who experienced complex trauma have endured multiple interpersonal traumatic events from a very young age.
Complex trauma has profound effects on nearly every aspect of a child’s development and functioning.

34. Additional Sources of Stress
Children in the child welfare system frequently face other sources of ongoing stress that can challenge workers’ ability to intervene. Some of these sources of stress include:
Poverty
Discrimination
Separations from parent/siblings
Frequent moves
School problems
Traumatic grief and loss
Refugee or immigrant experiences

35. The impact of a potentially traumatic event depends on several factors, including:
The child’s age and developmental stage
The child’s perception of the danger faced
Whether the child was the victim or a witness
The child’s relationship to the victim or perpetrator
The child’s past experience with trauma
The adversities the child faces following the trauma
The presence/availability of adults who can offer help and protection

36. Impact of Trauma on Child Development
Physical and Neurodevelopment
Psychosocial and Relational Development

37. Developmental Factors
Chronic early trauma – starting when the individual’s personality is forming – shapes a child’s (and later adult’s) perceptions and beliefs about everything.
Severe trauma can have major impacts on the course of life.
Childhood trauma can cause the disruption of basic developmental tasks.

38. Disruption of Developmental Tasks
Survivors of childhood trauma can have mild – several deficits in abilities such as:
Self soothing
Seeing the world as a safe place
Trusting others
Organised thinking for decision making
Avoiding exploitation
Disruption of these tasks in childhood can result in adapted behaviour, which may be interpreted as “symptoms:”
Disrupted self-soothing can be labelled as agitation
The disrupted ability to see the world as a safe place looks like paranoia
Distrust of others can be interpreted as paranoia (even when based on experience)
Disruptions' in organised thinking for decision making appears as psychosis
Avoiding pre-empting exploitation is called self-sabotage.

39. Exposure to Trauma – General Population
Until fairly recently, trauma exposure was thought to be unilaterally rare (combat violence, disaster trauma) (Kessler et al, 1995)
More recent research has changed this and studies completed indicate that trauma exposure is common across all demographics
56% of a general population adult sample reported at least one event (National Executive Training Institute NETI 2005)

40. Prevalence of Trauma – Mental Health Population
90% of mental health clients have been exposed (Muesar et al., 1998)
Most have multiple experiences of trauma
34 – 53% report childhood sexual or physical abuse (kessler et al., 1995)
43 – 81% report some form of victimisation

41. Prevalence of Trauma – Mental Health Population
97% of homeless women with SMI have experienced severe physical and sexual abuse – 87% experience this abuse both as child and adult (Goodman et al., 1997)
Current rates of PTSD in people with SMI range from 29 – 43% (Jennings & Ralph, 1997)
Whilst research needs to continue, studies are increasingly showing that trauma appears to be epidemic among the population in mental health services

42. Prevalence of Trauma What this means…….
A majority of adult and children in inpatient psychiatric treatment settings present with trauma histories (Lipschitz et. Al., 1999)
“ Many providers may assume that abuse experiences are additional problems for the person, rather than the central problem….” (Hodas 2004)

43. Impact of Trauma
Hyperarousal: nervousness', jumpiness, quickness to startle
Re-experiencing: intrusive images, sensations, dreams, memories
Avoidance and withdrawal; feeling numb, shutdown or separated from normal life, pulling away from relationships and/or activities
Avoiding things that trigger memories of trauma/s

44. Definition of Trauma Informed Care
Mental Health Treatment that is directed by:
A thorough understanding of the profound neurological, biological, psychological and social effects of trauma and violence on the individual and,
An appreciation for the high prevalence of traumatic experiences in persons who receive mental health services.
(Jennings 2004)

45. Symptoms as Adaptations
The traumatic event is over, but the person’s reaction to it is not.
The intrusion of the past into the present is one of the main problems confronting the trauma survivor.
Often referred to as re-experiencing, this is the key to many psychological symptoms and psychiatric disorders that RESULT from traumatic experiences.
This intrusion may present as distressing intrusive memories, flashbacks, nightmares, or overwhelming emotional states.

46. Trauma “symptoms” as adaptations
It is useful to think of all trauma “symptoms” as adaptations.
Symptoms represent the clients’ attempt to cope the best way they can with overwhelming feelings.
When we see “symptoms” in a trauma survivor, it is always significant to ask ourselves: what purpose does this behaviour serve?
Every symptom helped the survivor cope at some point in the past and is still in the present – in some way.
As humans we are incredibly adaptive creatures. If we help the survivor explore how behaviours are an adaptation, we can help them learn to substitute a less problematic behaviour.

47. The use of Adaptive Coping Strategies
Survivors of repetitive early trauma are likely to instinctively continue to use the same self-protective coping strategies that they employed to shield themselves from psychic harm at the time of the traumatic experience.
Hypervigilance, dissociation, avoidance and numbing are examples of coping strategies that may have been effective at some time, but later interfere with the persons' ability to live the life s/he wants

48. A model of treatment Safety and stabilization
Processing of traumatic material
Reconnection and reintegration

49. Phase one; Safety and stabilization
Attention to basic needs including; connection to resources, self care, identification of support system
Focus on regulation of emotion and develop capacity to self soothe.
Education on trauma and treatment process

50. Phase two: Processing and Grieving of Traumatic Memories
“The primary goal of this phase is to have the patient acknowledge, experience and normalise the emotions and cognitions associated with the trauma at a pace that is safe and manageable.”
(Luxenberg, Spinazzola, Hildago, Hunt and van der Kolk, 2001)

51. Phase Three- Reconnection
Development of a firm or a new sense of self
Development of healthy and supportive:
Friendships
Intimacy
Spirituality

52. Trauma informed Care Aims to avoid re-victimisation
Appreciates many problem behaviours began as understandable attempts to cope
Strives to maximise choices for the survivor and control over the healing process
Seeks to be culturally competent
Understands each survivor in the context of life experiences and cultural background
(Alvarez and Sloan, 2010)

53. Resiliency
“Resilience is the capability of individuals to cope successfully in the face of significant change, adversity, or risk. The capacity changes over time and is enhanced by protective factors in the individual and environment.”
(Stewart et al., 1991 as cited by Greene and Conrad, 2002)

54. Protective Factors
There are behaviours, characteristics and qualities inherent in some personalities that will assist in recovery after exposure to a traumatic event, these are called protective factors.

55. Environment A reliable support system (friends, family)
Access to safe and stable housing
Timely and appropriate care from first responders

56. Behaviours
Good self-care such as sleeping at least eight hours a night
Eating a well balanced diet
Exercise
Practising good boundaries
Using positive coping mechanisms verses negative coping mechanisms

57. Resiliency as a trait A vigorous approach to life
A sense of meaningfulness
An internal locus of control (vs. external)
A way to conceptualise this is the “ability of a person to bounce back from challenges through feelings of control, commitment and the ability to see change as a challenge.” Phelps et al., 2009)

58. Post-traumatic Growth
“Resilient survivors continue therefore, to grow and even thrive in spite of, and quite often because of their histories.” (Armour 2007)
Survivors of trauma who strengthen their abilities to find wisdom that allow them emotional growth in relationship with others are often referred to as experiencing post-traumatic growth.
Post-traumatic growth is reflected in the following:
Strengthening of relationships/sense of connection
Increased sense of personal strengths
Awareness of increased possibilities in life

59. References
Centers for Disease control and prevention (CDC). Adverse Childhood experiences (ACE) study. Available at
Alvarez, G. and Sloan, R., Trauma: Considering Behaviour Through a Trauma Lens, (2012). Powerpoint Presentation: Everly Ball – Westminster house, 1 – 49
Armour, M. (2007). Violent Death. Journal of Human Behaviour in the Social Environment, 14(4), 53 – 90.
Child Welfare information Gateway (2006). Long term Consequences of Child Abuse and Neglect. Retrieved from:

60. References
Child Welfare Information Gateway (2012), The Risk and Prevention of Maltreatment of Children with Disabilities. Bulletins for Professionals, (1 – 20).
Childhelp, National Child Abuse Statistics: Child Abuse in America, (1), Available at
Greene, R.R. (Ed), (2002). Resiliency: An Integrated approach to practice, policy and research. Washington, D.C.: NASW Press.
International Society for the study of Trauma and Dissociation, FAQs Trauma (1 – 8) Retrieved:

61. References
Marcenich, L., (2010) Trauma Informed Care, Powerpoint Presentation, available at:
James, R.K (2008). Crises intervention strategies (6th ed.) Pacific Grove, CA: Brooks/Cole Pub.
Phelps, A., Lloyd, D., Creamer, M., & Forbes, D. (2009). Caring for Carers in the aftermath of Trauma. Journal of Aggression, Maltreatment and trauma, 18(3),

62. Resources
International Society for Traumatic Stress Studies An international collection of studies, research and education regarding trauma. Also provides guidelines for treatment of trauma.
National Child Traumatic Stress Network Programme works to educate professionals and non professionals about trauma and evidence based practices for trauma interventions. Site provides definitions of different types of trauma and evidence based practice resources.
Sidran Institute: Traumatic Stress Education and Advocacy