1. Childhood Trauma and Trauma-Informed Systems of Care
Molly Lopez, Ph.D.
Texas Institute for Excellence in Mental Health
Center for Social Work Research
University of Texas at Austin

2. Types of Traumatic Events
Physical abuse
Sexual abuse
Domestic violence
Community violence
Traumatic loss
Car accidents
Bullying
Accidental injuries
Animal attack
Fires
Natural disaster
Life-threatening medical emergencies

3. Prevalence
out of every

4. Some Trauma Facts
Trauma is almost universal for boys (93%) and girls (87%) in the JJ System
Children in the child welfare system almost by definition have suffered trauma, often multiple traumatic events and 50-75% exhibit symptoms that need mental health treatment (Landsverk et al, 2009).
Trauma increases the risk of further trauma (most survivors have at least 2 distinct trauma incidents).

5. The Stress Response Surge in adrenaline, epinephrine, & cortisol
Increased metabolism
Faster heart rate
Faster respiration
Increased blood sugar
Increased blood pressure
Suppression of other systems
Surge in adrenalin, epinephrine, cortisol
Increase metabolism – faster heart rate, faster respiration
Blood pressure raises
Increased blood sugar for energy
Immune system suppressed
Digestion system suppressed
Higher order thinking suppressed
Ask them to remember an “almost” car wreck – How did you feel physically; How did you act? What was your thinking like?
Infants, children and adults will adapt to frightening and overwhelming circumstances by the body’s survival response, where the autonomic nervous system will become activated and switch on to the freeze/fight/flight response. Immediately the body is flooded with a biochemical response which includes adrenalin and cortisol, and the child feels agitated and hypervigilant. Infants may show a ‘frozen watchfulness’ and children and young people can dissociate and appear to be ‘zoned out’.
• Prolonged exposure to these circumstances can lead to ‘toxic stress’ for a child which changes the child’s brain development, sensitises the child to further stress, leads to heightened activity levels and affects future learning and concentration. Most importantly, it impairs the child’s ability to trust and relate to others. When children are traumatised, they find it very hard to regulate behaviour and soothe or calm themselves. They often attract the description of being ‘hyperactive’.

6. Normal vs. Sensitized Response following Trauma
Arousal
Time
Sensitized
Normal

7. The Role of Reminders triggers Reminders of past trauma
Alarm system is activated
Respond as though there is current danger
sight
taste
smell
feeling
sound
Traumatic memories are stored differently in the brain compared to everyday memories. They are encoded in vivid images and sensations and lack a verbal narrative and context. As they are unprocessed and more primitive, they are likely to flood the child or adult when triggers like smells, sights, sounds or internal or external reminders present at a later stage.
What do you remember from your almost wreck? Can you see yourself in the car? Can you remember the sound of the honking/screeching tires? Can you remember how your stomach felt or the pounding of your heart?
Most of us will be more nervous or more careful immediately following this experience but over time return to feeling safe and are able to drive.

8. DSM-IV PTSD Criterion A: Stressor
Criterion B: Intrusive Recollection (1)
Criterion C: Avoidance or Numbing (3)
Criterion D: Hyperarousal (2)
Stressor – developmental issues, what is threatening in the eyes of a child; how children display extreme fear
Intrusive recollection – intrusive distressing memories (can be play), recurrent dreams, flashbacks, distress at trauma reminders or cues; physical reactivity at reminders
Avoidance or numbing – efforts to avoid memories or thoughts about the event; efforts to avoid physical reminders; inability to remember parts of trauma; diminished interest in activities; restricted range of affect
Hyperarousal – difficulty falling or staying asleep; irritability and anger outbursts; difficulty concentrating; hypervigilance, exaggerated startle response
Only about 3 to 15% of children who experience a significant trauma meet full criteria for PTSD.

9. Endorsement of Trauma Symptoms
Early Onset abuse (<14)
Late Onset abuse (>14)
Disaster
Signific
Affect regulation 77 66 38
a,b>c
Anger 61 33
Self-destructive 62 36 21
a>b,c
Suicidal 39 12
a>b>c
Sexual involvement 81 9
Risk taking 54 26 16
Amnesia 78 46 15
Dissociation 80 59 44
Permanent damage 72 53
Guilt 69 49 24
Nobody can understand 57
Victimizing others 27 8 *
a>b
PTSD field trials, identified Disorders of Extreme Stress Not Otherwise Specified
van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola (2005). Journal of Traumatic Stress

10. Coping with Trauma
Trauma survivors adopt a set of survival skills that have helped them manage their trauma in the past.
These strategies make sense given what people have experienced, even if they are confusing to others or are seen as getting in the way of current goals.
Children are particularly vulnerable to flashbacks at quiet times or at bedtimes and will often avoid both, by acting out at school and bedtimes. They can experience severe sleep disruption, intrusive nightmares which add to their ‘dysregulated’ behaviour, and limits their capacity at school the next day. Adolescents will often stay up all night to avoid the nightmares and sleep in the safety of the daylight. Self harming behaviours release endorphins which can become an habitual response. These children require calm, patient, safe and nurturing parenting in order to recover, and may well require a multi-systemic response to engage the required services to assist.

11. The Adverse Childhood Experiences (ACE) Study
Collaboration between Centers for Disease Control and Prevention (CDC) and Kaiser Permanente HMO in California
Largest study ever that determined both the prevalence of traumatic life experiences in the first 18 years of life and the impacts on later well-being, social function, health risks, disease burden, health care costs, and life expectancy
17,000 adult members of Kaiser Permanente HMO participated
Subsequent 5-state study in 2010

12. Types of Adverse Childhood Experiences (Birth to 18)
Abuse of Child
Emotional abuse, 11%
Physical abuse, 28%
Contact sexual abuse, 22%
Neglect of Child
Emotional neglect, 19%
Physical neglect, 15%
Trauma in Child’s Household
Alcohol or drug use, 2%
Depressed, emotionally disturbed, or suicidal household member, 17%
Mother treated violently, 13%
Imprisoned household member, 6%
Loss of parent, 23%

13. Impacts of Childhood Trauma
(ACE Study)
Neurobiological Impacts
Disrupted development
Anger–rage
Hallucinations
Depression/other mental health challenges
Panic reactions
Anxiety
Somatic problems
Impaired memory
Flashbacks
Dissociation
Health Risks
Smoking
Severe obesity
Physical inactivity
Suicide attempts
Alcohol and/or drug abuse
50+ sex partners
Repetition of trauma
Self injury
Eating disorders
Violent, aggressive behavior

14. Impacts of Childhood Trauma
(ACE Study)
Disease and Disability
Ischemic heart disease
Autoimmune diseases
Lung cancer
Chronic obstructive pulmonary disease
Asthma
Liver disease
Skeletal fractures
Poor self-rated health
Sexually transmitted infections
Social Problems
Homelessness
Prostitution
Delinquency, criminal behavior
Inability to sustain employment
Re-victimization
Less ability to parent
Teen and unwanted pregnancy
Negative self- and other perception and loss of meaning
Intergenerational abuse
Involvement in MANY services
HIV/AIDS

15. ACE Model

16. Trauma-Informed Care
Incorporates proven practices into current operations to deliver services that acknowledge the role that violence and victimization play in the lives of most of the children entering our systems.

17. Trauma-Informed Care (TIC) provides a new paradigm under which the basic premise for organizing services is transformed.
From: To:
From: To:
What is wrong with you?
What happened to you?
Control
Collaboration

18. Trauma Informed Systems…
educate children, families, and providers on trauma exposure, its impact, and treatment;
engage in efforts to strengthen the resilience and protective factors of children and families;
routinely screen for trauma exposure and related symptoms;
use culturally appropriate evidence-based assessment and treatment;
School staff, educators, and administrators should:
􀂃 Recognize the potential effects of trauma on education (e.g., attendance,
grades, test scores, classroom behavior).
􀂃 Be able to identify students who are in need of help, due to trauma.
􀂃 Be able to respond to the needs of traumatized students.
􀂃 Pay attention to and understand the impact of policy issues (e.g., IDEA
legislation) and new authorization requirements.
􀂃 Recognize the importance of self care and the potential impact of
secondary traumatic stress.
Adapted from NCTSN definition

19. Trauma Informed Systems…
address parent and caregiver trauma and its impact on the family system;
emphasize continuity of care and collaboration across child-service systems; and
maintain an environment of care for staff that addresses, minimizes, and treats secondary traumatic stress, and that increases staff resilience.
Adapted from NCTSN definition

20. A Culture Shift: Core Principles of a Trauma-Informed System
Safety: Ensuring physical & emotional safety
Trustworthiness: Maximizing trustworthiness, making tasks clear, & maintaining appropriate boundaries
Choice: Prioritizing child & family choice & control
Collaboration: Maximizing collaboration & sharing of power with child and family
Empowerment: Prioritizing empowerment and skill-building
If an organization can honestly state that every contact,
every activity, every relationship, and every physical setting reflects these
values, then it is a trauma-informed culture.
We’ve learned a basic lesson: that it is possible for staff members to create a culture
of safety, trustworthiness, choice, collaboration, and empowerment only when
they experience these factors in their working environment and in their relationships
with supervisors, administrators, and colleagues.

21. Trauma-Specific Treatments
Interventions intended to increase coping skills and reduce trauma-related emotional and behavioral symptoms

22. Trauma Specific Treatments
Examples of Evidence-Based Trauma Treatments
Trauma-Focused Cognitive Behavioral Therapy
Parent Child Interaction Therapy
Real Life Heroes
Seeking Safety
Cognitive Behavioral Intervention
for Trauma in Schools (CBITS)
TF-CBT (Grief)
TF-CBT – appropriate for ages 3 – 18; most research evidence for support,
CPP – appropriate for ages 0 to 5; goal is to support and strengthen the relationship between a child and his or her parent (or caregiver) as a vehicle for restoring the child's sense of safety, attachment, and appropriate affect and improving the child's cognitive, behavioral, and social functioning.
RLH – appropriate for ages 6 – 17; focuses on rebuilding attachments, building the skills and interpersonal resources needed to reintegrate painful memories, fostering healing, and restoring hope; uses nonverbal creative arts, narrative interventions, and gradual exposure
Seeking Safety – appropriate for youth and adults with co-occurring PTSD and substance abuse; focuses on psychoeducation and coping skills
CBITS – generally grades 3 through 8, some testing with high school, group and individual sessions focused on reducing symptoms of PTSD, depression, and behavioral problems; improving peer and parent support; and enhancing coping skills

23. Key Components in Effective Trauma Interventions
Focus on relationship with caregiver
Psychoeducation on the effects of trauma on children
Building affective expression and modulation skills
Relaxation and anxiety management skills
Building cognitive coping skills
Safety planning
Retelling of trauma/exposure
Caregiver: focus on creating a stable environment, minimizing disruption related to trauma and aftermath, fostering or repairing attachment, minimizing effect of trauma on parenting skills
Psychoeducation

24. Resources
National Child Traumatic Stress Network (
National Center for Trauma Informed Care (
Child Welfare Information Gateway (
THRIVE Maine’s System of Care Inititiative (