www.TheNationalCouncil.org

Trauma Informed Care, Part 1:Trauma and the Adolescent

The National Council for Behavioral HealthMay 12, 2015

Karen Johnson, LCSWDirector of Trauma-Informed ServicesNational Council for Behavioral Health

•19 years working in child welfare and community-based mental health

•Certified in the ChildTrauma Academy’s Neurosequential Model of Therapeutics

•Parent of an adult child with severe and chronic mental illness

www.TheNationalCouncil.org

The National Council

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750,000 staff serving 8 million adults, children, and familieswith mental illnessand substance use disorders…

2147 Behavioral Health Organizations

Overview

• What is trauma?• Understanding ACES• Neuro/Bio/Psycho/Social impact of trauma• Trauma-informed care

We begin to ask, “What happened to you?” rather than “What is wrong with you?”

We have to ask, “What’s strong?”rather than“What’s wrong?”

Paradigm Shift

Understanding Trauma

• Pervasive• Impactful

•Life shaping•Self-perpetuating

Trauma is

What is Trauma?

Individual trauma results from an , series of events, or set of circumstances that is by an individual as overwhelming or life-changing and that has profound on the individual’s psychological development or well-being, often involving a physiological, social, and/or spiritual impact.

Definition (SAMHSA Experts 2012) includes

eventexperienced

three key elements

effects

Types of Trauma

• Child maltreatment and complex trauma

• Serious accident or illness

• Victim/witness to domestic, community and school

violence

• Natural disaster, war, terrorism, political violence

• Traumatic grief/separation, significant loss

• Historical and generational trauma

What Does Trauma Do?

Shapes our Beliefs

Worldview Spirituality

Identity

What Does Trauma Do?

Symptoms are adaptations

• Drinking = self medication

• Cutting = release of pressure

• Isolating = avoidance of fear

• Aggression = protecting oneself

Results in Vicious Loop

Prevalence

• In the general population, 61% of men and 51% of women reported exposure to at least one lifetime traumatic event, but majority reporting more than one traumatic event (Kessler, et al, 1995)

• 2012 numbers show that 59% of the general population has experience adverse childhood events

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Source: Washington State Family Policy Council

Prevalence of Trauma in Students

13 of every 30 students in a classroom will have toxic stress from 3 or more Adverse Childhood Experiences (ACEs)

What Does The Prevalence Data Tell Us?

• The majority of adults and children in psychiatric treatment settings have trauma histories

• A sizable percentage of people with substance use disorders have traumatic stress symptoms that interfere with achieving or maintaining sobriety

• A sizable percentage of adults and children in the prison or juvenile justice system have trauma histories (Hodas, 2004, Cusack et al., Mueser et al., 1998, Lipschitz et al., 1999, NASMHPD, 1998)

Polling Question Adverse Childhood Experiences Study

How much training have you had on the ACE Study?•None•Some•I know this work quite well

Therefore, we need to exercise…

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Adverse Childhood Experiences (ACE) Study

• Center for Disease Control and Kaiser Permanente (an HMO) Collaboration

• Over a ten year study involving 17,000 people • Looked at effects of adverse childhood

experiences (trauma)over the lifespan• Largest study ever done on this subject

Adverse Childhood Experiences1. Child physical abuse 2. Child sexual abuse3. Child emotional abuse4. Physical Neglect5. Emotional Neglect6. Mentally ill, depressed or suicidal person in the home7. Drug addicted or alcoholic family member8. Witnessing domestic violence against the mother9. Loss of a parent to death or abandonment, including

abandonment by divorce10. Incarceration of any family member

Dose gets bigger

Resp

onse

get

s bi

gger

Dose-Response Relationship: More ACEs = More Disease

Higher ACE Score Increases Smoking

6 of 100 people with 0 ACEs smoke

11 of 100 people with 3 ACEs smoke

17 of 100 people with 7 ACEs smoke

ACE Score Increases Suicide Attempt

1 of 100 people with 0 ACEs attempt suicide

10 of 100 people with 3 ACEs attempt suicide

20 of 100 people with 7 ACEs attempt suicide

Childhood Experiences and Adult Alcoholism

0

1

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4+

Life-Long Physical, Mental & Behavioral Health Outcomes Linked to ACEs

• Alcohol, tobacco & other drug addiction

• Auto-immune disease• Chronic obstructive pulmonary

disease & ischemic heart disease

• Depression, anxiety & other mental illness

• Diabetes• Multiple divorces• Fetal death• High risk sexual activity, STDs &

unintended pregnancy

• Intimate partner violence—perpetration & victimization

• Liver disease• Lung cancer• Obesity • Self-regulation & anger

management problems• Skeletal fractures• Suicide attempts• Work problems—including

absenteeism, productivity & on-the-job injury

Impact of Trauma Over the Lifespan

Are neurological, biological, psychological and social in nature. They include:•Changes in brain neurobiology;•Social, emotional & cognitive impairment;•Adoption of health risk behaviors as coping mechanisms (eating disorders, smoking, substance abuse, self harm, sexual promiscuity, violence); and•Severe and persistent behavioral health, health and social problems, early death.

(Felitti et al, 1998)

Adverse Childhood Experiences

The #1 Chronic Health Epidemic in the United States

“The impact of ACEs can now only be ignored as a matter of conscious choice. With this information

comes the responsibility to use it”(Anda and Brown, CDC)

ACE Study DVD from Academy on Violence and Abuse

Neuro/Bio/Psycho/Social Impact of Trauma

The Amazing Brain

Neuroscience & Trauma

• Prior to 1980’s – little attention paid to the impact of trauma on the brain

• 1980 – PTSD first introduced• 1990s – the Decade of the Brain• April 2014 – $100,000 million BRAIN• Study of the teenage brain has been

neglected until past decade

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Brain Development

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Cognition (Abstract & Reflective)Cognition (Concrete) AffiliationAttachmentRewardSexual BehaviorEmotional ReactivityMotor RegulationArousalAppetite/SatietySleepBlood PressureHeart RateBody Temperature

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Plasticity of the Human Brain

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Plasticity Complexity

Myths about the Teenage Brain

• Brain growth is complete by kindergarten• Teens are impulsive and emotional

because of surging hormones• Teens are rebellious and oppositional

because they want to be difficult and different

• Teen brains are the same as adult brains

Adolescent Brain is a Work in Progress

• Functioning, wiring and capacity are all different in adolescents than in the adult brain

• Teens don’t have the same tolerance for stress• New connections between brain areas are being built• Teenage brain has lot of gray matter and less white

matter• Connectivity to and from the frontal lobes is the

most complex and is the last to fully mature Jensen, F. E. & Nutt, A. E. (2015). The teenage brain: a neuroscientist’s

survival guide to raising adolescents and young adults.

Adolescent Brain

• Flexibility, growth, and exuberance of the teenage brain allow for tremendous learning

• “Open” and excitable brain also can be adversely affected by stress, drugs, chemical substances, and any number of changes in the environment

• Influences can result in problems that are dramatically more serious for teens than adults

• Dopamine, or reward neurotransmitter, is increased during adolescence

Survival Mode Response

Inability to • Respond• Learn • Process

At Risk Youth• Brain is impacted by trauma insults• Mistrustful of adults or most relationships• Often cannot access post high school education,

which can serve as buffer to taking on adult tasks

• Defined as an adult at 18 when the average age of financial independence is 26

• Ill equipped to navigate complex transition to adulthood

What to do?

• Encourage positive social connections• Intervene early to address alcohol and drug

abuse• Ask the question: What happened to you?• Focus on what’s strong in you• Promote resilience

Ability to adapt well to stress, adversity, trauma or tragedy

Promoting Resilience Involves Teaching

Working with Youth Involves

Trauma-Informed Approaches

Systems of care need to be trauma-informed. This includes all systems and organizations, their work force,

regulatory bodies and funders.

Principles of a Trauma-Informed Approach

(Fallot 2008, SAMHSA, 2012)

Safety

PhysicalPsychologicalSocialMoral

If you have never felt safe or remembered safety, how will you know it when it is present?

Trustworthiness and Transparency

Collaboration and Mutuality

Empowerment

Voice and Choice

Trauma Informed Services

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www.TheNationalCouncil.orgEvery contact with a client and with each other will affect us in one of two ways:

1. Contribute to a safe and trusting healing environment

OR2. Detract from a safe and trusting environment

We all play a role in assisting our clients to make progress in their lives

We all matter when it comes to creating a safe, trusting and healing environment

We all matter!

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• None of us are immune to traumatic experiences in our own lives.

• All of us work in human services where people are struggling with many challenges that are often overwhelming.

• It’s important to be aware of how these experiences may challenge our own emotional resources.

The stresses of our own work and lives make trauma a personal concern

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“Ultimately, what determines how children survive trauma, physically, emotionally or psychologically, is whether the people around them – particularly the adults they should be able to trust and rely upon, stand by them with love, support and encouragement. “ Dr. Bruce Perry, “The Boy Who Was Raised as a Dog”

The same applies to adults!

Contact Information

Karen JohnsonDirector of Trauma-Informed Serviceskarenj@thenationalcouncil.org

www.thenationalcouncil.org202/684-7457