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Building Capacity for Working with Young Children and Trauma

Mark Hald, PhD, Paula Ray, PsyD, 

Kate Crowley, OTD, Jennie Cole‐Mossman, LIMHP

Definitions of Trauma/Loss HistoryNational Child Traumatic Stress Network, 2013

• Neglect: Physical, Medical, Educational

• Emotional Abuse

• Sexual Abuse or Assault/Rape

• Domestic Violence Exposure

• Physical Abuse or Assault

• Extreme Personal/Interpersonal Violence

• Traumatic Grief/Separation

• Systems‐Inducted Trauma

• War/Terrorism/Political Violence

• School Violence Exposure

• Community Violence Exposure

• Serious Accident/Illness/Medical Procedure

• Forced Displacement

• Natural/Manmade Disasters

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What Do All Forms of Trauma have in Common?

The Body Keeps the Scorevan der Kolk, 1994

• The detection of safety or danger triggers neurobiologically determined prosocial or defensive behaviors. Even though we may not be aware of danger on a cognitive level, on a neurophysiological level, our body has already started a sequence of neural processes that would facilitate adaptive defense behaviors such as fight, flight or freeze. 

• Stephen W. Porges, PhD. The Polyvagal Theory

Adverse Childhood Events

ACE study: (Anda & Felliti, 1998) • Demonstrated a link between adverse childhood experiences and lifelong health and quality of life

–6 or more ACES = 20 years less in life expectancy

• Looked at: childhood abuse, neglect, and household challenges 

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ACE PYRAMID

http://www.americasangel.org/research/adverse‐childhood‐experiences‐ace‐study/

ACE Impact

• How common are ACEs?–⅔ of adults have 1 ACE–4 or more indicates high risk

How does a child make it through this?

By building resilience Working with the family systemWorking with multiple caregivers and providers, all of whom are “going to bat” for the childStability, routines, predictable occupationsHelping the brain build a new roadmap

(Van der Kolk, 2014; Koomar, 2009; Perry, 2006)

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Poverty

• Researchers at UC Berkeley reported findings that normal 9 - 10 year-olds differing only in socioeconomic status, with no prenatal exposure to drugs or alcohol, had detectable differences in the response of their frontal cortex compared to children from high socioeconomic levels. Children from lower socioeconomic levels show brain physiology patterns similar to someone who actually has damage in the frontal lobe as an adult.

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Poverty in Nebraska

• 2014 Kids Count Report in Nebraska - nearly 41% of Nebraska children are growing up in low-income families. A disproportionate number of these children are minorities.

– 10.7 percent of Caucasian children 17 & younger live in poverty;

– 44.9 percent for African American children;

– 42.2 percent for Native Americans;

– 31.9 percent for Hispanic children.

• The vast majority have parents working 2 or more jobs and earning less than they need to survive.

• Overall, 8% of Nebraskans work multiple jobs, the fifth-highest rate in the nation.

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Sleep is the Primary Activity of the Developing Brain  J. Mindell

• By age 2 the average child has spent about 9,500 hours (13 months) sleeping, in contrast to 8,000 hours for all waking activities combined.

• Between ages 2 & 5 children spend equal amounts of time awake and asleep.

• Throughout childhood and adolescence sleep continues to account for about 40% of a child’s average day. 

Circadian rhythms shift developmentally (D. Beebe, 2011)

• In teenagers, research has shown that melatonin levels in the blood naturally rise later at night than in most children and adults. Since teens may have difficulty going to bed early to get enough sleep, it can help to keep the lights dim at night as bedtime approaches. It can also help to get into bright light as soon as possible in the morning.

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White Matter Diffusion Tensor MRI

Diffusion MRI

Structural Abnormality

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Integrated Functioning

Delayed Effects in Children

• Immature brain has less potential compensate.

• Full effects only evident many years later, when brain maturation stages do no unfold normally.

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Creating a Safer Space:

tips for how to provide safety for children exposed to trauma

Jennie Cole-Mossman LIMHPNebraska Resource Center for Vulnerable Young Children

Center on Children, Families and the Law University of Nebraska Lincoln

The Invisible Suitcase• Trauma affects

development and therefore expectations, and beliefs about the world, the self, and the people who take care of the child.

• Many children carry around an “invisible suitcase” of beliefs about themselves and people who care for them.

Invisible Suitcase• You didn’t create it…

• Its not about you...

• But you can understand it and help unpack it.

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What’s in your suitcase? • Take a moment to think

about what things cause you to get stirred up?

• What regulation strategies do you have to get calm?

• To get calm, we need to be calm

Maya • Seems to take comfort

in a certain song

• 8 months old

• Cries and screams but doesn’t like to be comforted

• Is easily startled and upset by loud noises

• Becomes upset at the doctor

• Calms down when she can hold a bottle that is propped up but doesn’t want to be fed by caregiver

Maya’s Suitcase• Maya can’t tell you what is in her suitcase even if

she wanted to do so. • But her history tells you that she has experienced

significant traumas: exposure to domestic violencephysical abuseseparation from her mothermedical trauma – including time with her arms in casts

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Maya’s Memory Explicit Implicit

• Explicit memory develops around age 2 with language.

• You can tell the story of the memory.

• “The body remembers”• Young children take in

memory with their senses… touch, feel, taste, and sound

• Not tied to language

What does she believe?• People cause pain not

comfort. • People are not safe. • People cannot be

trusted. • The world is a

dangerous place. • Bottles and music are

good. • Hospitals are bad.

• Crying is scary.• When I cry, no one

responds.• When I cry, others hit

me or get mad at me. • Nobody comforts me

so I will do it myself.• I’m not worthy of care.

Repacking Maya’s suitcase

• The world is a safe place.

• People can be trusted. • I am important and

loved.

• People come when I cry.

• People know what I need.

• Touch isn’t scary. • Hospitals can be a

helpful place. • I can make people

respond to me in other ways rather than crying.

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Your own Suitcase• Be sure to check your

own “suitcase” and be aware of your own issues

• Many people who work in this field have experienced trauma or have secondary trauma

• Take care of your own baggage…

Helping Create Safety

Safety• Think of a time you felt

unsafe, endangered or worried… what do you remember feeling physically and emotionally?

• Think of what it took to make you feel safe and secure... What did you feel like physically and emotionally?

• The condition of being safe from undergoing or causing hurt, injury or loss

• Physical and emotional safety

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Safety and Trauma• Have valid concerns

about their own safety and safety of people they love

• Find it hard to trust adults CAN and will protect them

• May be hyperaware of threats, some that we find illogical

• Have trouble controlling physiological arousal when threatened.

• Children who have experienced trauma need more control and reassurance.

• Give some examples of this from your work

What is happening? 

Psychological Safety• Each child is different

and unique so provide them with opportunities to express themselves. Don’t think you “know” a child because of their history.

• Help them make connections with culture or their past if it seems comforting.. Follow their lead here.

• Familiarize them with surroundings

• Give them choices • Set some limit so they

aren’t overwhelmed• Talk about what is

going to happen next –give some direction of what is going on and how decisions are made

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Give a Safety Message• Ask the child what they

need to feel safe (use age appropriate language – young children can’t tell you what they need, watch behaviors)

• Follow the child’s lead – if they are too anxious or upset wait to give a safety message

• Engage the worker to help stay with the child or someone who is known to the child (secure bases)

• Be eye level and use age appropriate language

• Make a promise you can keep – “I’m going to do everything I can to keep you safe”

Rules and Routines• Have clear

expectations but don’t expect perfection

• Remember the invisible suitcase

• Start with essential rules and routines – don’t overwhelm

Emotional Container• You are much more

skilled than children at containing emotions.

• They feel overwhelmed and lack the skills to handle the difficult emotions brought on by the trauma and reminders of the trauma.

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Emotional Container• “I started cursing at the

foster mom. I figured that sooner or later she would say something that would hurt me. I wanted to hurt her first…”

• Negative beliefs and expectations in the invisible suitcase are often acted out to try to provoke “known” and predictable responses

• Staying calm and appropriately approving or disapproving of the child’s behavior is a gift.

Emotional Container• Be willing.. Be prepared… and Be tolerant of strong

emotional reactions.

• Remember the suitcase. Psst... Its not about you!

• Respond calmly but firmly.

• Help the child identify and label feelings.

• Set good examples of handling feelings appropriately

Hot Spots• Situations that are

difficult for children who have experienced trauma

• Trigger a child to act out, struggle, or become emotionally upset

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Hot Spots• Know your own “hot

spots”

• When are you less likely to be able to tolerate and handle calmly an emotional child?

• Hungry, sleepy, sick rule

• Separations

• Mealtimes or other situations around food

• Bed time, getting to sleep, staying asleep, and being awakened

• Anything involving boundaries – bath time, privacy, medical exams

Trauma Reminders• Prompt behavior that

seems out of place but originally made sense

• May bring up intense feelings

• May or may not be awareness that a trauma reminder is occurring

• To feel safe we need to feel control over the environment and control over ourselves

• Trauma reminders can be: sights, smells, things, places, people words, colors or even feelings.

Trauma Reminders• May cause

embarrassment in older children and adolescents

• May be mistaken for bad behavior

• Can be chronic

• May make the child appear to be overreacting or disruptive

• May cause isolation or avoidance of certain people, places or things

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Spotting Trauma Reminders

• Not just for therapists to spot trauma reminders

• Often happen during real world experiences

• Helps to understand behavior or strong emotions

How to Spot Trauma Reminders

1. Be Observant : When did the reaction occur? What happened before it? Where did it occur? What time of day? What other cues were present? Sights, sounds, smells, people places and things?

2. Reduce exposure until the child can regulate their emotions better.

3. Tell the therapist, caseworker, foster parent –whomever the child works with regularly to manage trauma reminders.

4. Stay regulated yourself – you provide cues about whether the environment is safe – if you are upset –so are children around you.

www.nebraskababies.com

Jennie Cole-Mossman LIMHPNebraska Resource Project for Vulnerable

Young Children Center on Children, Families and the Law - UNL

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Evidence Based PracticeNebraska Young Child Institute

June 2018. Kearney, NE

Evidenced Based Practice EBP is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient.

It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” (Sackett D, 1996)

Evidence Based Practices Therapeutic treatments for treating infants

– young children and their families. Child-Psychotherapy (Lieberman,Gosh Ippen, & Van Horn, 2015).

Attachment and Biobehavioral Catch-Up Intervention (Dozier, Meade, & Bernard, 2014).

Parent-Child Interaction Theray (Eyberg, 1988).

Trauma-Focused Cognitive Behavioral Therapy

Attachment, Self-Regulation, and Competence: A Comprehensive Framework

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Evidenced Based Practicesparenting programs for young children and families. NURSE-FAMILY PARTNERSHIP - This program strives to improve overall family

functioning through improved prenatal health resulting in healthier pregnancies and infants, improved care to infants and toddlers in the interest of optimal health and development and improved personal, health and vocational development on the part of parent(s).

PARENTS AS TEACHERS - Program Description: This program seeks to promote school readiness by working with parents and their children birth through age 5. It includes in-home visits by certified parent educators, parent group meetings, periodic developmental screenings and links to community resources

Evidenced Based Practicesparenting programs for young children and families. The Triple P-Positive Parenting Program - m is a multilevel, multidisciplinary,

evidence-based system of parenting and family support strategies designed to prevent behavioural, emotional and developmental problems in children (or, where applicable, to halt the progression or reduce the severity of such problems).

The Strengthening Families Program is an evidence-based 14-week family skills training program that involves the whole family in three classes run on the same night once a week.

Nurturing Parenting Programs

Evidenced Based Practicesparenting programs for young children and families. The Incredible Years - The Incredible Years parent, teacher and child

training series features three comprehensive, multifaceted and development based curricula for parents, teachers and children. The series is based on cognitive social learning theory, which emphasizes the importance of the family and of teacher socialization processes, especially those affecting young children.

FYI Love and Logic - actually has a low evidence base. There is outcome data from studies but that have weak designs. https://fyi.uwex.edu/whatworkswisconsin/files/2014/04/whatworks_08.pdf

https://www.unodc.org/documents/prevention/family-compilation.pdf

https://www.joe.org/joe/2012august/a8.php

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Evidenced Based Practicesparenting programs for young children and families. Circle of Security Parenting - The Circle of Security® Parenting™ program is

based on decades of research about how secure parent-child relationships can be supported and strengthened.

Video clips of parents and children were developed to introduce parents to attachment theory in an accessible manner. Parents are provided an opportunity to enhance their observational and inferential skills, and invited to engage in reflective dialogue regarding their strengths and struggles in parenting. Over the course of eight sessions, the focus of the intervention moves from discussing secure attachment and children's needs, to the more vulnerable process of parents reflecting on themselves and the defensive behaviors that maintain insecure and disorganized attachment.

Evidenced Based Practicesparenting programs for young children and families. There is strong evidence for the use of this model for both the general

population and for the repair of the child parent relationship.

Circle of Security Parenting is a Parenting Reflection Model.

Reflective parenting

Reflective parenting A process of reflecting a child's internal world; interpreting their actions with an

understanding of the underlying thoughts, intentions, feeling in children's behavior

Helps children provide a voice to a subjective experience, understand where things come from

Helps to repair attachment issues

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Circle of Security

Fear Seperation

Fear Closeness

Mean, weak, gone.Fear the care-giver

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Characteristics of Children with secure healthy attachments? The more secure children are the more they are able to: Know that most problems will be solved.Have high self esteem.Get along better with friends. Know how to be kind to those around them.Solve problems on their own.

The more secure children are the more they are able to: Have better relationships with brothers and

sisters. Feel less anger at their parents. Solve problems with friends. Turn to their parents for help when in trouble. Trust the people they love. Enjoy more happiness with their parents.