Understanding Trauma
from a Trauma Systems Therapy
perspective
B. Heidi Ellis, Ph.D.
Children’s Hospital Boston
The Basics
Denise
What do you do?
Bottom line…
The Trauma System
1. A traumatized child who is unable to
regulate emotional states,
2. A social-environment/system-of-care
that cannot help contain this
dysregulation.
Social-Ecological Model
Culture
Neighborhood
Peer Group
School
Family
Individual
Denise
Why does she act and feel the
way she does?
What is at stake if we ignore
her?
What can we do to help?
Denise
Why does she act and feel the
way she does?
Traumatic
Stress
Survival in the moment
The Trauma System
“The amygdala leads a hostile takeover of consciousness by emotion” (Joseph LeDoux)
Survival Circuits are adaptive…
Survival Circuits are adaptive…
unless they are triggered in nonthreatening situations
Phases of Dysregulation
Regulating
Affect
Awareness
Action
Reving
Reexperiencing
Reconstituting
The 3 A’s of Emotional
Regulation
Affect
Awareness
Action
The 4 R’s of Regulation Phases
Regulating
Reving
Reexperiencing
Reconstituting
Survival Circuits
Amygdala
Broca’s area
Rauch, S., Van der Kolk, B., Fisler, R., Alpert, N. (1996). A symptom provocation study of Posttraumatic Stress Disorder
using positron emission tomography and script-driven imagery. Archives of General Psychiatry, 53(5) pp. 380-387.
Situations That Can Be Traumatic
• Physical or sexual abuse
• Abandonment, neglect, or betrayal of trust
• The death, loss or life-threatening illness of a loved one
• Witnessing domestic violence
• Automobile or other serious accidents
• Bullying
• Life-threatening health situations or medical procedures
• Witnessing or experiencing community violence (e.g., drive-by
shooting, fight at school, robbery)
• Witnessing police activity or having a relative incarcerated
• Life-threatening natural disasters
• Acts or threats of terrorism
Denise
What is at stake if we ignore
her?
Understanding Child Trauma
One out of every four children attending school has been exposed
to a traumatic event that can affect learning and/or behavior. 1
Some of the most common types of trauma are physical
abuse, sexual abuse, domestic violence, and community
and school violence. By the age of 16…2
• 39% to 85% of youth have witnessed community violence
• 66% of youth have been victims of community violence
• 25% to 43% of youth have been exposed to sexual abuse
Trauma can have long-term effects on school
performance by1:
• Adversely affecting a child’s attention, memory
and cognition
• Reducing a child’s ability to focus, organize and
solve problems
• Decreasing reading ability and GPA
• Increasing rate of school absences
• Increasing suspensions, expulsions and drop-outs
1.
2.
National Child Traumatic Stress Network Schools Committee. (October 2008). Child Trauma Toolkit for Educators. From http://www.nctsn.org/resources/audiences/parents-caregivers
American Psychological Association (2008). Child and Trauma Update for Mental Health Professionals. From http://www.apa.org/pi/families/resources/update.pdf
Adverse Childhood Experiences (ACE) Study
Death
Whole Life Perspective
Early
Death
Disease, Disability,
and Social Problems
Adoption of
Health-risk Behaviors
Social, Emotional, &
Cognitive Impairment
Adverse Childhood Experiences
Conception
Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., and Marks, J.S.
(1998, May). Adverse Childhood Experiences (ACE) Study. (1998). Retrieved from http://www.cdc.gov/ace/about.htm.
Consequences of
Traumatic Stress
• Social
– Drug abuse
– Anti-social behavior
– Isolation/withdrawal
• Psychological
– Posttraumatic Stress
Disorder
• Reexperiencing,
Avoidance,
Hyperarousal
– Depression
– Conduct disorder
– Emotion Regulation
• Academic
What You Might Observe in Students
Who Have Experienced Trauma
• Anxiety or fear about safety of self and others (more clingy
with teachers or parents)
• Worry about recurrence of violence
• Increased distress (unusually whiny, irritable, moody)
• Changes in behavior:
• Increase in activity level
• Decreased attention and/or concentration
• Withdrawal from others or activities
• Angry outbursts and/or aggression
• Absenteeism
• Distrust of others, affecting how children interact with both
adults and peers
What You Might Observe in Students
Who Have Experienced Trauma (Cont.)
• A change in ability to interpret and respond to social cues
• Increased somatic complaints (e.g., headaches,
stomachaches, overreaction to minor bumps and bruises)
• Changes in school performance
• Recreating the event (e.g., repeatedly talking about,
“playing” out, or drawing the event)
• Over- or under-reaction to physical contact, doors slamming,
sirens, lightning or sudden movements
• Statements and questions about death and dying
• Difficulty with authority, redirection, or criticism
Denise
What can we do to help?
Trauma and
the Social
Environment
Playing Rats
In Panksepp JP (1998): Affective Neuroscience: The Foundation of Human and
Animal Emotions, Oxford, New York
Where is the cat hair?
Amount of Play over 10 days
Amount of Play
A lot
Cat hair
introduced
Some
A little
Cat hair
removed
None
1
2
3
4
5
6
7
8
9
10
Day
In Panksepp JP (1998): Affective Neuroscience: The Foundation of Human and
Animal Emotions, Oxford, New York
Social-Ecological Model
Culture
Neighborhood
Peer Group
School
Family
Individual
Where is the cat?
How much do you know about
the location of the cat hair and
the cat in the children you treat?
How important is this knowledge
for understanding the child’s main
emotional & behavioral problems?
What tools do you use for locating the
cat hair and the cat; and doing
something about it?
What Regulates the Survival Circuit?
Kirsch, P., Esslinger, C., Chen, O., Mier, D., Lis, S., Siddhanti, S., et al. (2005). Oxytocin modulates neural
circuitry for social cognition and fear in humans. Journal of Neuroscience, 25, 11489-11493.
A girl, a jump rope,
and a ball
Why?
• He bumped me because [I was in his way,
he wasn’t looking, by accident]
• He bumped me because he hates me
• He bumped me because he hates me and
he could really hurt me next time
Why is that the Why?
Signals of Care
•
Subtle interpersonal signals that people send
each other, all the time, wittingly or unwittingly
•
These signals can be signals of care or
carelessness; signals of safety or danger;
signals of love or hate
•
We all have a balance of positive and negative
signals in our lives. We base our expectations
of the world largely on this balance
Lucy’s Signals
• Father frequently drunk, enraged, and violent
• Mother scared and vulnerable, frequently
blames Lucy for ‘triggering’ father’s violence
by her cheekiness
• Teachers see Lucy as trouble-maker
• Lucy has learned that people generally are
hostile, unhelpful to her, and more likely to
hurt than help. Her world is saturated with
‘Cat hair’
Signals of Care:
Changing the balance
•
The remedy for Signals-of-Danger are
Signals-of-Care
•
These “Signals-of-Care” usually
communicate warmth, empathy, and
positive regard
•
Our job is to help build a ‘critical mass’ of
signals-of-care across the ‘system of care’.
We must help create a social environment
filled with Signals-of-Care
Moment-by-Moment Assessment
Regulating
Reving
Reexperiencing
Reconstituting
Description:
Child is in calm, continuous
emotional state and well
engaged with his or her
environment
Description:
Child has been
triggered
by a provocative
stimuli
and is engaging coping
skills to manage
emotion:
Description:
Child’s coping skills
have been
overwhelmed.
He or she has
entered into a state
of extreme emotion.
Description:
Child’s state of
emotion has
diminished. Child is
using existing coping
skills to manage
emotion and to
reengage with the
environment.
Clinical Priority:
How to minimize
triggers to prevent
Escalation.
Clinical Priority:
How to help child to
regulate emotion once
triggered.
Clinical Priority:
How to minimize
containment
interventions from
being retraumatizing
Clinical Priority:
How to help the child
continue to manage
emotion and to
reengage with the
environment.
Affect
Awareness
Action
Survival in the moment in action
Part 1
Video Clip
Survival in the moment in action
• What just happened?
• What happened with Esmeralda?
– Was she being deliberately disobedient and
disrespectful?
• What happened with Manuel?
Survival in the moment in action
• What just happened?
• What state is Esmeralda in now?
• How might she respond to consequences
right now?
• How might she respond to efforts to
reconnect?
• Did you see any signals of care?
Survival in the moment in action
• How did Esmeralda’s history make her
vulnerable to dysregulation when Manuel
spoke with her?
• What was the ‘cat hair’ for Esmeralda?
What Can Be Done at School to
Help a Traumatized Child?
1.
Maintain usual routines to send the message that the child is safe
2.
Give children choices to provide a feeling of control
3.
Increase support and encouragement for the traumatized child
4.
Set clear limits and logical consequences for inappropriate
behavior
5.
Provide a safe place for the child to talk about what happened
6.
Be sensitive to environmental cues that may cause a reaction in
the traumatized child (e.g.,the anniversary of a traumatic event)
7.
Warn children before doing something out of the ordinary, such as
turning off lights or making a sudden loud noise
When Should a Referral Be Made for
Additional Help for a Traumatized Child?
• Give referrals for additional help when reactions:
• Are severe (such as intense hopelessness or fear), or
• Go on for a long time (more than one month), and
• Interfere with a child’s functioning
• Severity can be difficult to determine – some
children may become avoidant or appear to be
fine (e.g., a child who performs well
academically no matter what)
• You don’t have to be certain before making a
referral – let a mental health professional
evaluate the likelihood that the child could
benefit from some type of intervention
NCTSN: Resources for School Personnel
From NCTSN Resources for School Personnel website: http://www.nctsnet.org/resources/audiences/school-personnel