coordinated behavioral care...presentation title amnesia a five year old child was roughly grabbed...

TRAUMACOORDINATED BEHAVIORAL CARE

DR. NORMAN N BLUMENTHAL DIRECTOR TRAUMA, BEREAVEMENT & CRISIS INTERVENTION, OHEL CHILDREN’S HOME AND FAMILY SERVICES

1/25/21

cbcare.org PRESENTATION TITLE

THANK YOU SAMHSA!

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COORDINATED BEHAVIORAL CARE

Coordinated Behavioral Care (CBC) is a not-for-profit organization dedicated to improving the quality of care for New Yorkers with serious mental illness, chronic health conditions and/or substance use disorders, through a Health Home, an Independent Practice Association (IPA)and other innovative programs, such as Preventative Case Management (PCM) services.

CBC seeks to create a healthcare environment where New Yorkers–especially those most impacted by social determinants of health–receive coordinated, individualized and culturally competentcommunity-based care that is effective in preventing and managing chronic physical and behavioral health conditions.

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CBC TRAINING INSTITUTECoordinated Behavioral Care’s Training Institute provides innovative, interactive, culturally sensitive training and professional development to New York State’s mental health providers. With an eye on adult learning theory, our trainings are cutting-edge, and delivered with compassion for and understanding of the complex demands on mental health professionals. It is our mission to ensure that we provide evidence-based training on a variety of topics to assist providers in supporting the service recipients on their caseload. With a love of learning ourselves, we create our trainings to be the scaffolding upon which a successful, rewarding career of service can be built.

Here are some previous trainings:

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• Supporting LGBTQIA+ Clients• HIPAA and Working from Home• Pathway Home Model Panel Discussion• Anti-racism Training• Interview: This is How I Recovered From Mental Illness• Working with Clients with Borderline Personality Disorder• Medication Management for Non-Prescribers• Helping Your Participants Reach Their Dreams• Treating Seasonal Affective Disorder


TOPICS COVERED1. Vignettes

2. Definition

3. Three types of trauma

Isolated instance

Chronic and unremitting

Prevailing and intermittent

4. PTSD

5. Moral Injury

6. Sleeper Effect

7. Post trauma environment

8. Immediate help

9. Post traumatic Growth

10. OHEL


FLASHBACKSArmed intruders broke into Derek’s home and heldeveryone at gunpoint while they ransacked the place. Theythen tied up Derek and his family and escaped. Everyoneis physically fine but Derek repeatedly sees over and overagain two or three scenes from that dreadful night. Thisoccurs particularly as he is going to sleep or if he startsdaydreaming during class. He wants to get rid of theseimages. Can he? Why is this occurring? How can you help?


The fire that destroyed the G’s home was all consuming. Miraculously, thewhole family escaped with survivable injuries. For over a year, they were busyrecovering medically, finding a house to rent, dealing with insuranceadjustors, reordering drivers licenses, passports and like, replenishing theirwardrobe, etc.. Now a year and half later they are settled in their beautifullyrebuilt home, with new clothing and documents. However, many of the familymembers are starting to report nightmares about fires, panic reactions tosirens and general irritability and tension. The four year old, is repeatedlyplaying a game in which a house burns down and people jump out. Why is thetrauma sinking in now when everything is fine and how should it beaddressed?

THE FIRE


TRAUMA OR REALITY?

Warren is a highly decorated marine stationed in theHelmand Province of Afghanistan which is consideredthe most dangerous in this war zone. There are nearlydaily attacks and attempted incursions at his isolatedmarine base. On guard duty at least every other day,Warren is easily triggered by mere rustling in a bush orany sudden movement or sound. He wonders if heexperiencing trauma or PTSD?


AMNESIA

A five year old child was roughly grabbed by a custodian in the school bathroom and nearly raped. A teacher heard her screams, came in, and rescued her. The perpetrator was arrested and awaiting trial in jail. There was obviously much concern about the child. However, she seemed fine a day or two later and claimed to only remember the teacher firmly taking her out of the bathroom. She was even confused why she held her hand so tight. Despite her amnesia for the event, should she see a trauma specialist? Could it be she really put it out of her mind? Could it come back?


POST TRAUMA?Erin and her siblings were regularly abused andmistreated by their psychopathic step father forthree years between her ages of 4 and 7. He wasfinally reported and removed from the home. Itis now 5 years since his removal and Erin doesnot talk about her past victimization nor hasany overt reactions or flashbacks. Yet, heracademic work is under par, she has few friendsand remains largely quiet and subdued. Couldall this be related to her past trauma?


For the first 23 years of his life, Shin Dong Hyuk lived in a Koreanconcentration camp exposed to severe privation, torture andneglect. He even told on his parents who were planning to escapeand watched them get executed with no emotion. At the age of 23he became the only known person to escape from these camps.Some people compare him to Holocaust survivors. Is that alegitimate comparison?

Escape From Camp 14, by Blaine Harden

A FAIR COMPARISON?


RECURRING CRISES

For most of the time the residents of this townconsider themselves most fortunate to livethere.. Moderate weather, scenic mountainsand fresh air are all part of their surroundings.However, three times in the last four yearsthere have been floods and mudslides causingproperty damage, injury and even fatalities.Scientists and meteorologists cannot predictwhether these floods will recur or how often. Isthis a trauma? What kind? How do you helpthe residents of this community?

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PANDEMICIt’s already 10 months into the pandemic and Ivyhas seen many of the residents of the nursingfacility that she works in succumb and die fromthis illness. Though taking every safetyprecaution possible, she lives with constant dreadthat she will catch the virus and pass it on to herfamily members. She is particularly concernedabout her son who is a cancer survivor andimmune deficient. Is this a trauma? How can shebe helped?

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RELOCATION?Sarah’s home was among othersdestroyed during a flood. Herfamily had to be rescued by boat.They are now residing with Sarah’sgrandparents in a different state.Until her house is rebuilt, she canstay with her grandparents or moveinto a more cramped apartment inher prior neighborhood. Is shebetter off in the more comfortablehome of her grandparents or in thesmaller apartment but reunitedwith her friends and school?


An army medic who had just returned from a tour of duty inAfghanistan, comes to talk to you. While he was spared any injury, hewitnessed horrific carnage including soldiers dying in his arms,severed limbs and the like. As he tells you all about these incidents,you remain attentive but in a stunned silence. At the end of this visit,he thanks you profusely and tells you how much you helped him.What in the world did you do?

RETELLING


LOST IN THE WOODS

During a family hike, Tommy got separated and foundhimself lost in the woods. For nearly three days hewondered aimlessly both hungry and cold. Whenalmost convinced he would die, he was miraculouslyrescued by a team of park rangers who searchedrelentlessly and never gave up. After recovering andbeing treated for the trauma, he announces to hisparents that he wants to work in the parksdepartment when he grows up and specialize in searchand rescue missions. Should this be encouraged ordiscouraged?

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FEELING GUILTYA first year resident in pediatric medicine, Serena worked very hard to gain admission to medical school and residency to fulfill her life’s dream to treat children especially from impoverished areas. Anxious to get home and with an emergency room full of children at 2:00 AM, the Chief Resident instructed her to spend no more than 10 minutes with each child who are ”mostly here for respiratory infections.” Three months later it comes to her attention that one of the children she rushed through an exam was diagnosed with a potentially deadly blood infection that she could have detected and more effectively treated had she not been so rushed. Since then, she can’t compose herself and sees that child’s face as she tries to to go to sleep. Is this trauma? What kind?

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A TRAUMA WE WOULDN’T MIND HAVINGSteven has been buying a state lottery ticket every Tuesdayfor the last 13 years. Once in a while he wins a nominalamount of money but does it more for fun than any remotethought that he’d hit the jackpot. Today on the train intowork he checks his numbers and realizes that he got allfive, winning 165 million dollars. He checks and rechecksand there is no doubt. He suddenly starts hyperventilating,sweating and feeling as if everyone on the train is staringat him. He’s not sure how to hide this ticket or to call hiswife in case he is overheard. He looks so overwrought that afellow passenger asks him if he is ok or needs a doctor. Foryears afterwards he cannot get the image and scenes ofthat train ride out of his mind.


RESPONSES TO SCHOOL SHOOTINGS:WHO’S RIGHT?


COLUMBINE HIGH SCHOOLOn April 20, 1999, seniors Eric Harris, 18, and Dylan Klebold, 17, went on a deadly shooting rampage that killed 12 of their classmates and a teacher, and wounded 23 others, before committing suicide.It took four months for the Littleton, Colo., school to reopen its doors after what was then the most fatal school shooting in recent history.The library, where 13 students were murdered, was torn down and turned into a memorial. On Aug. 17, 1999, students cheered "We are Columbine" over and over at a "Take Back the School" rally as they returned to campus to begin a new school year.


WEST NICKEL MINES SCHOOL

The white, one-room school housesurrounded by the fields of PennsylvaniaAmish country became the scene of atragedy on Oct. 2, 2006. Charles CarlRoberts IV, 32, lined up 10 girls against achalkboard and shot them, killing five. Aspolice closed in, Roberts took his own life.

Six months after the tragedy that shookthe tightknit and private community, anew schoolhouse opened a couple hundredyards from the scene of the massacre.

While the new school was a sign ofresilience, there were also lingeringreminders of the past. The schoolhousecame equipped with a locking steel doorand an emergency release bar.


VIRGINIA TECH

On April 16, 2007, Seung-Hui Cho, a senior at Virginia Tech, went on a shooting spree that terrorized the campus. The school's three-story engineering building, where 30 people were slain, was turned into a scene of carnage.

School officials heard suggestions that ranged from fully reopening all classrooms, to turning it into a memorial, to demolishing it entirely. The building went through extensive renovations and reopened as the Department of Engineering Science and Mechanics and the Center for Peace Studies and Violence Prevention offices and laboratory


CHARDON HIGH SCHOOLOn Feb. 27, 2012, three students were killed when T.J.Lane opened fire on his classmates in the cafeteria atChardon High School in Ohio. Three other students wereinjured.

After the shooting, the school developed a "healing andtransition" plan to make students feel comfortablereturning to classes. The cafeteria, where the shootingoccurred, was repainted and the tables were rearranged.

On March 1, 2012, students and parents attended a "walkthrough" of the school, where grief counselors were onhand before classes resumed the next day.


NEWTOWN MASSACRE

A panel of 28 Newtown officials voted unanimously for a planto tear down Sandy Hook Elementary school, the site of one ofthe worst school massacres in U.S. history, and rebuild a newschool in its place.

Twenty first-graders and six educators were killed when agunman opened fire at the school in December 2012. Threeweeks later, students went back to school at the building thatused to be the Chalk Hill Middle School in Monroe, about sixmiles away.

Each classroom was painstakingly recreated to match how ithad been left at Sandy Hook, down to the placement of aCrayon on a desk


MARJORIE STONEMAN DOUGLAS HIGH SCHOOLOn Feb. 14, 2018, former student Nikolas Cruz, armed with alegally purchased assault rifle, opened fire inside the schoolkilling 17 and wounding more than a dozen others. Roughly3,000 students attend the sprawling high school in Parkland,Florida. After the shooting, residents erected a large makeshiftmemorial outside the school with 17 crosses bearing the namesand pictures of the victims. The freshman building, where theshooting occurred, will not reopen. School officials plan toeventually raze the building. In barely a few days, the “digitalnative” students started a movement dubbed #NeverAgainlaunching a nation-wide campaign with demonstrations and walkouts protesting gun violence.


DEFINITION• Traumatic experiences shake the foundations of our

beliefs about safety, and shatter our assumptions of trust.

• Because they are so far outside what we would expect, these events provoke reactions that feel strange and "crazy". Even though these reactions are unusual and disturbing, they are typical and expectable.

• “An abnormal reaction to an abnormal situation is normal


SUBTYPES

• Isolated instance of traumatic proportion unlikely to recur (e.g. 9/11)

• Chronic and unremitting trauma (e.g. child abuse)

• Recurring and intermittent trauma (e.g. natural disaster in area prone, terrorism in countries with ongoing conflict)


ISOLATED TRAUMA

• While there are often residual effects and compromised functioning (e.g. PTSD), the victimized can remain reasonably assured that they are now safe and re-exposure is highly unlikely.

• This facilitates the recouping of a prevailing sense of security and predictability.


CHARACTERISTICS

• Those that bring the victimized psychologically back to thetrauma such as flashbacks ,startle reactions or triggers.

• Those that try to take the person away from the traumasuch as avoidance, numbing, foreshadowing, amnesia ofboth psychological and neuroanatomical etiology


CHRONIC AND UNREMITTING TRAUMA

• Violence, profound deprivation and mistreatment become the “norm” with little or no expectation or anticipation of change or liberation.

• This nurtures a overriding pessimism, withdrawal and resignation accompanied by a lack of faith in the goodness of people and the world.

• Victims are often devoid of emotion, self isolative and deficient in cognitive and attachment skills.


CHRONIC VERSUS DISRUPTIVE

Unlike those who have survived a concentrationcamp, Shin had not been torn away from acivilized existence and force to descend into hell.He was born and raised there. He accepted itsvalues. He called it home.”

(From Escape From Camp 14, by Blaine Harden)


CHRONIC STRESS AND ACADEMIC ACHIEVEMENT

Chronic stress is known to significantly affect children’sbehavior and achievement in school.

In one study of 2100 elementary students in 10 schools inSpokane, Washington found that 20 percent had two or moreACE’s or adverse childhood experiences such as homelessness,chronic violence, drugs or incarceration.


ACE’S

• These children were 2 to 4 times more likely to have problems with attendance, behavior and health.

• The disorder at home makes it much harder to feel safe or process ideas in a coherent and sequential fashion.

The Adverse Childhood Experience Study (ACE Study), a joint research project by Dr. Vincent Felitti at Kaiser Permanente in San Diego, and Dr. Robert Anda of the Centers for Disease Control and Prevention

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http://www.cdc.gov/ace/index.htm


ACE• Roughly 9500 people were surveyed for the presence of past ACE

including psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned.

• More than half of respondents reported at least one, and one-fourth reported 2 or more childhood exposures.

• Those who had experienced four or more categories of childhood exposure had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health. (American Journal of Preventive Medicine, 14(4), 1998)


PREVAILING AND INTERMITTENT

• Whereas the prevailing experience is one of safety and predictability, the disruption of that state is always looming and feasible.

• In contrast to chronic trauma, the victim has a predominant reference point for the inherent goodness and stability of life.

• However, the victim cannot relinquish his or her alert and vigilance for a recurrence of the trauma.


PREVAILING AND INTERMITTENT

• Two subtypes

• Repetition of same trauma

• Two different traumas concurring or in close proximity.

• The mathematics of trauma


SDEROT, ISRAEL

Sderot is a city in Southwestern Israelless than a mile from the Gaza strip.Since 2001 it has been the target ofthousands of Quassam rocket attacksfrom the Gaza Strip that have killed 13Israelis, wounded dozens, causedmillions of dollars in damage andprofoundly disrupted daily life.


SDEROT

”The situation in Sderot requires a different paradigm…Astraumatic events can be expected to continue indefinitely pre-,peri- and post-traumatic. Further, in a situation of constantexposure to missile attacks, ’survival mode’ is a rational and evenadaptive reaction…Sderot’s residents require a new approach totreatment, one that can minimize the negative effects of traumawhile acknowledging the ongoing threat and the necessity ofprotecting oneself and one’s children.”Pat Horenczyk, R. et al, Growing up under fire: Building resilience in young children and parentsexposed to ongoing missile attacks. Journal of Child and Adolescent Trauma, 5: 303-314, 2012


THOUGHT QUESTIONOf these three categories oftrauma, which do you thinkthe current pandemic fallsinto?

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POST TRAUMATIC STRESS DISORDER (PTSD)• Difference between disorder and response• Various sensations as if back in the traumatic situation (e.g. flashbacks)• Startle and protective reactions to stimuli reminiscent of the trauma.• Avoidance of situations or reminders of the trauma.• Amnesia or memory lapses• Diminished interest in activities. • Pervasive detachment and constricted affect• Sense of a foreshortened future (e.g., does not expect to have a career,

marriage, children, or a normal life span)


PTSD RATES• Estimates of PTSD prevalence rates among returning service members vary widely

across wars and eras.

• In one major study of 60,000 Iraq and Afghanistan veterans, 13.5% of deployed and non-deployed veterans screened positive for PTSD, while other studies show the rate to be as high as 20% to 30%. As many as 500,000 U.S. troops who served in these wars over the past 13 years have been diagnosed with PTSD. (Eber S. et al Mil Med. 2013;178:966–969: U.S. Department of Veterans Affairs PTSD in Iraq and Afghanistan veterans. Jun 3, 2015)

• Those rates rise significantly in proportion to duration of service and exposure to life threatening combat.


MORAL INJURY• Moral injury is a subset of post trauma

reactions that can be defined as “acharacter wound that stems from abetrayal of justice by a person ofauthority in a high stakes situation.”

• Induced by Potentially Morally InjuriousEvents (PMIE) not uncommonlyassociated with war but can includemedical or political decisions or any thatare so consequential.


SLEEPER EFFECT

• Dormant period while pragmatic matters are addressed.

• Survivors of residential fires

• Holocaust survivors and Vietnam war veterans

• Confusing to the survivor


THE ENVIRONMENT TO WHICH THEY RETURN

• Dr. Paul Plotsky’s studies (1990’s) of maternal separation of rats from their mothers found that 15 minute separations replicating foraging for food in the wild prompted no adverse response.

• A 180 minute separation caused panic reactions on both mother and child and parental neglect and assault.

• More recently, Dr. Plotsky replicated the studies but had the post 180 minute family reunite in a different and more tranquil setting. He found the response indistinguishable from the 15 minute separations.


THE ENVIRONMENT TO WHICH THEY RETURN

• In 2006 anthropologist Dr. Brandon Kohr (George Washington University) studied Nepalese children who between ages 5 and 14 were coerced into military service for Maoist rebels witnessing much violence and trauma.

• Upon return to their villages, those who were ostracized and rejected experienced high levels of PTSD

• Those who were embraced and reintegrated via rituals and celebration had no more adverse effects than those who were never abducted.

• Impact for soldiers returning from war, Holocaust survivors, children from high conflict divorce or incarcerated parent, etc.


SELF CARE AND ROUTINE• In the weeks following a traumatic event individuals should be encouraged to

keep as normal a schedule as possible such structure and distraction is morelikely to facilitate healing then an open schedule.

• Prinstein et al. (1996, Journal of Clinical Child Psychology) found fewerPTSD symptoms among children who survived Hurricane Andrew whoreported high levels of assistance from parents, friends and teachers inresuming their prior normal roles and routines.

• Resumption of activity or return to location of trauma.


SELF CARE AND ROUTINE


CONCRETE HELP

• “Helpers often underestimate the valueof just being present. Meeting basicneeds such as providing small physicalcomforts like food, a warm blanket ortissues is a concrete manifestation ofsupport.”

• Concrete guidance in filling out papers,finding helpful community resourcessuch as housing or financial assistanceare all beneficial.


IMMEDIATE HELP

• Psycho-education • Define it as an injury• Navigating the common route and

trajectory of trauma• Avoid the quick fix• Identify pre-existing psychiatric illness

or vulnerability that may reemerge or come to fore


IMMEDIATE HELP• Prior trauma both similar or different.

• Individuality of response

“In the immediate aftermath of traumatization the specific way by which the person copes with a stressor is often less important then the extent to which coping has been successful”

• Attenders versus distractors


PTSD AND SHAME• There is recent data associating PTSD with experiences of shame

particularly if the trauma was interpersonal in nature and complicates healing

• Shame is differentiated from guilt as the difference between “I am bad” versus “I did something bad.”

• May be adaptive as a way to internalize retaliatory wishes and account for the tragic occurrence.

• Addressing shame seems to be an important corollary of treatment.(Castro, T.L. et al. Meta analysis of shame and post stress. Journal of Traumatic Stress, August 2019, 32(4))


FORMAL TREATMENTSExposure therapies

• Military uses PE – Prolonged Exposure Therapy which entailstalking over and over about event until it no longer evokes horror.

• Eye Movement Desensitization and Reprocessing (EMDR) wasaccidentally discovered. Today it is several phases of treatmentbeginning with skills building and education while latter involvebilateral stimulation. It is believed that the process allows forretrieval of memories and unresolved emotions from the traumathat now can be integrated and organized.


FORMAL TREATMENTS

• Trauma – Focused Cognitive Behavioral Therapy (TFCBT) – develop aneither verbal, written or artistic narrative, correct distortions andreprocess thinking, feelings and behaviors when reminded in the future.Ehlers and Clark

• Acceptance and Commitment Therapy (ACT) is a newer behavioraltherapy encouraging to face and engage in activities now potentiallyavoided due to trauma (e.g. reconnect with friend after sexual assaultand fear of closeness with others).

• Somatic Experiencing Therapy – helps the patient revive memories oftraumatic experiences and pays attention to any physical responses whenthe memory is recovered.


POST TRAUMATIC GROWTH• Attaching meaning • Chinese letter for crisi• Tedeschi and Calhoun found that 2/3 of survivors of 9/11 reported post-

traumatic changes often include: a greater sense of appreciation, warmerand more meaningful relationships, re-evaluating of priorities, and theexploration of new directions in career paths, spiritual pursuits andcreative endeavors.

• Peterson and Seligman happened to have collected a survey on positivetraits among 4,817 participants prior to 9/11. They re-administered thesurvey both 2 months and 10 months afterwards and found increases ingratitude, hope, kindness, leadership, love, spirituality and teamworkthough lower at the 10 months level


SCHOOL OF HARD KNOCKS?• A study of police recruits in NYC and San Francisco reported at 2012

conference found that those exposed to trauma as children are significantly more prone to developing PTSD as adults.

• Studies on PTG found that highest rates were among those who could tolerate negative affect and an optimistic life attitude

• In contrast, a high tolerance for failure and tendency to see life as a series of “challenges” was inversely related to PTG.

Orginska-Bulik, N. Omega, 2015)


MAN’S SEARCH FOR MEANINGDR. VIKTOR FRANKL

“What was needed was a fundamental change in our attitude toward life. We had to learn ourselves and, furthermore, we had to teach despairing men, that it did not really matter what we expected from life, but rather what life expected from us. We needed to stop asking about the meaning of life, and instead to think of ourselves as those who were being questioned by life – daily and hourly. Our answer must consist, not in talk and meditation, but in right action and in right conduct. Life ultimately means taking responsibility to find the right answer to its problems and to fulfill the tasks which it constantly sets for each individual.”


OHEL TRAUMA TEAM

• Founded in 1969, OHEL Children’s Home and Family Services is a New York based social service agency with over 1500 professionals and volunteers providing foster care, housing, day programs, outpatient facilities and comparable provisions of care.

• The trauma team consists of licensed mental health professionals providing assistance in the event of trauma and loss of life.

• They have been instrumental in assisting communities during the pandemic and following the shooting in Pittsburgh, Woolsey fires in California, floods in Houston among others.

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MY COVID 19 RESILIENCE WORKBOOKGeared for children ages 5-10, this workbook consists of skill building activities that can be done with parents or teachers and children. Key messages on coping and growing are presented through child oriented activities.

For more information, assistance contact or training opportunities please call 1 800 603-OHEL (6435) or [email protected]. The link for the workbook is https://www.ohelfamily.org/workbook/

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mailto:[email protected]://www.ohelfamily.org/workbook/

TRAUMAThank you SAMHSA!Coordinated Behavioral CareCBC training institute��Coordinated Behavioral Care’s Training Institute provides innovative, interactive, culturally sensitive training and professional development to New York State’s mental health providers. With an eye on adult learning theory, our trainings are cutting-edge, and delivered with compassion for and understanding of the complex demands on mental health professionals. It is our mission to ensure that we provide evidence-based training on a variety of topics to assist providers in supporting the service recipients on their caseload. With a love of learning ourselves, we create our trainings to be the scaffolding upon which a successful, rewarding career of service can be built. ��Here are some previous trainings: TOPICS COVEREDFLASHBACKSTHE FIRETrauma or reality?AMNESIAPOST TRAUMA?A FAIR COMPARISON?RECURRING CRISESPANDEMICRELOCATION?RETELLINGLost in the woodsFEELING GUILTYA TRAUMA WE WOULDN’T MIND HAVINGRESPONSES TO SCHOOL SHOOTINGS:�WHO’S RIGHT?Columbine High SchoolWest Nickel Mines SchoolVIRGINIA TECHCHARDON HIGH SCHOOLNEWTOWN MASSACREMARJORIE STONEMAN DOUGLAS �HIGH SCHOOLDEFINITIONSUBTYPESISOLATED TRAUMACHARACTERISTICSCHRONIC AND UNREMITTING TRAUMACHRONIC VERSUS DISRUPTIVECHRONIC STRESS AND ACADEMIC ACHIEVEMENTAce’sSlide Number 34ACEPREVAILING AND INTERMITTENTPREVAILING AND INTERMITTENTSDEROT, ISRAELSDEROTTHOUGHT QUESTIONPOST TRAUMATIC STRESS DISORDER (PTSD)PTSD RATESMORAL INJURYSLEEPER EFFECTTHE ENVIRONMENT TO WHICH THEY RETURNTHE ENVIRONMENT TO WHICH THEY RETURN�SELF CARE AND ROUTINE�SELF CARE AND ROUTINE�CONCRETE HELPIMMEDIATE HELPImmediate helpPTSD AND SHAMEFORMAL TREATMENTSFORMAL TREATMENTSPOST TRAUMATIC GROWTHSCHOOL OF HARD KNOCKS?Man’s Search for Meaning�Dr. Viktor FranklOHEL TRAUMA TEAMMY COVID 19 RESILIENCE WORKBOOK

coordinated behavioral care...presentation title amnesia a five year old child was roughly grabbed...

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