ENGAGING FAMILIES WITH MULTIPLE TRAUMAS IN

MENTAL HEALTH SERVICESBrenda Ingram, EdD, LCSW

Clinical Consultant and Trainer,Trauma and Trauma Informed Care

Learning Objectives

– Understand the neurobiology of trauma and it’s neurodevelopmental impact on students in Early Head Start and Head Start■ Recognize the signs of trauma in young children and

their families;– Understand the process of engaging families along

with barriers to mental health services;– Describe the integration of mental health services in

the classroom through a trauma informed lens;■ Develop a plan to institute a mental health internship

program;

Trauma

• Understanding trauma is not just about acquiring knowledge. 

It’s about changing the way you view the world. 

• It’s about changing the helping paradigm from   “What is 

wrong with you?” to “What happened to you?”—Sandra 

Bloom, 2007

What is Trauma?■ Literally means “wound”.

■ It can come from a physical or psychological injury.

■ An overwhelming amount of stress that exceeds one's ability to cope, or integrate the emotions involved with that experience.

■ It can come from:– Threat to life or limb– Severe physical injury or harm, such as sexual assault, domestic violence,

community violence– Intentional injury or harm– Exposure to the grotesque– Sudden, violent death of a loved one or witnessing/learning of harm to a loved one– Exposure to a noxious agent, e.g., diagnosis of a terminal illness, Ebola, HIV+, etc.– Causing harm or death of someone else, intentional or accidental

There are Different Types of Trauma

■ Traumatic responses can come from various sources:– Medical – Immigration– Historical– Collective/Social – Racial– Community– Sexual– Enduring/Chronic/Ongoing– Secondary/Vicarious/Compassion Fatigue

Trauma

• According to Judith Herman’s book, Trauma and Recovery 

(1992), psychological trauma is characterized by feelings of:

– Intense fear

– Helplessness

– Loss of control

– Threat of annihilation

Prevalence of Trauma Exposure for Children

■ In a national sample of children:■ Over 60% were exposed to violence or abuse in their

homes or communities during the past year.■ One in 10 children were victims of violence five or more

times.■ More than 25% had been exposed to family violence.■ 8% reported a lifetime prevalence of sexual assault.■ 17% report having been physically abused (The National

Child Traumatic Stress Network, 2013).

Head Start Families and the Prevalence of Trauma■ The Head Start FACES 2000 reported almost 13 percent of their parents

indicated that they have been victims of domestic violence.

■ Almost one-fifth of the parents reported that someone in their household had been arrested and charged with a crime.

■ Children in these families were more than three times more likely to have been a witness to violent crime or domestic violence in the past year.

■ In another study (2008) by Early Promotion and Intervention Research Consortium (E-PIRC), it was found that about one-third of the children were exposed to violence in the community; 15% witnessed a close relative being attacked or beaten; and 44% of the children were reported by parents to be experiencing trauma symptoms.

■ Families with multiple traumas can be the norm in Early Head Start or Head Start.

A List of Traumas Experienced By Head Start Families

■ Sexual abuse or assault

■ School violence

■ Physical abuse or assault

■ Natural or manmade disaster

■ Emotional abuse or psychological maltreatment

■ Forced displacement

■ Neglect

■ War/terrorism/political violence

■ Serious accident or illness/medical procedure

■ Victim/witness to extreme personal/interpersonal violence

■ Witness to domestic violence

■ Traumatic grief/separation

■ Victim/witness to community violence

■ System-induced trauma

Trauma

■ Traumatic events are external, but they quickly become incorporated into the mind (Terr, 1990) and the body (Van Der Kolk, 1991).

■ Traumatic Event

Trauma Response and the Brain

HPA AXIS (Hypothalamic-Pituitary-Adrenal)Cycle of Panic

Amygdala(scans the senses for signs of threat, danger, change, or

stress)

HypothalamusCRF (corticotrophin releasing factor)

Pituitary GlandACTH (adrenocorticotropic hormone)

Adrenal GlandsCortisol (adrenaline, stress hormones)

Source: Carter, R. (1999). Mapping the mind. Berkeley, CA: University of California Press. From The National Child Traumatic Stress Network, 2013.

The Developing Brain: Rapid Growth of Synapses Building Neural Connections

Trauma and Brain Development (Neurodevelopment)

■ A key issue in understanding altered brain development in children who have been exposed to trauma is that the way in which their brains develop is often a very adaptive response to their negative environment, but it is maladaptive in other environments. 

■ If a child lives in a threatening, chaotic world, his brain will be hyper‐alert for danger; his survival may depend on it. But if this environment persists, and the child's brain is focused on developing and strengthening its strategies for survival, other strategies may not develop as fully. 

■ If a child lives in a world that ignores him, if he is not provided with appropriate stimulation for growth, his brain will focus on survival from day to day and may not fully develop healthy cognitive and social skills

Trauma and Infant Development

■ Trauma has different impacts depending on the developmental stage of the child:– Infants & toddlers (0-3 years):

■ Are learning how to form secure attachments and are learning through play and exploration.

■ When exposed to traumatic events, infants and toddlers need the emotional support from their caregivers to feel safe.

■ They may encounter barriers from their parents, i.e., such as parents with their own trauma experiences from childhood abuse, domestic violence, community violence, etc., which interfere with the development of a strong infant-parent bond.

■ Children become fearful of exploring their world, which may interfere with play and subsequent learning.

Some Signs of Trauma for Infants and Toddlers

■ Eating disturbance

■ Sleep disturbances

■ Somatic complaints

■ Clingy/separation anxiety

■ Feeling helpless/passive

■ Irritable/difficult to soothe

■ Constricted play, exploration, mood

■ Repetitive/post-traumatic play

■ Developmental regression

■ General fearfulness/new fears

■ Easily startled

■ Language delay

■ Aggressive behavior

■ Sexualized behavior

■ Talking about the traumatic event and reacting to reminders/trauma triggers

Trauma and Young Child Development

■ Pre-Schoolers (3-6 years):– Are learning how to express all of their emotions, including those of

aggression and anger. – Living in a trauma inducing environment can teach children

unhealthy ways to express anger and aggression. – They become confused with mixed messages of what they see

versus what they are told. ■ An example of such a mixed message occurs when children get spanked

for hitting a sibling, and yet they see their parents hit each other. ■ Preschoolers are beginning to learn about gender roles based on social

messages. They may get the message that men are violent perpetrators and women are victims.

Some Signs of Trauma for Young Children■ Avoidant, anxious, clingy

■ General fearfulness/new fears

■ Helplessness, passive, low frustration

■ Restless, impulsive, hyperactive

■ Physical symptoms (headache, etc.)

■ Difficulty identifying what is bothering them

■ Inattention, difficulty problem solving

■ Daydreaming or dissociation

■ Irritability ■ Aggressive behavior ■ Sexualized behavior ■ Loss of recent developmental

achievements ■ Repetitive/ post-traumatic play ■ Talking about the traumatic event

and reacting to reminders/trauma triggers

■ Sadness/depression ■ Poor peer relationships and social

problems (controlling/over permissive)

“….toxic stress in childhood from abandonment or chronic violence has pervasive effects on the capacity to pay attention, to learn, to see where other people are coming from, and it really creates havoc with the whole social environment. And it leads to criminality, and drug addiction, and chronic illness, and people going to prison, and repetition of the trauma on the next generation.”-- Dr. Bessel van der Kolk, leading expert on Developmental Trauma, author The Body Keeps Score: Brain, Mind and Body in the Healing of Trauma (2015)

Engaging Families in Child Mental Health Services…

■ Engaging families in child mental health treatment is challenging– This problem is particularly exacerbated in low-income, urban

communities, where children are exposed to poverty, community violence and trauma, high rates of psychosocial stress, as well as insufficient housing, health, and mental health resources.

– These environmental factors render children more vulnerable to developing mental health problems. Not surprisingly, rates of child psychopathology in low-income inner-city settings have been found to be as high as 40% (Gopalan et al, 2010).

■ National Institute of Mental Health (2001) reports that approximately 75% of children with mental health needs do not have contact with the child mental health service system.

Engaging Families in Child Mental Health Services…

■ Engaging families requires a multi-phase process:– Recognition of children’s mental health problems by parents,

teachers, or other important adults; – Connecting children and their families with a mental health

resource; and – Children being brought to mental health centers or being seen by

school-based mental health providers■ Studies from across the country estimate that 40% to 60% of children

receiving outpatient mental health services attend few sessions and drop out quickly.– It was found that at the end of 12 weeks, only 9% of children remained

in treatment in urban inner-city clinics (Gopalan et al, 2010)

Engaging Families in Child Mental Health Services

■ Research also continues to highlight that minority children and their families are less likely to be engaged in mental health services compared to non-Hispanic Caucasian families.

■ Even among those receiving mental health treatment, minority children make fewer mental health treatment visits and receive less adequate mental health treatment than Caucasian children.

■ Some barriers to mental health services:– Stigma of mental health– Multiple family problems– Logistical issues, e.g., transportation, time commitment, waiting

lists for services, availability of appointment times, etc.– Poor therapeutic alliance

Best Practices for Engaging Families in Mental Health Services for Children

■ The child mental health sector is in the midst of a significant paradigm shift towards a more family-centered, inclusive and meaningful system for families accessing care.

■ Family engagement is increasingly understood as the ideal model of service delivery.

■ Definitions of family engagement focus on families’ level of participation, collaboration and partnerships with service providers.

How Trauma Informed Approaches Support Family Engagement

■ The principles of trauma informed care are:– Connect – Focus on Relationships – Protect – Promote Safety and Trustworthiness – Respect – Engage in Choice and Collaboration – Redirect (Teach and Reinforce) – Encourage Skill-Building and

Competence (Hummer, V., Crosland, K., & Dollard, N., 2009)

– Cultural Humility – ongoing self-reflection, eliminating power imbalances, and taking action for social justice

Why Use Trauma Informed Care Approaches?

■ Although schools are not mental health facilities and teachers are not therapists, teaching today’s students requires alternative strategies and skills compared to what worked a generation ago.

■ Focusing on what actually are symptoms of traumatic stress as opposed to the root cause, which is trauma itself, has not resulted in the desired outcomes for students or schools.

■ The field of education, from preschool through teacher training, cannot ignore the issue of traumatic stress if schools are to meet the expectations of parents, community, and the nation (Oehlberg, 2008).

The Benefits of Being a Trauma Informed School…

■ Improved academic achievement and test scores.

■ Improved school climate.

■ Improved teacher sense of satisfaction and safety in being a teacher.

■ Improved retention of new teachers.

■ Reduction of student behavioral out-burst and referrals to the office.

■ Reduction of stress for staff and students.

■ Reduction in absences, detentions, and suspensions.

■ Reduction in student bullying and harassment.

■ Reduction in the need for special educational services/ classes.

■ Reduction in drop-outs or expulsions (Oehlberg, 2008).

Trauma Informed Interventions with Pre-School Students

■ All educational staff receive training on trauma reactions of young children and training for parents as well.

■ Teach Stress Management/Relaxation Skills:– BREATHE! Teach breathing for relaxation– Provide students with a calm or quiet place to sit or talk.

■ Remain calm, quiet, and present. Use LOW and SLOW when needed.– Watch the tone and speed of your voice/words—these children are hypersensitive to facial

expressions, volume of voice, tone, etc. they pick up on stress-related behaviors of adults– Don’t lecture or ask too many questions because the student can’t process too much– Make sure to take deep breathes yourself to calm yourself and the student will imitate you– Slow yourself down, talk slower, use a lower pitch for your voice, don’t use complex sentences,

don’t use lots of body movements

Trauma Informed Interventions with Pre-School Students

■ Offer suggestions on self-calming techniques, such as mindfulness, grounding, tracking, positive memories.

■ Teach positive self-talk to students and practice it before you need it. “I am safe” “I can calm myself down” “I am a good loving person”

■ Use music, exercise, movement, stretching

■ Incorporate more opportunities for humor and laughter into the curriculum. (Laughter reduces the traumatic response in the brain)

Utilizing Mental Health Interns in Early Head Start and Head Start Programs

■ Obtaining an advanced degree in mental health, e.g., MFT, MSW, LPC, etc.

■ Internship is 16-24 hours per week for a year; cost efficient;

■ Under the supervision of the licensed mental health consultant

■ Situated in the classroom and available for homevisits;

■ Provide classroom observations, assessments and treatment

■ Outreach to parents for family counseling, parent counseling, individual

■ On-site to handle mental health crises

■ Provide consultation to educational staff

■ Provide trauma-informed interventions in the classroom

Contact Information

Brenda Ingram, EdD, LCSWConsultant and Trainer, Trauma and Trauma Informed Care, Cultural Humility & Competence

Brenda.ingram4@Verizon.net

562-243-2798