Trauma Informed Care

Did you know that 26% of children will witness or experience a traumatic event before they turn four? That 4 out of 10 children have sustained physical assault in the last year and that 1 out of 10 sustain an assault related injury? That 2% of our children experienced sexual assault or sexual abuse during the past year, with the rate at nearly 11% for girls aged 14 to 17 (http://www.recognizetrauma.org/statistics.php).

Holy. Crap. Take a second and let those statistics sink in. Breathe it in, let it sink into your soul... This means that this blog post isn’t just for 1 or 2 kids in our schools, in our churches, in our community. This message is for 25-40% of the connections we make with kids on a daily basis. That is hugely significant for anyone who works with children.

I think when you work in jobs that are NOT around children and you were brought up in kind, loving and developmentally stimulating homes, when you raise YOUR own children in the same way- we get the chance to be so sheltered. What I know now is that this is PRIVILEGE. If you grew up without trauma and dysfunction, you are privileged. Period. So many children do not get this privilege. I genuinely believe that it is our duty to understand this and do what we can to develop compassion and operate with trauma informed insight.

Before we get in too deep, please know that I am NOT at all an expert on this topic. There are parents (foster parents and adoptive parents especially) that deal with this topic on a daily basis; they are knee deep in the effects of trauma on a continuous basis. THESE are the experts. There are healthcare professionals with PhDs in helping professions that specialize in this field. THESE are the experts. I am simply a therapist who has had a passion lit to make sense of this from the lens of an OT, a mother, a friend. Someone who hopes to shine a light on this epidemic, to inform you, to get into the areas that I specialize in as an OT and pray that these insights will change lenses and open hearts to compassion and understanding regarding trauma. All this so that we can become better teachers, administrators, therapists, friends and ministry leaders... Also, I get to talk about neuroanatomy AND sensory processing- this is my nerdy little love language.

So, what is trauma?

There are two general types of trauma: shock trauma and developmental trauma. Shock trauma is an experience of an overwhelming event that is PERCEIVED as life threatening at any point in our lives and we are unable to protect ourselves. Developmental trauma is ONGOING abuse or inadequate nurturing during critical developmental periods. Causes of trauma include: violence, car accidents, natural disasters, war, divorce, household food insecurity, neglect, rape/sexual assault, terrorism, emotional abuse, attachment disruptions (parents going to prison), disorganized attachment, medical (often life-saving) interventions (especially being immobilized in fear). (Finding Trauma & Stability: A Trauma Informed Sensory Approach).

Did you also know that trauma can be carried throughout our genetic makeup and that it can be passed from mom to baby in utero? Ugh! How could we possibly ever know every child that has been impacted by trauma. That's the key here... we likely won't. But it's my hope that we can all begin to understand that sometimes that part of their story is not ours to share or even know. That it is absolutely best practice to treat every child with the love and compassion and opportunities for healing that we will talk about later.

What can trauma in kids look like?

It can look like anxiety, difficulty sleeping, irritability, exaggerated startle response, difficulty concentrating, impairment of daily functioning, disturbing memories, lapses in memory, clumsiness, awkard motor movements, aggressive behavior, nightmares, detachment or flat facial expressions, flashbacks. It can also cause hyper arousal, hyper vigilance, pervasive thoughts, irrational (or over responses to rational) fear, distorted/catastrophic thinking, self-blame, shame, poor body image, decreased attention, memory and orientation, poor emotional regulation and impaired executive functioning (higher level cogitive skills like foresight and planning, organization, problem solving and self-awareness). (Kemp, E. & Weaver, L., 2018).

Brain development

Ok here's where my geek comes out and I get all excited to talk about things like myelin sheaths, neuro pathways, the autonomic nervous system and the polyvagal theory. I seriously get geeked over this but I do realize that I'm likely the exception more than the norm, so I'm going to try to keep this basic. However, if this is as fascinating to you as it is to me, please please please let's talk. I love it.

Here's what we know about trauma. In typical development, pathways form throughout the brain as babies and children have experiences. As pathways are formed, we no longer have to think about and process reactions so that we can focus on more and more new inputs. This allows for higher level processing and developmental function. We know that children depend on caregivers to give them these experiences and that children learn though physical and sensory experiences (especially motor patterns and sensory inputs like rocking, being swaddled, hearing mom singing to them, hearing the rhythm of mom's heartbeat, touching fabrics, holding dad's hand, learning to suck in order to receive adequate nutrition, etc.). What happens in children who experience trauma is that these pathways do not develop fully or develop in a developmentally effective manner. These pathways become scattered and erratic and take a series of "wrong turns" (Finding Trauma & Stability: A Trauma Informed Sensory Approach).

I want to make sure you hear me here. There is an actual neurological and physiological hardwire disruption that occurs with trauma. The brain actually changes and development is disrupted.

We also know that when trauma occurs, it occurs across many senses. This means that these memories get stored in multiple locations in the brain. Here's a personal example. About 7 years ago, I had a fallopian tube that ruptured suddenly and pretty intensely. The surgeons indicated that I had lost so much blood that I needed two transfusions and was within about 30 minutes of bleeding to death internally. I'd say this was a pretty traumatic event. Seeing shows like Grey's Anatomy or being in a hospital or smelling something that smells like an Emergency Room all bring back memories so intense that I can sometimes feel the sensation of my abdomen filling with blood. I can remember exactly what the operating room smelled like. The sounds of the machines, the hustle of the doctors around me and the disabling fear and pain. These memories come back in several different areas of my brain. Those that store long term memory, the visual center of my brain, the fear and pain centers, the area that processes smell, and dozens more I'm sure.

My point in telling you that story is that we all have a trauma story like that, I'm sure. In my case, I know that it was medically necessary. A child can have any number of triggers from any of these brain centers that are receiving all kinds of input, from sounds to smells to tones of voice. Anything. We can't possibly know. BUT, we can pay attention to the environment when behavior shifts occur and work diligently to compassionately make changes to prevent escalation and re-traumatization.

The thing about kids is that they don't WANT to remember or feel most of these traumatic memories and so they have learned coping mechanisms based in survival. Stealing food, negative behaviors that result in avoidance of people or circumstance, being the person feared rather than the one in fear, perseveration on topics of interest or seemingly insignificant things to occupy their minds as avoidance, these are avoidant behaviors that are coping mechanisms for kids. They don't have the insight to say WHY they are behaving in the way they do. Just that this is the mechanism that has worked so far in their lives.

Fight, flight or freeze

Imagine you're walking down a dark alley at night alone (I know this is a ridiculous scenario but bear with me here), you start to feel a little anxious so you have your keys in one hand, pepper spray in the other. Out of nowhere, a man starts walking towards you at a very brisk pace.... what do you do? Some of us are hardwired to stand our ground and fight. This is me- no matter what, I cannot run. I have to stand and fight. Give me the pepper spray and prepare to get punched, kicked, hit, whatever it takes. I know I cannot scream. I cannot do a thing but fight. (I'm pretty feisty. Ask my older brother! Haha!) Other people are hardwired to run. They are just gone. Take their chances, GONE. Lastly there's a small group of people who will just freeze and do absolutely nothing. They "play opossum" in a sense.

Here's another thing we know about trauma, these children's brains have been rewired to emit chemicals that leave them in this fight, flight or freeze state nearly continuously. It is extremely common for a simple stressor to send a child into a pattern of fight, flight, freeze. Can you imagine the physical and emotional toll of this? To have almost no control over their reactions and to prepare to go to battle against fear at all times. These kids literally cannot help but overreact to certain stimuli because of the chemicals and hardwiring in their brains.

Do you know what I found fascinating in one of my courses that I recently took on trauma? Animals in the wild do not demonstrate signs of post traumatic stress. Why? because of natural recovery and release from a hyper aroused state. The ONLY place where we see animals demonstrates PTSD behaviors are in captivity. Animals that are not able to physically unwind from traumatic experiences. Animals AND CHILDREN need to discharge via trauma releasing exercises (Finding Safety & Stability: A Trauma-Informed Sensory Motor Approach). They need the opportunity to run, to climb, punch or hit, to be free from hovering and boundaries. They NEED a safe space where this is ok.

Sensory Inspired Applications

Awareness: I think awareness is key. We just don't know what we don't know. Education and insight is the first step to making the necessary compassionate change
Connection and relationships: Guys, it's no secret that these kids can be SO HARD. Especially if all you see is the superficial, difficult behaviors. We have to be willing to push past that and make relationships. Let them know they are safe and secure when they're with us. Kids cannot be playful if they don't feel safe
Facial expressions and voice tones: A flat, expressionless face and low, monotone vocal sounds are perceived as danger to babies (and to our children since their systems did not regulate properly). Be very intentional about facial expressions. Use lots of expression, especially smiles and joy- open eyes and mouth wide when speaking and use lots of variance in your voice. Higher tones indicate calm and safety.
Provide a safe space. A room a child knows they can go to where there are few rules. Pad the floors and the walls with mats, have a punching bag, give them appropriate items to throw, let them crash into a giant crash pit, facilitate climbing and running and jumping. Prepare to only intervene if you truly feel there's a safety risk.

Vestibular input: this is the sensory system that allows us to understand gravity and where we are in space. Taking risks on the playground is critical to relieving stress from trauma
Effects of vestibular system movements can last up to 6 hours
Front to back and rhythmic movement is calming
Erratic and spinning movements are alerting

Proprioception: helps us understand force and where our body is in space
Effects can last up to four hours
Flexion patterns are calming
Extension patterns are alerting
Use heavy work (moving furniture, carrying weighted backpacks, rolling, crashing, etc)
Prop activities are generally very calming

Interoception
The interoceptive system is sort of newly researched but very much invaluable in it's feedback
This system is strongly tied to the vagus nerve, which regulates things like heart rate, the bladder, intestines, lungs, etc.
In kids with trauma, the vagus nerve does not accurately relay messages to the brain. These kids have a very difficult time telling you when they're hungry, thirsty, need to use the bathroom, have headaches or stomach aches, etc.
This system is strongly affected by the vestibular system mentioned above
Activities like yoga and mindfulness are so good for helping children understand what their bodies are feeling (I love the app The Smiling Mind for mindfulness activities!)

Tactile
One of the first to develop in utero
Much of babies first sensory inputs is tactile, so when trauma happens early, touch sensory input is powerful
Vision
Kids with trauma are often visual scanning the environment for perceived danger
They may have poor visual attention, and precise saccades
they may demonstrate difficulty looking up without moving their head
Work on isolation of the eyes from the head, scanning up down, side to side and down a diagonal line
The website eyecanlearn.com provides a lot of visual scanning and perception activities
Oral Motor
Sometimes neglect can lead to poor oral motor skills, swallowing issues or nutritional deficits
Ensure that a child can tolerate developmentally appropriate feeding/drinking items: straws, sippy cups, spoons, forks, etc
Blow bubbles, blow through a straw, suck through a straw (especially thick drinks like smoothies and milkshakes as the provide oral motor strength as well as good proprioception)
Encourage a variety of textures when eating/drinking

Olfactory
Smell has a direct path to the amygdala- the center for our long term memories
Smells can often be a trigger for re-traumatization so pay close attention to smells in correlation with behavior changes.
Myofascial Release
This is a huge topic of interest for researchers and currently there's not a TON of data
What we do know is that fascia holds emotions and motor patterns
Roll a small ball (like a tennis ball) over the palms of hands and arches of feet
Extension over a therapy ball releases facsia and sets new motor patter
Seek a professional in MFR- massage therapists or PTs/OTs- They are great resources!

Sensory Modulation and Self Regulation
Anyone who has worked with children with tough backgrounds know this one is huge! These children very much struggle to maintain regulation. It looks like meltdowns or overreactions to stress
Every single person has a "optimal range of attention/learning". It's our goal to stay in this range for as much of the day as we can.
Some kids are more likely to be in a low arousal state- difficulty waking up in the morning, loses attention quickly and constantly need to be moving to stay awake; others are high arousal kids- they are constantly 'on the go', are hyper verbal and easily distracted
Consistently use programs like: The Alert Program or Zones of Regulation to teach language and self-awareness

Conclusion:

If you are a teacher, administrator, school counselor or therapist, I would highly encourage you to seek more information and courses regarding becoming a trauma informed school. (Check out the Karyn Purvis Institute. They have a great course on the Trauma Informed Classroom!) Also, starting with small changes within your own classrooms can be a great first step! As always, I'd love to hear your feedback on this post and PLEASE send me pics of any changes you've made at home or school that have been effective for your kids!

References:

Finding Safety & Stability: A Trauma-Informed Sensory Motor Approach

Kemp, R. & Weaver, L. (2018). Utilizing Sensory Processing Theory and Strategies in Trauma Informed Care: A General Guide for the Occupational Therapy Practitioner; The Ohio State Unversity School Based Symposium 2018.

Kuypers,. L (2011). Zones of Regulation. Minneapolis, MN: Social Thinking

Williams, M.S. & Shellenberger, S. (1994). "How does your Engine Run? A leaders guide to the Alert Program for Self Regulation. Albuquerque, NM. TherapyWorks.

https://www.childrenslantern.org

http://www.recognizetrauma.org/statistics.php