Health Care

Informed care picks up the pieces left by trauma

Trauma creates strong neurological pathways in a child’s brain that surge with impulses to fight, flee or freeze. Trauma-informed care helps caregivers, from teachers to parents and beyond, understand a child’s behavior, identify triggers and learn how to help form new and more positive associative pathways in the child’s brain.
Trauma creates strong neurological pathways in a child’s brain that surge with impulses to fight, flee or freeze. Trauma-informed care helps caregivers, from teachers to parents and beyond, understand a child’s behavior, identify triggers and learn how to help form new and more positive associative pathways in the child’s brain. The Kansas City Star

Never mind the little girl’s name. What’s important is that she was about 10 years old and all the doctors she had seen month after month had failed to ease her pain.

The girl’s stomach wrenched. Her chest tightened. Her skull seared with lightning-bolt headaches.

Then at Children’s Mercy Hospital, pediatrician Lisa Spector decided to probe with a different set of questions. Instead of asking what was wrong physically, Spector asked the girl what had happened to her in her young life. Quickly, the crux of her pain became clear:

Trauma.

“It was impacting her physical and mental health,” Spector said.

At school, she was bullied. At home, she witnessed repeated domestic violence. She talked of her dad belittling and abusing her emotionally. She recently had been a victim of an attempted carjacking; the thief fled after seeing her in the back seat.

Day to day, she was living a tense and unsure existence that was translating itself into hobbling pain.

That the child’s troubles ultimately eased not with medication but with counseling can be credited to a serious effort by Children’s Mercy to focus on “trauma-informed” care.

For a growing number of children across the country, the approach has become the key to their emotional and mental health, “the most important thing we can do for people,” said Marsha Morgan, chief operating officer for behavioral health at Truman Medical Center.

Trauma-informed care focuses on the notion that a traumatic event in childhood, either experienced or witnessed, can alter the biology of the brain. A trauma-informed strategy works on multiple fronts — using counseling and changes to one’s personal interactions and environment — to lessen or bypass those negative associations while forming new and more positive associative pathways in the brain.

“I’ve worked in this field for over 42 years, and this is the most important thing I’ve ever done,” Morgan said.

Together with Wyandot Inc. of Kansas City, Kan., Truman and others are helping lead a communitywide task force, Trauma Matters KC, to transform Kansas City into a trauma-informed community. Meanwhile, across the region, scores of entities are offering programs of their own: Head Start preschools; Kansas’ child welfare system; mental health providers such as Crittenton Children’s Center; shelters for battered women; and courts, jails and police departments.

The Health Care Foundation of Greater Kansas City has funded 18 projects related to trauma since 2008.

“This has become a national conversation,” said Joan Gillece, director of the National Center for Trauma-Informed Care, which in 2005 was launched by the federal Substance Abuse and Mental Health Services Administration to combat trauma’s pernicious effects. “It’s really taken off.”

The brain changes

The underlying tenet of trauma-informed care is simple, with roots stretching to Sigmund Freud:

The past matters.

When children experience singular or repeated traumas, those traumas can exert a powerful influence on their behavior and mental health, now and as they become adults. Data from as far back as the 1990s, for example, show that the vast majority of incarcerated females were abused as children — sexually, physically or emotionally.

Mental illness, physical illness, substance abuse, behavior problems, eating disorders, promiscuity, criminality: All have strong links to previous abuse or neglect, to violence, to abandonment, to the traumas exerted by the deprivations of poverty. Other traumas might include anxiety surrounding family illness, or personal illness, or the feared or real loss of loved ones.

Even witnessing such events can create misery.

“We know that witnessing someone else being hurt is often as traumatizing as being hurt yourself,” Gillece said. “What about kids who hear Mom being beaten night after night, or kids who go to bed hearing gunshots?”

Such connections seem intuitive, but they’re also being borne out scientifically with mounting neurological research offering evidence on how trauma can change the biology of the brain, flooding it with hormones in ways that keep its victims in easily triggered states of fight, flight or freeze.

In the late 1990s, the broad and long-lasting effects of childhood trauma became especially clear after Kaiser Permanente published its Adverse Childhood Experiences Study. The survey of 17,000 people at its HMOs between 1995 and 1997 showed that the more ACEs one reported, the more likely one was to experience mental, emotional, physical and social problems.

The hope of trauma-informed care, experts said, is that by teaching parents, teachers, social workers, doctors, police and even children to address underlying trauma, children’s emotions, behaviors and futures can be changed. The triggers that prompt children, or even adults, to erupt (fight) or mentally escape (flight or freeze) through drugs, alcohol or other means can be averted.

Revealing triggers

A Johnson County mother with more than 20 years of experience as a foster parent understands.

“All of the children who have been through foster care have been through some kind of trauma. They have trauma similar to war veterans; it is a PTSD,” said Lee, who asked that her full name not be used to protect the privacy of children who have been under her care.

In Johnson County and 29 other counties in eastern Kansas, child welfare services such as foster care, adoption and mental health services are provided under a state contract to a private company, KVC Health Systems Inc. The organization manages about 3,000 of the 6,100 children in Kansas’ welfare system.

KVC is now in the fourth year of a five-year study, funded by the Annie E. Casey Foundation, to measure the effectiveness of the system it uses, Trauma Systems Therapy, to train children’s caseworkers and foster parents.

Although many trauma-informed care systems exist (the California Evidence-Based Clearinghouse for Child Welfare rates at least 25), they generally work in similar ways, starting with inclusion.

“It really works well when all the players in a child’s life can come together,” said Kelly McCauley at KVC, director for evidence-based initiatives.

That means bringing together parents or foster parents, grandparents, physicians, case workers, law enforcement, teachers and even the rest of a school’s staff, if possible. Then, in classes over a series of weeks, they learn the fundamentals of brain science and how trauma creates metaphorical circuits, strong neurological pathways, in a child’s brain that surge with impulses to fight, flee or freeze.

This differs from the traditional method of care, which experts say tends to focus broadly on the symptoms of depression, bipolar disorder, anxiety, or other mental or emotional problems. Medications are prescribed for the disorder. Then behavior modification therapy teaches children to try to control their actions, showing that positive behaviors bring positive results and negative actions bring negatives, like scoldings, timeouts and school expulsions.

Medication and behavioral therapy have been shown to be effective mainstays of treatment, but the fact that many children continue to emerge deeply troubled has been a hint that something significant was missing.

“The focus became the depression or the anxiety,” McCauley said, “but the trauma aspect was being overlooked.”

In trauma-informed care, time is spent teaching caregivers and others how to view the world through the eyes of a trauma victim and to look for “triggers” that cause behavior or moods to shift negatively.

In its facts for caregivers, the National Child Traumatic Stress Network explains, for example, how ketchup might suddenly remind a child of blood from a father’s beating, or a dropped book could prompt memories of gunshots, or a packed suitcase might trigger thoughts of being removed from home.

Lee, the Johnson County foster mom, recalled one child who went into fits every time Lee’s husband returned home from work. They realized that for that foster child, the man’s arrival triggered past associations with abuse. Another foster child would break down at the sight of a man’s underarm hair at a swimming pool.

“The child would freak out,” Lee recalled. “His face flushed, his body tensed, his breathing became rapid.”

Trauma-informed training helped reveal the triggers. At home, Lee made sure the child felt safe and loved each time the dad arrived home, replacing negative associations with positive. The same happened for the foster child triggered by underarm hair. Knowing the trigger allowed the family to avoid it or to deal with it in a calm, understanding and even therapeutic manner.

McCauley of KVC said that since it began using trauma-informed methods, the use of medications on children in state care has been cut drastically.

Meredith Hengel, 32, of Grain Valley, said she and her husband didn’t know the magnitude of the problems that their son Josh, now age 5 and recently adopted, had endured when he came to them as a foster child shortly before Christmas 2012.

But they knew he didn’t trust adults. He slept erratically.

“He might fall asleep at 8, but he’d be up at 2 in the morning. He’d be wandering the house,” Hengel said.

Food was a major issue. The boy would scrounge through the refrigerator.

“If he thought he wasn’t getting any food, he would be absolutely frantic,” Hengel said.

At Children’s Mercy, Hengel and her son worked for some 20 weeks at the hospital’s Safe and Healthy Families Trauma Prevention and Treatment Center, using Parent-Child Interaction Therapy, which for Josh was designed to create a trusting parent-child connection.

“Kids who have been in trauma need some sense of control,” Hengel said, “even if it is just playing with a Hot Wheels car. It was that play, coupled with positive praise, that helped. He loved it. I do feel it helped us bond and build a relationship.”

In the courtroom

In some cases, a trigger can be one’s physical environment.

Courtrooms, for example, may mete out justice, but they also can trigger fear and foreboding.

Wyandotte County District Judge Kate Lynch for five years has been finding ways to reduce trauma for the adults who appear in front of her for mental health hearings. Lynch said she was forever changed after hearing a woman, who was not from Kansas and who suffered mental health problems, describe the trauma of appearing before judges.

“This woman said she knew that once she was going to the court, she was probably going to end up in a state hospital,” Lynch recalled. “She knew it because that’s what had happened all the times before. She talked of how she would perspire and her palms would itch and her heart rate would go up. She talked about the judge sitting up there on the bench in that black robe.”

Since that day, Lynch has put her black robe aside at mental health hearings. To lessen trauma more, she has changed her language, referring to those who appear before her as Mr. or Ms, or by their first names, rather than by the cold and formal “respondent.” She even changed the name of the hearings and their focus.

“I like to refer to it as the wellness docket,” Lynch said. “I like to think of it as people getting well.”

Equally significant, she now requires mental health reviews more frequently than the old schedule of waiting up to six months, a period so long that people can easily fall ill again.

As a result, revocations in her courtroom, returning people to state hospital care, have been cut 50 percent, she said.

Meanwhile, United Community Services of Johnson County has been working since 2011 with more than a dozen organizations to reduce trauma for clients, both children and adults.

“For some organizations, they trained every single one of their staff,” said community planning director Valorie Carson of groups that include Johnson County Court Services, CASA of Wyandotte and Johnson Counties, Sunflower House for abused children, and Safehome for battered women, as well as police departments and jails.

Help at Head Start

One recent Wednesday night, 14 adults, mostly moms and grandmothers, took seats at tables inside a preschool classroom that is part of the Northland Head Start program in the YMCA building at 2701 Burlington St.

“We’re talking about attunement today. It’s about attachment, building a relationship with your child,” licensed counselor Alisha Persaud, 30, told the group.

She guided the adults through exercises on reading children’s faces and body language, noticing their frowns, smiles, the way they cross their arms and tilt their heads, and then openly acknowledging those emotions. I see you’re smiling. Are you happy? I see you frowning. Are you sad or mad?

“What does that build?” she asked the group.

“Trust,” several parents responded. “Communication,” said another.

Her class — the third of six sessions based on a trauma system known as ARC, for Attachment, Self-Regulation and Competency — is part of the Trauma Smart program developed by the Crittenton Children’s Center in Kansas City. Over the last year, Trauma Smart has received national media attention in The New York Times and on “PBS NewsHour.”

The program, which began about 2008, has expanded tremendously. It started by reaching parents, caregivers, teachers and staff of some 810 children, ages 3 to 5, at Head Start sites in Kansas City, Kan.

Now, backed by more than $4 million in grants from organizations that include the Robert Wood Johnson Foundation, it is expected to reach more than 3,250 children a year at 156 Head Start classrooms in communities as far south as Joplin, east to Columbia and north toward the Iowa border.

On its website, the Robert Wood Johnson Foundation says that “the program holds promise to become a federally designated best-practice model to benefit the more than 900,000 children in Head Start programs nationwide.”

Seeing results

In Lee’s Summit, Mitch Pycior would like to see trauma-informed instruction become part of his school’s regular curriculum.

“Every school should have this. Every school,” said Pycior, who is assistant principal at Summit Ridge Academy, an alternative school serving about 120 students, grades seven to 12, with learning, behavioral or other difficulties.

Children with emotional and behavioral disorders are the fastest-growing population he sees. This year, working with Crittenton, 11 students went through a trauma-informed class on topics that included coping skills, peer interactions and triggers. A Crittenton licensed clinical social worker, with parental or guardian permission, also provides in-school, personal therapy two or three times each week to a handful of students.

Improvements are anecdotal at this point, Pycior said, but he already knows that he’d like to see the curriculum expanded to include all students. “Verbal confrontations” dropped from an average of 20 in the first semester last year to 10 this year.

In the classroom, “teachers are seeing the results,” he said. “Much less disruptions. Kids I have known for the last couple of years are focusing more. They’re controlling their emotions. They are reaching out for help.”

Beyond trauma

Beyond helping troubled children, advocates said, trauma-informed methods can help all kids.

Toni Gydesen, 26, from Hamilton, Mo., east of St. Joseph, was skeptical at first.

“I heard about it,” she said, “and I’m like, ‘My child is not in an abusive household. My child is not strung out. My child is not seeing other people get shot. My child has not experienced trauma.’”

What her nearly 4-year-old daughter, Emma, did have was a persistent and severe case of eczema, which left her skin red and itchy. At home, Emma was outgoing and energetic. “Talk your arm off,” her mother said.

But not when it came time to go to school. She’d curl herself into a ball and refuse to leave the car.

“The more frustrated she got, the more she’d scratch her eczema,” her mother said. “It got red, scaly, open.”

Her behavior in school turned so troublesome, Gydesen frequently had to pick up her daughter and take her home. Tension mounted.

“I felt like I was doing everything wrong,” Gydesen said. “I felt like I was the main cause of what was wrong. Was it the soap I was using, or the food I was feeding her, or I wasn’t putting on enough medication? You doubt yourself as a parent.”

The Trauma Smart instruction, which also includes personal therapy at home, turned it around, helping Gydesen tune into Emma’s feelings and helping Emma express them.

“Now if she has an issue,” Gydesen said, “she knows she can come to me no matter what. She knows she isn’t going to get disciplined or reprimanded for opening up and speaking her feelings. And I can see the precursors to her frustration and can stop the situation before she gets frustrated.”

Gydesen said she is convinced that without the instruction, Emma’s behavior would have derailed her academics from the beginning.

“I definitely feel this has put Emma on the right track for kindergarten,” she said.

To reach Eric Adler, call 816-234-4431 or send email to eadler@kcstar.com.

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