Trauma-Informed Approach for Occupational Performance & Engagement in School Practice

1. Using a Trauma-Informed Approach to Support & Enhance Occupational Performance & Engagement in School-based Practice Elizabeth Richardson Shelly Bloomfield

2. A little about us

3. Tell Us About You OT, OTA, Other? Schools? Other? Currently work in a “trauma-informed” or “trauma-sensitive” school/organization? Familiarity with TIC? ACE Assessment?

4. Objectives • Identify signsthat a student has been exposed to trauma & gain a basic understanding of screening/assessment methodsthat can be used in the school environment. • Interpret and use assessment results to effectively apply 3 intervention strategieswhich consider and address a student’s exposure to trauma. • Identify and collaborate with key partners within the school system to create an environment that supports students who have experienced trauma.

5. Laws, Policies & Initiatives Accomodations & Environmental Modifications • Safe zone/space System-wide, trauma-informed/ sensitive approaches benefit ALL children IEP Process-Trauma sensitivity: • Evaluations • Meetings • IEPs H.R. 1757 (115th): Trauma-Informed Care for Children and Families Act of 2017 (bill proposed; did not pass): Developed to address the psychological, developmental, social, and emotional needs of children, youth, and families who have experienced trauma, and for other purposes. www.GovTrack.us

6. Trauma-Informed/Sensitive Schools Six core attributes: • Shared understanding among all staff; a whole-school approach • Safety for all children – physical, social/emotional and academic • Consider relationships, self-regulation, academic competence and physical and emotional well-being when addressing student needs • Connection of students to the school community and opportunities to practice new skills • Embraced teamwork and shared staff responsibility for all students • Leaders’ and staff members’ anticipation of and adaptation to students’ ever-changing needs https://traumasensitiveschools.org/trauma-and-learning/the-solution-trauma-sensitive-schools/

7. Trauma • Individual trauma results from an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. (SAMHSA, 2014) • More than 3 million cases of child abuse and neglect are reported in the U.S. each year (U.S. Department of Health and Human Services

8. ACE Scores • Developed in collaboration with Kaiser Permanente and the CDC • Study recruited participants between 1995-1997 • “Adverse childhood experiences (ACEs) are stressful or traumatic events, including abuse and neglect. They may also include household dysfunction such as witnessing domestic violence or growing up with family members who have substance use disorders.” (SAMHSA, 2015) • ACEs are strongly related to the development and prevalence of a wide range of health problems throughout a person’s lifespan

10. Kaiser Study Results

12. Kaiser Study cont’d As the number of ACEs increases so does the risk for the following: • Alcoholism and alcohol abuse • Chronic obstructive pulmonary disease • Depression • Fetal death • Health-related quality of life • Illicit drug use • Ischemic heart disease • Liver disease • Poor work performance • Financial stress • Risk for intimate partner violence • Multiple sexual partners • Sexually transmitted diseases • Smoking • Suicide attempts • Unintended pregnancies • Early initiation of smoking • Early initiation of sexual activity • Adolescent pregnancy • Risk for sexual violence • Poor academic achievement

14. Image accessed from CDC, 2016

15. Image accessed from CDC, 2016

16. Resilience (2016) • Showings can be requested on their website

17. Diagnoses & Categories What is the connection?! Mental Health IP: • ODD (F91.3) • DMDD (F34.81) • PTSD (F43.1) • Unspecified trauma (F43.8) • Upbringing away from parents (Z62.2) • Parent child relational problems (Z62.82) • MDD recurrent (F33.0)Anxiety (F41.9) • Schizophrenia (F20.9) • Psychosis (F29.0) • Others School-based (IDEA) • Autism • Deaf-blindness • Deafness • Developmental delay • Emotional disturbance • Hearing impairment • Intellectual disability • Multiple disabilities • Orthopedic impairment • Other health impairment • Specific learning disability • Speech or language impairment • Traumatic brain injury • Visual impairment, including blindness

18. Overlapping Symptoms

19. Trauma Informed Care (outlined by SAMHSA) Trauma Informed Approach: • Realizes the widespread impact of trauma and understands potential paths for recovery; • Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; • Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and • Seeks to actively resist re-traumatization." Six Key Principles of a Trauma-Informed Approach • Safety • Trustworthiness and Transparency • Peer support • Collaboration and mutuality • Empowerment, voice and choice • Cultural, Historical, and Gender Issues Trauma Specific Interventions consider: • survivor's need to be respected, informed, connected, and hopeful regarding their own recovery • interrelation between trauma and symptoms of trauma • Significance of working collaboratively with survivors, family and friends of the survivor, and other human services agencies in a manner that will empower survivors and consumers

20. Occupational Therapy and Mental Health • On February 2, 2015 the Substance Abuse and Mental Health Administration (SAMHSA) released their draft criteria for a demonstration program that will expand access to quality mental and behavioral health services by establishing new Certified Community Behavioral Health Clinics (CCBCHs). • SAMHSA included “licensed occupational therapists” as one of the disciplines that could be used to meet the staffing criteria for the CCBHCs • AOTA (2018a) identifies “mental health” as key practice area in the 21st Century • We provide holistic care, this must include mental health

21. OTs Role in SBP Address self/emotion-regulation Teach coping skills Focus on strengths & assets Modify environment (identify sensory factors/triggers, create “safe” spaces) Emphasize significance of positive & supportive relationships Establish, Maintain, Restore Assist with development of consistent routines & rituals System-wide, trauma-informed/ sensitive approaches benefit ALL children Accomodations & Environmental Modifications • Safe zone/space IEP Process-Trauma sensitivity: • Evaluations • Meetings • IEPs

22. OT Process

23. Case Scenario-Referral & Background Information Tony is an 11 year old male who was referred for an OT evaluation secondary to challenges with self regulation, attention, and fine motor skills. Access to student records reveal that Tony is diagnosed with ADHD and has a history of poor school performance and physical altercations.

24. Case Scenario-OT Traditional Evaluation Assessments used: BOT-2, Sensory Profile, clinical observations, records review, teacher report Tony participates well in the evaluation initially, requiring minimal verbal prompts for redirection during the BOT-2 and during gross motor observations. He laughs frequently and seeks out encouragement and verbal praise often. When discussing self regulation and social skills at the end of the evaluation, Tony becomes defiant and at times refuses to speak. He has difficulty sitting still and won’t respond to redirection. OT attempts to engage student in a preferred activity but Tony continues to refuse, becoming destructive with materials and equipment, avoiding eye contact, and remaining silent. Due to safety concerns, the evaluation is terminated and the main office is contacted for support.

25. Case Scenario-OT Traditional Evaluation Conclusions: Student became tired and overwhelmed as the evaluation came to a close. He has difficulty engaging appropriately with others and maintaining attention when challenged. He exhibits below age level fine and gross motor skills and difficulties with sensory processing.

26. Trauma Informed Assessment Simple screen questionnaire ACEs River Project (Kawa Model) Rosenberg Self Esteem Scale/ Perceived Stress Scale Child Behavior Checklist Interview

27. ACES Resilience Questionnaire Screening option - safer way to gather an estimated ACE score without parent having to disclose specific abuse

28. River Project

29. Case Scenario-Expanded Evaluation Assessments used: River Project, quick screen (completed by foster parent), additional records review Tony’s mother lost custody when he was 2 years old secondary to physical abuse, he then went to foster care and was later removed and placed with his paternal uncle after 8 months. He was then removed from his paternal uncle secondary to neglect and placed with his biological father from ages 4-6. Biological father overdosed while Tony was in the home (age 6). Tony was placed with his godmother from ages 6-11. During this time he experienced significant physical, sexual, and emotional abuse almost daily. He was removed from school during this time by his godmother and remained in his godmother’s custody until he was taken to the hospital after being severely beaten. Tony was then placed in a foster home where he currently resides and has been re-enrolled in school for the first time since Kindergarten 2 months prior to evaluation.

30. Case Scenario-Expanded Evaluation NEW Conclusions: Student is triggered when speaking about personal topics and has difficulty with frustration tolerance and self regulation skills. He has limited coping skills and is unable to communicate assertively. He has difficulty engaging appropriately with others and maintaining attention when he feels threatened. He presents with below age level fine motor skills, gross motor skills, and difficulties with sensory processing.

31. Goal Examples Tony will independently use coping strategies to maintain optimal arousal leveland stay on-task during writing tasks in 4/5 opportunities. Tony will demonstrate self regulation during interactions with peers and adults throughout the school day in order to reduce conflict and increase participation in 4/5 opportunities. Potential Intervention Activities • Anxiety/Stress Management • Worry Stone • Self Esteem • Emotional Baggage • Distress Tolerance • Don’t Lose your Marbles

32. Intervention • There are many different strategies, at VCU, OT’s in adult and pediatric acute inpatient psychiatry focus on the following • Stress management and coping skills • Anger management • Assertive communication • Self esteem • Sessions at VTCC and VCU Health are primarily done in group settings, however, outpatient OTs at VTCC utilize the same principles and many of the same activities in a 1:1 setting • Let’s try out a few activities that can be adapted or utilized for intervention in school-based practice

33. Activities • Anxiety/Stress Management • Worry Stone • Self Esteem • Emotional Baggage • Distress Tolerance • Don’t Lose your Marbles

34. Intervention plan brief outline • Session 1- Rapport building, gross motor skills, introduction of Zones of Regulation • Session 2- Rapport building, fine motor skills, Zones, teacher consultation • Session 3- Rapport building, bilateral coordination, preferred tasks, gross motor skills • Session 4- Rapport building, frustration tolerance, sensory processing linked to coping skills, fine motor skills, Zones of Regulation, teacher consultation • Session 5- Rapport building, Zones of Regulation, in-class intervention

35. Know your limitations • As an entry level OT we are qualified mental health professionals • Your comfort level when discussing and treating according to Trauma Informed Care is extremely important • Education is critical • Safety precautions will likely be different when treating children and adults from a TIC perspective • Know when to refer • We do not need to discuss specific traumatic events during evaluation and intervention, but we do address the impact on occupational engagement • Know limits when discussing suicidal ideation • When to allow a student to leave and when to take action

36. Take Away Points • Trauma is prevalent and the effects are tremendous in physical, mental, social, and emotional health • Holistic, evidence-based practice supports the use of Trauma Informed Care in all interventions and interactions • Parents, service providers, and other caregivers who use trauma-sensitive approaches can (Virginia Family Special Education Connection, n.d.): • Help children improve self-regulation skills and their ability to cope with trauma “triggers" & maintain predictable routines. • Promote a shared understanding of the child’s unique experience with trauma. • increase consistency of care that reflect the best available evidence on how to promote resilience. • Support adults in using more effective strategies to cope with their own responses to trauma. • Integration of trauma based interventions are possible with our creative OT touch

37. Advocacy, Education & Collaboration School Administrators Teachers School Psychologists School Counselors Other related services **Self-care Children’s Mental Health Resource Center- (804) 828-9897 • Do you work in a “trauma-informed” or “trauma-sensitive” school? • Is there already a trauma-informed curriculum in place? • Has OT been included? • How can a conversation be started?

38. Share & Ask Shelly Bloomfield- michelle.bloomfield@vcuhealth.org ; Liz Richardson- richaree@jmu.edu

39. Resources https://www.acf.hhs.gov/trauma-toolkit/people-with-disabilities https://www.parentcenterhub.org/trauma-schools/ https://traumasensitiveschools.org/tlpi-publications/download-a-free-copy-of-a-guide-to-creating-trauma-sensitive-schools/ https://www.schoolcounselor.org/asca/media/asca/ASCAU/Trauma-Crisis-Management-Specialist/TransformingSchools.pdf https://www.elc-pa.org/wp-content/uploads/2015/06/Trauma-Informed-in-Schools-Classrooms-FINAL-December2014-2.pdf https://www.formedfamiliesforward.org/resource_category/trauma-specific-topics-schools/page/2/

40. References American Occupational Therapy Association [AOTA]. (2018a). Mental-Health. Retrieved from https://www.aota.org/Practice/Mental-Health.aspx Beck, A. J., Barnes, K. J., Vogel, K. A., & Grice, K. O. (2006). The dilemma of psychosocial occupational therapy in public schools. Occupational Therapy in Mental Health, 22, 1-17. doi: 10:1300/J004v22n01_01 Center on the Developing Child at Harvard University. (2007). A science-based framework for early childhood policy: Using evidence to improve outcomes in learning, behavior, and health for vulnerable children. Retrieved from http://developingchild.harvard.edu/index.php/resources/reports_and_working_papers/policy_framework/ Copeland, W.E., Keeler, G., Angold, A., & Costello, E.J. (2007). Traumatic events and posttraumatic stress in childhood. Archives of General Psychiatry, 64(5), 577-584. DeRuiter Blackwell, C. & Bilics, A. (2018). Preparing occupational therapy students to address mental health promotion, prevention, and intervention in school-based practice, Journal of Occupational Therapy, Schools, & Early Intervention, 11(1), 77-86, doi:10.1080/19411243.2017.1386605 “H.R. 1757 — 115th Congress: Trauma-Informed Care for Children and Families Act of 2017.” www.GovTrack.us. 2017. Accessed March 4, 2019 https://www.govtrack.us/congress/bills/115/hr1757 Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., & Marks, J.S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventative Medicine, 14(4), 245-258. National Survey of Children's Health. NSCH 2011/12. Data query from the Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health website. Retrieved November 9, 2018 fromwww.childhealthdata.org. Nielsen, S., K., & Hektner, J. M. (2014). Understanding the psychosocial knowledge and attitudes of school-based occupational therapists. Journal of Occupational Therapy, Schools, & Early Intervention, 7, 136-150. doi:10.1080/19411243.2014.930615

41. References Occupational Therapy Included as a Part of New Community Behavioral Health Centers. (2015, February 03). Retrieved from https://www.aota.org/Advocacy-Policy/Congressional-Affairs/Legislative-Issues-Update/2015/OT-included-draft-samhsa-ccbch-criteria.aspx SAMHSA (2011). Helping Children and Youth Who Have Experienced Traumatic Events. National Children’s Mental Health Awareness Day. HHS Publication No. SMA-11-4642. Retrieved from http://www.samhsa.gov/children/SAMHSA_Short_Report_2011.pdf. SAMHSA (2014, April 25). Trauma-Informed Approach and Trauma-Specific Interventions. Retrieved from https://www.samhsa.gov/nctic/trauma-interventions Slamat, A., Javaherian-Dysinger, H., Krpalek, D., Parikh, S., Lee, K., Christensen, B., ...Goya, Y. (2016). Perspective of school-based occupational therapy practitioners in addressing students’ mental health needs. American Journal of Occupational Therapy, 70(Supplement 1). doi:10.5014/ajot.2016.70S1-PO5121. Violence Prevention. (2016, June 14). Retrieved from https://www.cdc.gov/violenceprevention/acestudy/about.html Violence Prevention. (2016, April 01). Retrieved from https://www.cdc.gov/violenceprevention/acestudy/about_ace.html Virginia Family Special Education Connection (n.d.). Trauma Informed Care: What and Why?. Accessed March 4, 2019 from https://vafamilysped.org/Resource/JWHaEa5BS7489_S2gil8zw/Resource-trauma-informed-care-what-and-why