Trauma Conference 2010

I have just returned from the 21st Annual International Trauma Conference in Boston. This conference is directed by Bessel van der Kolk and the staff of the Trauma Center at the Justice Resource Institute (http://www.jri.org/). As usual this conference offered a unique combination of science and practice. In this article I will attempt to extract a few central ideas that I think can immediately add value to our every day work.

The conference focused a great deal on the contributions of neurofeedback, both in understanding the brain and it treatment. In addition, information continues to grow about the parts of the brain, their purposes, and the ways in which a developmental path which includes neglect, trauma and attachment disruption can derail their functioning.

The most emergent theme for me in this conference was the idea of rhythm. All human functioning depends on the establishment of rhythm, and perhaps our basic rhythms start with the mother’s and baby’s heartbeat. When infants are born, they can almost immediately respond to music. Presenters such as Ed Tronick, PhD (Infants’ Reactivity and Coping With Stress: Here Today, Gone Tomorrow?) demonstrated the exquisite musicality of the mother/baby attuned interactions, and how the tune is often led by the baby. Our interactions with babies emphasize rhythm (such as baby songs) and any parent can confirm how important routines and predictability are to the regulation of the infant’s emotions. All this rhythmic interaction has many functions for the growth and development of the baby. One result is becoming socialized to the rhythms of human interaction and social communication.

It is clear that the children we work with did not have either the attuned communication or stable rhythms in their daily lives.

This suggests an area of intervention that we do not utilize enough. Rhythmic interaction between people offers opportunity for attunement without words. This can be done in many ways: bouncing a ball back and forth, dancing, singing together, drumming, listening to music and clapping the beat, swinging, etc. These activities could easily be incorporated more into our daily lives, school and recreational activities.

I attended a workshop on SMART: Sensorimotor Arousal Regulation Treatment for Traumatized Children presented by Anne Westcott, LICSW, Elizabeth Warner, PsyD, Jane Koomar, PhD, OTR/L, FAOTA, and Alex Cook, PhD. This treatment integrates knowledge from child development, occupational therapy sensory regulation, and sensory motor psychotherapy. At their clinic they have outfitted a treatment room with various OT equipment such as cushions, large balls, wedges, etc. They utilize bodily work and rhythmic interactions between the child, the therapist and the care giver to produce regulation and a window of opportunity for connection. With this support the child can often talk about difficult topics in a way they otherwise cannot. They will soon be releasing a manual for this treatment.

Through careful research using fMRIs and Neurofeedback, more evidence has been gathered about the biological result of trauma. One important finding is that the area of the brain that is responsible for self reflection is significantly impaired. Children who have grown up in disruptive situations have less ability to think about themselves. They also have considerably less ability to recognize and interpret their own internal sensations. They cannot identify the sensation, associate it with a specific need, or figure out what to do about it. This includes the sensations of hunger, thirst, satiety, needs to eliminate, pain, and tiredness.

Think how significant this is to understanding the daily struggles we experience. Not being able to observe ones self- that has implications for the ever popular concept of taking responsibility for one’s actions. Not being able to notice and interpret bodily signals- that can be part of the explanation for the constant hygiene and toileting problems these children experience.

Inability to recognize and identify bodily sensations can also lead to serious social problems.

In examining brain waves of traumatized children, researchers discover that some parts of the child’s brain are over active and some are under active- often at the same time. Children especially have difficulty moving between states, such as between sleep and wakeful attention, or excitement and calm.

Researchers have also learned that the sleep problems experienced by children with trauma may be more significant than previously thought. We have all noticed that large numbers of our kids cannot get to sleep, or wake up, or have nightmares. However, it is now known that even when these kids appear to be sleeping they spend much less time in deep sleep than other children- and deep sleep is what is restorative and nourishing.

Understanding the biology behind the behavior we see can be helpful in not taking it personally, having patience, and deliberately designing interventions to target certain kinds of brain changes.

The presenters gave many examples of how neurofeedback had helped children, including for ADHD and even for schizophrenia. Neurofeedback also improved the musical performances of both skilled musicians and novice nine year olds, as reported by John Gruzelier, MD in Neurofeedback and its Benefits for Psychological Integration and Creativity.

Margaret E. Blaustein, PhD earned a standing ovation with her presentation Lessons from Kids and Families on the Treatment of Developmental Trauma. She brought the voices of the children and families into the conference, relating her ten lessons. They included both seeing the oak tree in every acorn (the strengths in the kids and families) and sometimes admitting that life sucks. Her strongest message was that traumatized kids are complex and deserve a thoughtful, complex intervention from us.

And as Ed Tronick, PhD said in his presentation Infants’ Reactivity and Coping With Stress: Here Today, Gone Tomorrow: The best tool is a "polymorphic stress resolver: an adult who unconditionally cares in all ways and at all levels."

That would be us.

I cannot write about this conference without mentioning the campaign led by Bessel van der Kolk to establish a new diagnosis to be included in the DSM V: Developmental Trauma Disorder. With a diagnosis that more completely and accurately captures the reality of children and adults that grow up with neglect, trauma and attachment disruptions, we can have research, medication, and treatments that really make a difference. To learn more about this diagnosis and the criteria for it, visit http://www.traumacenter.org/announcements/DTD_papers_Oct_09.pdf. To contribute badly needed funds to its establishment, see http://www.traumacenter.org/products/DTD_Field_Trial.php.

Every presenter was passionate about the importance of this change in our system.

I am sure I have only scratched the surface of the ideas presented at the conference. If you were there, or have any opinions on these subject, please click on "comment" and add your thoughts.

Children Act Better When They Feel Better

I believe that children act better when they feel better. Do you agree?

What would our worlds look like if we deeply believed this, and put it into practice? Then our mission would become to help the children feel better. How could we do that? Of course, we do that already in many ways- but what if we deliberately made helping the children to feel better our top priority?

It would be essential to define “feeling better” in a complex and multi-faceted way. Each area has many parts and of course they overlap. It could include:

Feeling Better Physically:

• Addressing any health problems
• Establishing good nutrition
• Helping with sleep
• Engaging the kids in exercise, helping them overcome their fears and shame around moving their bodies
• Providing nice, comfortable clothes
• Addressing sensory distress

Feeling Safer:

• Eliminating bullying
• Addressing signs of danger
• Being caring, welcoming, sensitive to their needs

Felling Calmer:

• Teaching self soothing skills
• Teaching yoga, meditation, neuro-feedback
• Help with life problems

Feeling Less Shame:

• Exploring areas of self blame
• Forming relationships
• Experiencing competency

Feeling more competent

• Building on strengths
• Teaching new skills
• Encouraging self expression
• Providing opportunities to help others
• Providing praise and recognition of achievement

Feeling more effective:

• Providing many opportunities to control ones own life
• Teaching and practicing conflict resolution skills
• Providing opportunities to make a difference
• Developing leadership

Feeling more connected:

• Developing strong relationships between ourselves and the kids
• Providing assistance to help them maintain relationships with family and friends outside the agency
• Providing assistance to help maintain connections with communities such as religious organizations, their own school, sports teams, etc.
• Encouraging and facilitating appropriate relationships between the kids
• Encouraging exploration of their own culture and history

Obviously these are the things we do anyway- but does this way of looking at them help understand or organize our work in a new way? If a child acted out, we can wonder in what way they are feeling bad, and how can we help them feel better. Our response should be focused on helping them feel better, not explaining what was wrong with what they did.

I am just beginning to think about this. What is your reaction? Click on comment to respond.

Accommodation

I am in the middle of a six week training of foster parents. The topic is: Trauma Informed Foster Care. The foster parents are teaching me what they need to know in order to stick with these difficult children. The information about trauma and its effects is important; the practical applications are essential.

We were talking about the idea that children are doing the best they can, and how the biological changes they have experienced create real challenges for them. One foster father said to me: "I don’t expect anything different from my foster son as I do from my biological sons. I expect him to do everything they do and if not, have the same consequences they do."

This led me to think about how we readily make accommodations for physical disabilities that we can see. Yet is so much harder to see trauma in the same way. So this led to the creation of the following skit:

I asked two foster care social workers, Jaime and Neftali, to play two brothers. One (Jamie) played the son with a badly broken leg. He had broken it when his friends challenged him to try a jump on his skate board. We wrapped Jaime’s leg with gauze and an ace bandage, and gave him some crutches. The other (Neftali) was fine. But he was angry and resentful that Jaime is getting all the attention and is getting out of doing things.

As the two sons sat in front, I gave volunteer foster parents cards with situations, and asked them how they would handle them. The first was: "Your sons attend the local high school. There are long halls, stairs, and lots of changing classes." The foster father who chose this card, John, said he would go to the school and advocate for his son, ask for a longer time to change classes, a wheelchair, use of the elevators. Immediately both boys began to object. Jaime said that would be embarrassing and he could manage it himself. Neftali said he would NOT be pushing Jaime’s wheelchair. John was sure that he would insist that the accommodations be made even if Jaime objected.

The next scenario was that Jaime’s doctor had recommended PT for his recovery. Jaime did not want to go. PT would hasten his recovery, but it was not life or death. Jaime immediately said it was stupid and he knew he wouldn’t like it and it wouldn’t help. Neftali said he should be forced to go. The foster mom, Rose, who took this card said she would insist that he at least go- he could decide what to do when he got there. Other foster parents disagreed, and said that at least by some unspecified age he should decide for himself once the pros and cons had been explained to him.

The next situation brought us to chores. The boys usually handle the outside, mowing the lawn etc. Naturally Jaime could not do this. This time he was willing to accept his limits and do nothing. Neftali said if he had to do it all he should get Jaime’s allowance. The foster parents all suggested finding other ways Jaime could help such as doing the dishes while sitting in a chair. We had a spirited discussion of allowance, whether it should be used (it is mandated by DCF) and whether it should be contingent. If someone has a physical problem and can’t do the chores should the allowance be withheld?

I thought it would be obvious why I was doing this, but interestingly when I asked the foster parents none of them mentioned the connection between the broken leg and the broken brains our children have. When I pointed this out, the parents wrestled with the implications.

We are used to the idea of being flexible to accommodate visible physical limitations. I wonder if it would help if some how we could see our children’s broken brains?

What are your thoughts? Click on "comment" to respond.

How to Enhance Hope

A central concept in our Risking Connection® teaching is that healing relationships are characterized by Respect, Information, Connection and Hope. In fact, the concept is so integral to Risking Connection that the acronym RICH has been trademarked by Sidran. I would like to look at the concept hope.
I began thinking about this today as I wrote a book review of Trauma Stewardship by Laura van Dermoot Lipski with Connie Burk. This review will be in our May newsletter- be sure you are on our mailing list to get it (www.traumaticstressinstitute.org).

Van Dermoot Lipsky describes organizations as to whether they have a hopeful, energetic feel or a defeated, listless feel. I began thinking how essential hope is to all our endeavors. Do we make enough deliberate efforts to strengthen hope in our organizations, our staff, ourselves and our clients? How can we do this? Here are a few ideas- please add yours in comments.

Organizations
1. Hold regular celebrations
2. Communicate successes
3. Share stories of clients who return to visit and are doing well
4. Reward all sorts of staff efforts
5. Share any honors, recognitions or praise widely
6. Regularly and publicly reflect on where we have been and where we are now and where we are going
7. Articulate a vision of what kind of organization we want to be. Specify values and refer to them often.
8. Organize many child activities such as plays, field days, art shows, science fairs. As many staff as possible attend and applaud.
9. When something goes wrong, pull together and identify the parts that were done well. Praise the staff for those. Be specific about what we have learned from the event.
10. Articulate our pride in our agency and specifically what we are proud of.
11. Have fun, make jokes, do silly things
12. Celebrate staff milestones (new babies, weddings, etc.)

Staff
1. Praise, praise, praise- little and big things
2. Comment on any instance of staff doing their work well.
3. Assist staff in meeting their personal goals through providing training and education reimbursement
4. Provide supervision
5. Share client success stories
6. Promote from within when possible
7. Deliberately groom people for their next job
8. Remark on extra effort
9. Make room for creativity and individual interests, like the child care worker that hooks the kids up with a horseback riding stables through their personal interests
10. Do something different
11. Encourage staff to say yes- and say yes to them
12. Be flexible whenever possible
13. Maintain a clean and beautiful environment, fix damage quickly
14. Create fun events together such as pot luck lunches or volleyball teams
15. See above organizational ideas

Personal
1. Reframe experiences to focus on what you have learned.
2. Maintain balance with work and non-work connections
3. Take breaks and vacations
4. Decorate your space when possible
5. Notice changes in clients even when small
6. Notice changes in yourself such as increasing skill, and point them out in others
7. Notice ways the work has grown you as a person
8. Set goals for areas you would like to learn more about or new things you would like to do
9. Connect with others in the profession
10. Talk about your experiences11. Use supervision and therapy.
12. Laugh.

Clients
1. Point out small changes
2. Set small goals with them, notice when they are met
3. Express delight
4. Celebrate their achievements, attend their plays, admire their art
5. Arrange for them to take extra classes in an area of skill
6. Fantasize the future when they are a famous football player and are returning to your place to speak with the kids who are there then- what will they say?
7. Show that they matter by speaking from your heart.
8. Allow them to take some risks and try something new.
9. Offer new responsibilities
10. Arrange ways they can help others
11. Encourage the older to teach the younger
12. Put them in charge of things
13. Have a Youth Council that has real power
14. Tell stories of other successful kids
15. Have fun together.

What do you think? How can we be more active in cultivating hope, which is the core of everything we do? Click on “comment” and add your ideas.