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Trauma Informed Care
The participant will understand:
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Sources of potential trauma and complex
trauma for individuals served by child serving
systems.
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Impact of trauma on emotional and
behavioral functioning
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Principles of trauma-informed systems.

Ways to decrease the possibility that those
seeking services and staff experience trauma.
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“an emotional shock that creates significant and
lasting damage to a person’s mental, physical and
emotional growth.”
Traumatic experiences can significantly alter a
person’s perception of themselves, their
environment, and the people around them. In
effect, trauma changes the way people view
themselves, others and their world.
Can impact safety, well-being, permanence.
This is Anna at age one.
This is Anna years later –
in a mental institution.
What happened?
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Over 90% of mental health clients have trauma histories
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In state hospitals, estimates range up to 95%
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90% or more of women in jails and prisons are victims of
physical or sexual abuse
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Up to 2/3 of men and women in substance abuse
treatment report childhood abuse or neglect
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Similar statistics exist for foster care, juvenile justice,
homeless shelters, welfare programs, etc
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Boys who experience or witness violence are 1000 times
more likely to commit violence
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Children & women
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American Indian/Alaska Native
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Veterans
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Refugees and immigrants
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People who are homeless
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People who are institutionalized in mental
health or criminal justice systems
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Annual Direct Costs: Hospitalization, Mental
Health Care System, Child Welfare Service
System, Law Enforcement = $33,101,302,133.
Annual Indirect Costs: Special Ed, Juvenile
Justice, Mental Health & Health Care, Criminal
Justice System, Lost Productivity =
$70,652,715,359.
Total Annual Cost: $124 billion.
Economic Impact Study. (September, 2008). Prevent Child Abuse America
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NOT a diagnostic category
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There is no universal definition of trauma. It is
defined by the person who has had the experience.

An experience or series of experiences that elicits
feelings of terror, powerlessness, & out-of-control
psychological arousal; result in survival driven
behaviors, thoughts, emotions, & needs.

Often misinterpreted & assigned as
symptoms of disorders (depression, Bipolar
Disorder, ADHD, Oppositional Defiant
Disorder, Conduct Disorder, Attachment
Disorder, etc.)

These diagnoses generally do not capture full
extent of developmental impact of trauma.
Exposure to Trauma
Trauma can be:
•A single event
•A connected series of events
•Chronic lasting stress
Trauma is under-reported and under-diagnosed.
(NTAC, 2004)
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Loss of a loved one
Abandonment
Accidents
Homelessness
Community/school
violence
Bullying, including
cyber-bullying
Domestic violence
Neglect
Frequent moves
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Serious medical Illness
Physical abuse
Sexual abuse
Emotional/verbal
abuse
Man-made or natural
disasters
Witnessing violence
Terrorism
Refugee and War Zone
trauma.
Types of Trauma
A single traumatic event
that is limited in time.
The experience of multiple
traumatic events.
Acute
Trauma
Chronic
Trauma
Vicarious
Trauma
Complex
Trauma
Both exposure to chronic trauma, and
the impact such exposure has on an
individual.
System
Induced
Trauma
The traumatic removal from home,
admission to a detention or residential
facility or multiple placements within a
short time.
Trauma can occur at any age.
Trauma can impact
anyone.
Bridging the gap between
childhood trauma and
negative consequences later
in life.
50% of study participants
reported at least one adverse
childhood experience
25% reported at least two or
more untreated trauma
Heart
Disease
4 or more
traumatic
experiences
shorten life
expectancy by 20
years
Chronic
Lung
Disease
Immune
Diseases
Adverse
Childhood
Experiences
Liver
Disease
Cancer
Diabetes
Mental
Illness
4 or more
traumatic
experiences
shorten life
expectancy by 20
years
Relationship
Problems
Suicide
Adverse
Childhood
Experiences
Substance
Abuse
Behavior
Problems
Poor SelfEsteem
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Adults with ACE score >4 are 460% more
likely to have lifetime history of depression.
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Adults with ACE score >5 are 16 times more
likely to have lifetime history of alcoholism.
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Male child with ACE score of 6 has 4,600%
increase in likelihood of later becoming IV
drug user.
Can cause impairments in many areas of
development & functioning, including:
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Attachment – Difficulty relating to &
empathizing with others; believe the world to be
uncertain & unpredictable
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Biology – problems with sensation & movement,
including hypersensitivity to physical contact &
insensitivity to pain; physical symptoms &
increased medical problems
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Mood Regulation – difficulty identifying &
controlling emotions & internal states
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Behavioral Control - poor impulse control,
self-destructive behavior, aggression, risk
taking behavior
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Dissociation – feeling detached, as if
observing something happening to them that
is not real
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Cognition – difficult focusing & completing tasks or
anticipating future events; learning difficulties &
problems with language development
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Self-concept – feeling shame/guilt; low self-esteem,
disturbed body image
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Loss & Betrayal - loss of part(s) of their life; distrust
of others
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Powerlessness – perceive self as victim; have no say
in what happens to them; unable to control their
lives, etc.
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Has serious consequences for normal development
of children’s brains, brain chemistry & nervous
system.
Trauma-induced alterations in biological stress
symptoms can adversely effect brain development,
cognitive & academic skills, & language
development.
Result in increased levels of stress hormones
(impacts response to future stress)
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Affects “cross-talk” between brain’s hemispheres,
including parts that:
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regulate emotions
manage fears, anxieties & aggression
sustain attention for learning & problem solving
control impulses & manage physical responses to
danger
 allow realistic appraisal of danger & safety
 promote consideration of consequences of behavior
 allow ability to govern behavior & meet longer term
goals
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People of different cultural, national, linguistic,
spiritual & ethnic backgrounds may define &
describe “trauma” differently
Assessment of trauma history should always take
into account cultural background & modes of
communication of assessor and family
Strong cultural identify & community/family
connections can contribute to strength &
resilience or can increase risk for & experience of
trauma.
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Child traumatic stress reactions vary by
developmental stage.
Children with traumatic experiences may spend
much energy responding to, coping with, &
coming to terms with the experience – results in
delays in mastering age-appropriate
developmental tasks – delayed development
The longer traumatic stress goes untreated, the
farther children tend to stray from appropriate
developmental pathways.
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The impact of a potentially traumatic event depend
on
 Individual’s age & developmental level
 Individual’s perception of the danger faced
 Whether the individual was victim or perpetrator
 Individual’s relationship to victim or perpetrator
 Individual’s past experience with trauma
 Adversities the individual faces following the
trauma
 Presence/availability of others who can offer
help/support/protection
TRIGGERS
For trauma survivors, it is different…
Triggers
Seeing, feeling, hearing, smelling something that reminds us of past trauma
Activates the alarm system…
The response is as if there is current danger.
Thinking brain automatically shuts off in the face of triggers.
Past and present danger become confused.
Our experience.
A trauma survivor’s
experience.
We all have buttons that can be pushed…
Your response is keyNonTrauma
Informed
Response
Trigger
Trigger
Negative
Outcome
Trauma
Informed
Response
Positive
Outcome
Protective Factors
• Parental/caregiver resilience
• Social connections
• Knowledge of parenting and child development
• Concrete support in times of need
• Nurturing and attachment/social and emotional
competence of children
“It’s about the right to have a
present and a future that are not
completely dominated and
dictated by the past.”
Karen Saakvitne
TRAUMA INFORMED PRACTICE
Trauma Informed
Non-Trauma Informed
Recognition of high prevalence of
trauma
Lack of education on trauma
prevalence & “universal”
precautions
Recognition of primary and cooccurring trauma diagnoses
Over-diagnosis of Schizophrenia &
Bipolar D/O, Conduct D/O &
singular addictions
Assess for traumatic histories &
symptoms
Cursory or no trauma assessment
Recognition of culture and practices
that are re-traumatizing
“Tradition of Toughness” valued as
best care approach
TRAUMA INFORMED PRACTICE
Trauma Informed
Non-Trauma Informed
Power/control minimized - constant
attention to culture
Keys, security uniforms, staff
demeanor, tone of voice
Caregivers/supporters –
collaboration
Rule enforcers – compliance
Address training needs of staff to
improve knowledge & sensitivity
“Patient-blaming” as fallback
position without training
Staff understand function of
behavior (rage, repetitioncompulsion, self-injury)
Behavior seen as intentionally
provocative
TRAUMA INFORMED PRACTICE
Trauma Informed
Non-Trauma Informed
Objective, neutral language
Labeling language: manipulative,
needy, “attention-seeking”
Transparent systems open to
outside parties
Closed system – advocates
discouraged
(Fallot & Harris, 2002; Cook et al., 2002, Ford, 2003, Cusack et al., Jennings, 1998, Prescott, 2000)
Trauma Informed Systems
UNIVERSAL PRECAUTIONS
Presume that every person in a treatment setting has been
exposed to abuse, violence, neglect, or other traumatic
event(s).
“What has
happened to you?”
Though no one can go back
and make a brand new start,
anyone can start from now
and make a brand new
ending.
Carl Bard
Trauma is when
people live with
more fear than
hope.
Trauma
Recovery
is when
people live
with more
hope than
fear…
How people cope with trauma determined by:
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How they experience what they are exposed to
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Who they were exposed to in their traumatic
past
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What they are exposed to in the present
environment
Trauma-Informed Care provides a new
paradigm under which the basic premise
for organizing services is transformed
from
“What’s wrong with you?”
“What happened to you?”
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S
U
C
C
E
S
S
What
happened
to you?
John is a 16 year old boy who, with his younger brother, was
placed in DHHR custody at age 5 as a result of parental
abuse/neglect. He has been in multiple placements,
including numerous foster homes, residential care in all
levels, psychiatric inpatient care on multiple occasions. He
has been been kicked out of all levels of care for disruptive
behavior. He was diagnosed with ADHD, conduct disorder,
bipolar disorder, and substance abuse. He was placed in
detention for physical aggression/ assault. He has been in
outpatient care several times, and is now court ordered to
outpatient care again. His intake assessment was being done
by his previous outpatient therapist. He got angry during the
intake and stormed out of the office and agency.
What went wrong?
When an agency takes the step to become
trauma-informed, every part of its
organization, management & service
delivery system is assessed & potentially
modified to include a basic understanding of
how trauma impacts the life of individuals
seeking services.
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Trauma-informed organizations, programs, &
services are based on an understanding of the
vulnerabilities or triggers of trauma survivors
that traditional service delivery approaches
may exacerbate, so that these services &
programs can be more supportive and avoid
retraumatization.
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Provides the foundation for a basic
understanding of the
psychological, neurological,
biological, and social impact that
trauma and violence have on
many individuals.
Incorporates proven practices into
current operations to deliver
services that acknowledge the role
that violence and victimization
play in the lives of most of the
individuals entering our systems.
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The provision of “trauma-informed care” is a
seminal concept in emerging efforts to
address trauma in the lives of children, youth
and adults.
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In a trauma-informed system, trauma is
viewed as “a defining and organizing
experience that forms the core of an
individual’s identity.”
Source: Harris, M. and Fallot, R.D. (Eds), 2001
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Understanding of Trauma
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Understanding of the Consumer/Survivor
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Understanding of Services
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Understanding of the Service Relationship
 Traumatic events are not rare; experiences of life disruption are
pervasive and common
 The impact of trauma is seen in multiple, apparently unrelated life
domains
 Repeated trauma is viewed as a core life event around which
subsequent development organizes
 Trauma begins a complex pattern of actions and reactions which
have a continuing impact over the course of one’s life
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An integrated, whole person view of individuals and their
problems and resources
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“Symptoms” are understood not as pathology but primarily as
attempts to cope and survive; what seem to be symptoms
may more accurately be solutions
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A contextual, relational view of both problems and solutions
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Appropriate and collaborative responsibility allocation
 Primary goals are empowerment and recovery
 Survivors are survivors; their strengths need to be
recognized
 Service priorities are prevention driven
 Service time limits are determined by survivor selfassessment and recovery/healing needs
 Risk to the consumer is considered along with risk
to the system and the provider
 A collaborative relationship between the consumer and
the provider of her or his choice
 Both the consumer and the provider are assumed to have
valid and valuable knowledge bases
 The consumer is an active planner and participant in
services
 The consumer’s safety must be guaranteed and trust must
be developed over time
Safety: Ensuring physical and emotional safety
 Trustworthiness: Maximizing trustworthiness,
making tasks clear, and maintaining appropriate
boundaries
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Choice: Prioritizing consumer choice and control
 Collaboration: Maximizing collaboration and
sharing of power with consumers
 Empowerment: Prioritizing consumer
empowerment and skill-building
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Maximize one’s sense of security
Assist individual in reducing overwhelming
emotion.
Help individual make new meaning of trauma
history & current experiences.
Address impact of trauma & subsequent
changes in one’s behavior, development &
relationships.
Coordinate services with other
agencies/systems.
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Utilize comprehensive assessment of trauma
experiences & their impact on development &
behavior to guide services
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Support & promote positive & stable relationships
in the life of the individual.
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Provide support & guidance to the individual’s
family & caregivers.
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Manage professional & personal stress.
“Don't
ever take a fence
down until you know why
it was put up.”
-Robert Frost
Screening & Assessment
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Trauma-informed care refers not only to the
recognition of the pervasiveness of trauma,
but also to a commitment to identify and
address it early, whenever possible.
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Numerous assessment/diagnostic issues
complicate the identification & treatment of
trauma.
Screening
Assessment
Questions about trauma should be part of the
routine mental health intake, with parallel questions
posed to a child’s parent or legal guardian.
 Screening and assessment for trauma should occur
also in juvenile justice and out-of-home child
protection settings as well.
 Assessment for trauma exposure and impact should
be a routine part of psychiatric and psychological
evaluations, and of all assessments that are face to
face.
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Hodas 2004
Three basic approaches to assessment of trauma and
post-traumatic sequelae through tools and
instruments:
 Instruments that directly measure traumatic experiences
or reactions
 Broadly based diagnostic instruments that include PTSD
subscales
 Instruments that assess symptoms not trauma specific but
commonly associated symptoms of trauma
Wolpaw & Ford 2004
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Identification of PTSD or sub-threshold PTSD
symptoms is complicated by the fact that these
symptoms mimic symptoms of anxiety and
depression
Many individuals with PTSD also abuse alcohol
and drugs
If trauma screening isn’t conducted, these
individuals are usually treated as people with
just depression, or just anxiety, or just AOD
Begin Initial Screening Process
Assess Through Clinical Interview & Standardized
Measures (Trauma History Crucial)
Integrate Assessment Information and
Form Unique Client Picture
Narrow Clinical Focus Select Symptom Domains &
Identify Treatment Priorities
Identify Appropriate Treatment
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Individual is exposed to traumatic event in
which:
 They experienced, witnessed, or were
confronted with event/events that involved
actual or threatened death or serious injury
to themselves or others
 Response to event included intense fear,
helplessness, or horror
 Combat-related PTSD vs. non-combat
related
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Reexperiencing the traumatic event (nightmares,
intrusive memories, flashbacks, etc.)
Intense psychological or physiological reactions
to internal or external cues that symbolize or
resemble some aspect of the original trauma
Avoidance of thoughts, feelings, places, 7/or
people associated with the trauma
Emotional numbing (detachment, estrangement,
loss of interest in activities, etc.)
Increased arousal (heightened startle response,
sleep disturbance, irritability, etc.)
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Trauma Symptom Checklist for Children (TSCC)
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Trauma Symptom Checklist for Young Children
(TSCYC)
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Child Sexual Behavior Inventory (CSBI)
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UCLA PTSD Index for DSM-IV
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Chadwick Center Trauma History Checklist
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Trauma Assessment for Adults (TAA)
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PTSD Checklist for Adults (PCL-A)
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UCLA Adult PTSD Scale
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Traumatic Events Screening Inventory (TESI)
Is alcohol/substance abuse a desperate attempt at selfhealing?
(Felitti, et al, 1998)
Ste 1
Screening Questions for Mental Health
 Have you ever been worried about how you are thinking, feeling, or acting?
 Has anyone ever expressed concerns about how you were thinking, feeling, or acting?
 Have you ever harmed yourself or thought about harming yourself?
Screening Questions for Substance Abuse
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Have you ever had any problem related to your use of alcohol or other drugs?
Has a relative, friend, physician, counselor, or other person been concerned about your drinking or
other drug use or suggested that you cut down or stop drinking/using?
Have you ever said to another person, “No, I don’t have an alcohol or drug problem,” when you
questioned yourself and felt, maybe I do have a problem?
Screening Questions for Trauma
 Have you ever been hit, kicked, choked, or received a more serious punishment from a parent or other
adult?
 Has anyone ever touched you in a sexual way or made you touch them when you did not want to?
 Have you had an experience that was so frightening, horrible, or upsetting that you have nightmares,
upsetting thoughts or memories that come to your mind against your will or have bodily reactions (felt
numb or detached from others/surroundings, been constantly on guard/watchful or easily startled, fast
heartbeat, stomach churning, sweatiness, dizziness, etc.) when you are reminded of the event?
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Services designed specifically to address violence,
trauma, and related symptoms and reactions.
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The intent of the activities is to increase skills and
strategies that allow survivors to manage their
symptoms and reactions with minimal disruption to
their daily obligations and to their quality of life, and
eventually to reduce or eliminate debilitating
symptoms and to prevent further traumatization
and violence.
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Characteristics of trauma-informed services
 Incorporate knowledge about trauma—prevalence,
impact, and recovery—in all aspects of service
delivery
 Hospitable and engaging for survivors
 Minimize re-victimization (particularly use of
restraint & seclusion)
 Facilitate recovery and empowerment
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Trauma Focused Cognitive Behavioral
Therapy (TF-CBT)
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Dialectical Behavioral Therapy (DBT)
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Parent-Child Interaction Therapy (PCIT)
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Abuse-Focused Cognitive Behavioral Therapy
(AF-CBT)
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Make your environment, policies, procedures
and interactions are empowering,
collaborative, safe, and respectful.
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Include trauma survivors as evaluators,
informants, and members of your team.
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Ensure that staff trauma is also a part of your
plan.
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Staff also experience symptoms of trauma.
 Use clinical supervision – consult with others
about concerns/approaches
 Peer support – not just for service recipients;
find agency/peer trauma champions; let
survivor be the champion on themselves
 Be aware of burnout, compassion fatigue,
secondary/vicarious trauma – contribute to
non-trauma informed care
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Conduct an organizational readiness assessment
to evaluate specific criteria related to traumainformed care.
Include clients/consumers/patients in evaluation
& planning
Develop an organization plan that includes:
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Leadership buy-in
Policy development
Staff training/supervision/support
Culture/environmental changes
Follow through on organization plan
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Early screening & assessment process in place
Consumer/survivor driven care & service
 Encourage consumers to participate in their care
 Hire consumers/survivors in organization
 Implement continuous consumer feedback loop
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Trauma-informed, educated & responsive
workforce
 All staff trained in TIC & understand how their
behaviors impact care received
 Provide & encourage staff to seek support
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Provision of trauma-informed, EB & emerging best
practices
 Trauma-focused/specific services
 Allow clients to explore their trauma in culturally &
gender-specific way
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Create safe & secure environment
 Environment, policies/practices established promote
safe/secure environment & prevent re-traumatization
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Engage in community outreach & partnership
building
 Help community understand impact of trauma & that
recovery is possible
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Florida Dept. of Children & Families Children’s Mental Health,
Jane B. Streit, Ph.D., Sr. Psychologist, 2010.
National Child Traumatic Stress Network, Child Welfare Trauma
Training Toolkit, 2008.
http://www.cdc.gov/ace/prevalence.htm. The ACES Experience.
Kerker & Dore (2006). Mental health needs and treatment of
foster youth: Barriers and opportunities, American Journal of
Orthospychiatry, 76(1), 138-147.
Pynoos & al., Issues in the developmental neurobiology of
traumatic stress. Annals of the New York Academy of Sciences, 821,
176-193.
Perry, B. (2003). The cost of caring: Secondary traumatic stress and
the impact of working with high-risk children and families. The Child
Trauma Academy.
Pecora et al., Assessing the effects of foster care: Early results from
the Casey National Alumni Study. Casey Family Programs.
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Eyberg, S.M. (1988). Parent-child interaction therapy: Integration of
traditional and behavioral concerns. Child and Family Therapy, 10, 33-46.
Complex Trauma in Children and Adolescents. Focal Point, Winter/2007, Vol.
21, No.1. www.rtc.pdx.edu.
National Registry of Evidence-based Programs and Practices.
http://www.nrepp.samhsa.gov.
Models for Developing Trauma-Informed Behavioral Health Systems and
Trauma-Specific Services.--pdf, (2007) Update: Draft for Publication by
SAMHSA/CMHS Ann Jennings, Ph.D
Criteria for Building a Trauma-Informed Mental Health Service System.pdf.
Ann Jennings, Ph.D.
Blueprint for Action: Building Trauma-Informed Mental Health Service
Systems: State Accomplishments(pdf), (2007) States’ Reports on TraumaInformed Activities Organized by Individual States, Ann Jennings, Ph.D.
Blueprint for Action: Building Trauma-Informed Mental Health Service
Systems: State Accomplishments(pdf). (2007) States' Reports on TraumaInformed Activities Organized to Trauma Informed Criteria. Anna Jennings,
PhD.