Applied Behavioral Analysis within a Traumainformed Framework

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Applied Behavioral Analysis within a
Trauma-informed Framework
Victoria Hummer, MSW, LCSW vhummer_at_fmhi.usf.edu K
imberly Crosland, Ph.D. kcrosland_at_fmhi.usf.edu
Norín Dollard, Ph.D. dollard_at_fmhi.usf.edu Depart
ment of Child and Family Studies Louis de la
Parte Florida Mental Health Institute
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Trauma What is it?

• Trauma can result from experiences of violence.
  Trauma includes physical, sexual and
  institutional abuse, neglect, intergenerational
  trauma and disasters that induce powerlessness,
  fear, recurrent hopelessness and a constant state
  of alert.

-National Center on Trauma-Informed Care
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Complex trauma

• A subset of children experience multiple traumas
  simultaneously or experience trauma chronically
  early in life and these experiences impede
  appropriate development.
• Because of neurological rewiring in the brain as
  a result of these traumas, children who
  experience complex trauma may suffer an impaired
  ability to self-regulate and changes in the ways
  in which they react to environmental cues. This,
  in turn, may result in mis diagnoses such ADHD,
  ODD, etc.

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Adverse Childhood Events Study

• Trauma markedly increases the risk of mental
  health and substance abuse problems, as well as,
  obesity, cardiac problems and even premature
  death.
• Experiencing a single traumatic event increases
  the likelihood that an individual will experience
  additional traumatic events, often through
  increased risk of victimization.
• Anda, Felitti, Bremner, Walker, Whitfield, Perry
  et al (2006)

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ACE study findings
N17,337 http//www.cdc.gov/nccdphp/ACE/prevalence
.htm
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Trauma why does it matter?

• General population
• Estimates of lifetime exposure to traumatic
  events from the National Comorbidity Survey were
  as high as 61 of men and 51 of women (Kessler
  et al, 1995).
• Vulnerable populations
• Children in the child welfare system almost by
  definition have suffered trauma, often multiple
  traumatic events and 50-75 exhibit behaviors or
  symptoms that need mental health treatment
  (Landsverk et al, 2009).

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Trauma why does it matter?

• Children schools
• Exposure to violence has been associated with
  lower IQs and reading ability (Delaney-Black et
  al, 2002) lower GPA attendance (Hurt et al,
  2001), and lower graduation rates (Grogger,
  1997).

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Trauma why does it matter?

• Juvenile justice
• Rates of posttraumatic stress disorder range as
  high as 50 (Wolpaw Ford, 2004) and more than
  90 (Abram et al 2004) of youth in detention
  reported experiencing at least one traumatic
  event.

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Trauma-informed Systems 8

• Integrate an understanding of trauma, substance
  abuse and mental illness.
• Involve consumers in designing/evaluating
  services.
• Acknowledge that the effects of trauma can change
  the way in which victims perceive their
  environment, and in how they interact and react
  to the world.
• Create a collaborative relationship between
  providers and consumers, and place priority on
  consumer safety, choice and control.
• Focus on empowerment and emphasize strengths.

8 Adapted from Ohio Legal Rights Service
(2007). A closer look Trauma-informed
treatment in behavioral health settings.
http//olrs.ohio.gov/other/trauma.pdf. Downloaded
6/1/2009.
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What is common to both trauma-informed care and
ABA?

• Changing the kid isnt enough, you have to change
  the systems around him or her.
• Change the environments where children live, go
  to school, receive healthcare or receive mental
  health care.
• Change interactions between children and their
  parents or caregivers

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Applied Behavior Analysis through a
Trauma-Informed Care lens

• Trauma-informed care principles help to explain
  the etiology of behavior, decreasing reactivity
  on the part of caregivers staff, setting the
  stage for empathy attunement

• Applied behavior analysis
• examines the function of behavior, offering
  caregivers and staff tools that promote
  pro-social skill development positive
  interactions.

• Origin etiology of behavior

• Function of behavior

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• People who work with trauma survivors need a
  framework and tools!
• How do we merge both theoretical models to
  improve practice implementation?

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What is the connection between trauma-informed
care and ABA?

• Both address the following as essential to
  practice
• Connect - Focus on Relationships
• Protect - Promote Safety Trustworthiness
• Respect - Engage in Choice Collaboration
• Teach Reinforce (Redirect) Encourage
  Skill-Building Competence

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Connect Building Relationships

• Trauma, particularly when in childhood, impacts
  ones ability for healthy attachment11
• Trauma interventions are person-centered,
  relationship-focused, individualized, and family
  driven12.
• Many approaches focused on forming relationships
  and actively building mental representations of
  these relationships in the childs brain 13.

11 Kinniburgh, K.J., Blaustein, M., Spinazzola,
J., van der Kolk B. (2005). Attachment,
Self-Regulation and Competency Psychiatric
Annals, 35 (5), 424-430. 12 Jennings, A.,
(2004). Trauma informed mental health service
systems Blueprint for action. Alexandria, VA
National Association of State Mental Health
Program Directors, National Technical Assistance
Center for State Mental Health Planning. 13
Wilcox, P. (2008). The Restorative Approach.
Children's Voice,17 (3). Washington, CWLA.
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Caregivers are taught 12 Coercives to avoid
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Connect
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Protect (Safety)

• Environmental, emotional psychological
• Clear boundaries expectations
• Avoidance of re-enactment retraumatization
• Includes ongoing evaluation of safety concerns
• Frequent de-briefing of critical incidents
• Attends to safety of youth, families staff

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Protect
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Respect (Choice Collaboration)

• Promotes safety well-being
• Teaches pro-social skills problem-solving
• Empowers youth and families
• Helps to identify coping strategies incentives
  more likely to be effective
• Is person-centered
• Flattens the hierarchy of coercion control14

14McCorkle, D. and Peacock, C. (2005) Trauma and
the isms-A herd of elephants in the room A
Training Vignette. Therapeutic Community The
International Journal for Therapeutic and
Supportive Organizations 26 (1) 127-133.
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Respect
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Teach, Reinforce, Redirect

• Psycho-education about trauma for consumers,
  families staff
• Developmentally suited curricula
• Ongoing practice, coaching reinforcement
• Opportunities to demonstrate skills leadership
• Progress based on skill attainment rather than
  earned points or levels.

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Teach
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Reinforce
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Case examples

• A child in foster care is stealing food from the
  kitchen and hiding it under her bed. Her foster
  parents are quite upset because the food is
  rotting.

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Case examples

• An adoptive parent calls because her child
  refuses to take a shower or keep himself clean
  and presentable.

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Questions?

• Vicki Hummer vhummer_at_fmhi.usf.edu
• Kim Crosland - kcrosland_at_fmhi.usf.edu
• Norín Dollard dollard_at_fmhi.usf.edu

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References

• Abram, K.M., Teplin, L.A., Charles, D.R.,
  Longworth, S., McClelland, G., Duncan, M.
  (2004). Posttraumatic stress disorder and trauma
  in youth in juvenile detention. Archives of
  General Psychiatry, 61, 403-410.
• Anda, R.F., Felitti, V.J., Bremner, J.D., Walker,
  J.D., Whitfield, C., Perry, B.D., Dube, S.R.,
  Giles, W.H. (2006). The enduring effects of
  abuse and related adverse experiences in
  childhood A convergence of evidence from
  neurobiology and epidemiology. European Archives
  of Psychiatry and Clinical Neuroscience, 256,
  174-186.
• Delaney-Black, V. Covington, C., Ondersma, S.J.,
  Nordstrom-Klee, B., Templin, T., Ager, J. et al
  (2002). Violence exposure, trauma, and IQ and/or
  reading deficits among urban children. Archives
  of Pediatrics Adolescent Medicine. 156 (3),
  280-285.
• Grogger, J. (1997). Local violence and
  educational attainment. Journal of Human
  Resources, 32, 659-82.
• Hurt, H., Malmud, E., Brodsky, N.L., Gianetta,
  J. (2001). Exposure to violence Psychological
  and academic correlates in child witnesses.
  Archives of Pediatrics and Adolescent Medicine,
  155, 1351-1356.
• Kessler, R.C., Sonnega, A., Bromet, E., Hughes,
  M., Nelson, C.B. (1995). Posttraumatic stress
  disorder in the National Comorbidity Survey.
  Archives of General Psychiatry, 52, 1048-1060.
• Landsverk, Burns, Stambaugh, Rolls Reutz
  (2009). Psychosocial Interventions for Children
  and Adolescents in Foster Care Review of
  Research Literature. Child Welfare, 88(1), 49-69.
• Wolpaw, J.W., Ford, J.D. (2004). Assessing
  exposure to psychological trauma and
  posttraumatic stress in the juvenile justice
  population. National Child Traumatic Stress
  Network.