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Youth interrupted: stopping the cycle of institutionalization for traumatized youth

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Youth interrupted: stopping the cycle of institutionalization for traumatized youth

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Youth Interrupted:
Stopping the Cycle of Institutionalization for Traumatized Youth
Final Capstone Paper
Erin Perry, LCSW
University of Southern California
Suzanne Dworak-Peck School of Social Work
DSW Program
Dr. Ron Manderscheid
August 2023

©Erin Perry 2023
TABLE OF CONTENTS

I. Executive Summary 1
II. Abstract 6
III. Positionality Statement 7
IV. Problem of Practice and Literature Review 8
V. Conceptual/Theoretical Framework 15
VI. Proposed Solution 17
VII. Methodology 26
VIII. Implementation Plan 29
IX. Conclusions and Implications 32

Ac k n owle d ge m e n ts
A great many people contributed to and supported this doctoral capstone work, for which I will
be forever grateful. I would like to start by thanking my DSW cohort 13 colleagues. Thank you
for your feedback, support, and friendship. Though our expertise and interests are widely varied,
you kept me inspired and motivated over the last three years. Congratulations to each of you.
Thank you also to the professors who shared your knowledge and experience and challenged us
to grow. Thank you especially to Professor Cassandra Fatouros for your relentless support and
guidance, and your inflexibility about page limits. As predicted, learning to write more concisely
turned out to be a very helpful skill during our capstone year.
A big thank you to more colleagues than I can name here who generously offered their time and
expertise to my research. Thank you for your enthusiasm about my pursuit of a DSW, and about
the topic. Knowing you all agree that we need to reexamine how we support kids in crisis and
how we understand trauma gives me hope for the future of the field. A special thank you to
Lauren Dellacava and Samantha Null for enthusiastically agreeing to play a key role.
Thank you to my parents, who never said no to my curiosity about the world, my insatiable thirst
for learning, and my desire to keep growing. Your constant and natural belief that I could do
anything is the reason I am here today. Every girl deserves parents like you.
Thank you to my sisterhood, Jill Johnson, Julie Figueroa and Lori Sokoloski. I don’t know how
an only child got lucky enough to end up with three amazing sisters, but I could not be more
grateful for each of you. Thank you for always cheering me on and believing in me. You are
everything friends should be, and you will be my sisters until the end of time.
A big thank you to my partner, Avram Mack for your unwavering belief in me and everything I
do. Thank you for always seeing the light in me and encouraging me to chase my dreams.
Looking forward to endless adventures and accomplishments together.
This capstone is dedicated to my children, Hannah and PJ. You light up my world. You are more
than I could have ever hoped for and if I did nothing else in my life, I would have been bursting
at the seams with pride just for being your mama. I hope you see this achievement and know that
it means that you too can do anything. Never stop growing.
Finally, this capstone is also dedicated to Lori. My kindred spirit, soul sister, and best friend. I
could never thank Temple University enough for randomly assigning us to the same group that
first day of grad school. Thank you for encouraging me to pursue my doctorate when I first
floated this idea, and for your immediate confidence that I was more than capable. I wish you
were here to celebrate with all of us. I hope that wherever you are, you are proud.
‘Long live the walls we crashed through; I had the time of my life with you’

1

Executive Summary

Prevention and early intervention are at the center of the Grand Challenge: ‘Ensure
Healthy Development for Youth’ (Fong et al, 2018; Perry, 2022). Recognition of behavioral
health conditions and concerns, and access to services as early as possible is imperative to
maximizing healthy development (Landa, 2018; Perry 2022). Achieving this Grand Challenge
requires the utilization of interventions and initiatives that promote positive youth development
and that address the many challenges and risk factors that young people confront on a regular
basis (youth.gov, n.d.; Perry, 2022). Exposure to prolonged adversity and trauma during
childhood is a significant risk factor with health impacts throughout the life course. Without an
appropriate understanding of the role trauma plays in mental health crisis episodes during
childhood and adolescence, young people are at risk of repeated hospitalization and eventual
institutionalization within the mental health system.
Traumatic life experiences during childhood and adolescence are strongly correlated with
serious emotional disturbance and externalizing behaviors in youth (Layne et al, 2014; Perry,
2022). Frequent or sustained high levels of stress, often referred to as “toxic stress” in the
literature, has the potential to cause significant changes to the brain, particularly when
experienced during critical developmental phases (childwelfare.gov, 2015; Perry, 2022). Studies
on the effects of childhood adversity also find that youth demonstrate significant increases in
attachment issues, sexual exploitation, running away from home, criminal activity, suicidality,
and self-injurious behavior with each additional traumatic event experienced during the
developmental years (Layne et al, 2014; Perry, 2022). These behaviors often result in referrals
for crisis mental health evaluation, and ultimately to inpatient psychiatric treatment or long-term
residential treatment settings. This is problematic due to the treatment options and goals in these
2

care settings, which are not attuned to addressing the dysregulated nervous system driving
dangerous behaviors. A greater understanding of the neurobiology of trauma is critical for crisis
mental health staff to appropriately assess, refer and treat a behaviorally active trauma response.
Conceptual Framework and Purpose of Innovation
The TRACI for Kids Curriculum is a six session training series geared towards
improving the consideration of the role of trauma in crisis mental health assessment and the use
of trauma-focused exercises and tools in crisis intervention. Curriculum content was developed
through the lens of contemporary trauma theory and Dr. Judith Herman’s Stages of Trauma
Recovery. Dr. Herman identifies the Three Stages of Trauma Recovery as (1) Establishment of
Safety and Security, (2) Remembrance and Mourning, and (3) Reconnection with Ordinary Life
(Herman, 2022). The focus of the TRACI intervention is on fully completing Herman’s first
phase, Establishment of Safety and Security. This first phase includes the key tasks of resolving
real danger, distinguishing between real and perceived danger, and developing skills in self-
regulation, relaxation, grounding, and containment (Zaleski et at, 2016). Common practice in
mental health crisis assessment is based on the medical model and accordingly, primarily
focused on identifying the presenting behavioral concerns and the least restrictive environment in
which those behaviors can be addressed. As a result, when a patient does identify an abuse
history during a crisis mental health evaluation, the focus often shifts to whether the abuse has
been appropriately reported, with minimal or no exploration of the abuse endured or whether any
specialized treatment had been received to address it. Further, the current model does not provide
the opportunity to obtain the information required to be able to engage in psychoeducation with
youth and their families regarding trauma response, a necessary step of completing the Safety
3

and Stabilization phase, and a missed opportunity to provide tools to support stabilization at
home (Herman, 2022).
The current approach to resolving behaviors in the mental health system has a heavy
focus on containment and control of behaviors. The literature is clear that this is not a solution
that is effective at resolving behaviors that occur as a trauma response and in fact, can cause
significant additional trauma, particularly for those who exhibit externalizing behaviors where
injectable medication and physical restraints are frequently employed during behavioral
outbursts (Hammer et al, 2011). A study of interventions that work to regulate an overtaxed or
sensitive stress response system reveals that many brief interventions in the integrative health
field show the most promise (Ortiz & Sibinga, 2017). Empowering traumatized youth to
understand agitation and related behaviors as a trauma response, and to learn how to self-regulate
when triggered gives them back a sense of control that is critical to establishing safety and
security and preparing survivors for beginning the work of the Remembrance and Mourning
phases through evidence-based trauma therapy, where trauma histories can be more deeply
explored and processed.
A shift of this nature among crisis mental health providers requires application of
Transformative Learning Theory, a framework focused on shifting perspectives to allow for new
learning amongst adult learners (Mezirow, 1997). To that end, sessions in the proposed solution
begin with an emphasis in increasing crisis mental health provider understanding of the role of
neurobiology in behavioral outbursts amongst traumatized youth. This allows for a perspective
shift to occur regarding the ‘why’ behind behaviors, before moving on to provide tangible
interventions that can support stabilization and healing.
Overarching Methodology and Methodological Tools
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Using human centered design as a framework, academic research and community based
participatory research techniques were utilized to conduct the first phase of design thinking,
where clarifying and understanding the problem with empathy are central to the task
(Landry,2020). For this capstone, the primary focus is working to fully understand the role of
trauma in externalizing behaviors amongst youth, and the limitations of inpatient psychiatric
treatment settings in addressing chronic trauma and related symptoms during stays. Additionally,
understanding the barriers to managing trauma response and related behaviors at home and in the
community were explored. Ultimately, the problem was understood as two-fold. First, crisis
mental health providers are lacking in-depth knowledge of the neurobiology of trauma response
that would allow them to understand behavioral challenges in youth differently. Further, even if
crisis mental health evaluators did understand the underlying cause of behavioral outbursts
better, there is an additional need for traumatized youth and their families to be presented with
information on how to regulate the overtaxed nervous system if youth are going to be able to be
successfully supported in the community. Once the problem was well understood, the next steps
of idea generation and prototype building were underway.
To validate that the identified knowledge gap and proposed solution were well matched, a
pilot study was conducted. A focus group at one pediatric emergency department was held in two
steps with social workers in mental health evaluator roles. First, social workers completed a
knowledge survey to assess their current knowledge of trauma response and learning needs.
Later, social workers reviewed the proposed curriculum content and provided feedback. Family
feedback was also sought to ensure brief interventions felt useful and easy to learn and try
implementing at home. Both steps were used to make amendments to the curriculum to ensure
content was best aligned with end user needs. Finally, the proposed curriculum was reviewed
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with mental health system leaders in two counties to explore opportunities for larger scale
implementation.
Project Implementation and Future Action Steps
The TRACI curriculum will be rolled out initially to emergency department social
workers at one pediatric hospital in Montgomery County, PA in Fall 2023. Data collection will
be completed on the rate of re-presentation for psychiatric emergency for families receiving
enhanced mental health evaluation, psychoeducation and brief interventions for regulation and
nervous system stabilization. Additional metrics to be studied are pre and post training
knowledge assessments for training participants. Conversations with children’s mobile crisis
team leadership in the same county have also begun to explore possible implementation in their
agency. Outreach to other county hospitals responsible for youth mental health crisis evaluation
will begin in Summer 2023 to assess interest. Simultaneously, grant, state and county funding
opportunities will be explored that would help offset or cover costs associated with
implementing training in organizations. Opportunities to partner with school districts, first
responders and other child serving roles will be explored as implementation progresses.
Implementation across settings and roles of those supporting children’s mental health
crisis has the greatest chance of changing the culture of hospitalizing traumatized youth for
behavioral concerns in a community. Given the invisible role trauma has in so many child and
adolescent behavioral concerns, the ability to establish the same crisis evaluation framework,
response to behavioral escalations and interventions to support traumatized youth and their
families has the possibility of transforming a community’s response to trauma and shift the
narrative of behavioral concerns in youth in ways that allow children to truly heal and thrive.

6

Abstract
Though the long-term health effects of adversity and trauma are well documented, our
understanding of the impact on children’s physical and mental health is evolving. Developments
in neuroscience demonstrate that experiencing chronic trauma during formative years can have
impacts on the developing brain that can result in externalizing behaviors largely driven by
dysregulation of the body’s stress response system (childwelfare.gov, 2015; Perry, 2022). The
origins of behavioral challenges, however, are easily misunderstood, resulting in the use of
interventions that do not address the core problem of an overtaxed nervous system. Frequent
episodes of behavioral health crisis can then result in chronic institutional placement and an
impaired ability to function in home and community environments over the life span.
Opportunities exist to improve crisis assessment and intervention for traumatized youth,
including the use of brief interventions that support nervous system regulation. Additionally,
providing psychoeducation on the neuroscience of childhood trauma to survivors and caregivers
has the potential to remediate chronic behavioral health crisis episodes. The development of a
trauma responsive crisis assessment and intervention curriculum works to evolve clinical
practice beyond traditional trauma informed care by teaching advancements in neuroscience and
tangible interventions. The Grand Challenge “Healthy Development for Youth’ seeks to reduce
behavioral health problems and address disparities for all youth (Barth et al, 2022). In line with
this goal, use of the curriculum across crisis providers in a community is a scalable intervention
that can evolve crisis mental health systems towards a more holistic model of care.

7

Positionality Statement

Reflecting on positionality is an important aspect of conducting qualitative research. It
requires sensitivity by the researcher to their cultural, political, and social context as an
individual’s ethics, personal integrity, and social values may influence the research process
(Holmes, 2020). As a white person working in healthcare, with access to education and
opportunity, I acknowledge my privilege in having the necessary resources to conduct my
research. It is important to note that I am at a distance from many of the adverse experiences of
those I am going to talk about. My knowledge of the experiences of those facing significant
childhood trauma, racial disparities, and related impacts on access to and quality of healthcare
has primarily come from my professional work, rather than my personal experiences. Having
worked in mental health crisis settings with diverse populations for nearly 20 years, my
observations of the limitations of the current structure of the mental health system and crisis
assessment processes inspire this work. Though my own lived experience with trauma makes me
personally familiar with some of the trauma response concepts discussed in this paper, I
recognize my positionality, personal journey and recovery is shaped by my privilege and access
to resources, and I am cautious to not make assumptions based on my own experiences and
opinions.

8

Problem of Practice and Literature Review
Traumatic life experiences during childhood and adolescence are strongly correlated with
emotional dysregulation and behavioral concerns in youth (Layne et al, 2014; Perry, 2022).
Advancements in neuroscience have revealed that chronic trauma and adversity during childhood
can result in significant impacts to brain development, leading to further behavioral concerns that
may be misunderstood (childwelfare.gov, 2015; Perry, 2022). An inadequate understanding of
and plan for managing trauma related behavioral crisis typically results in an overreliance on
institutional behavioral health treatment settings that hinder the ability of youth to function in
typical family environments and to reach their full potential over the life course. As we enter the
post- COVID 19 pandemic era, concerns regarding youth mental health and the impact of
widespread trauma have never been more prevalent. Data from the Centers for Disease Control
and Prevention (CDC) showed that in 2020, emergency room visits for mental health reasons
increased by 24% for ages 5 to 11 and by 31% for ages 12 to 17 (www.aecf.org). Experts
highlight that seemingly maladaptive, acting out behaviors were helpful coping mechanisms for
some youth in the height of the pandemic crisis (Sweet, 2022). In this landscape, understanding
the role trauma plays in mental health crisis and associated behaviors is more critical than ever.
Addressing this problem is in line with the aims of the Social Work Grand Challenge, ‘Healthy
Development for Youth’, which highlights the importance of prevention, early identification, and
intervention in achieving mental wellness for youth (Fong et al, 2018; Perry, 2022).
Impact of Adversity & Trauma
Well established research on Adverse Childhood Experiences (ACEs) demonstrates
increased risk for long term physical and mental health concerns with each adverse event
experienced (CDC, 2019, Perry, 2022). Though the long-term impact of ACEs on physical and
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mental health is widely reported, there are also significant physical health concerns and
behavioral changes that can occur during the developmental years that receive far less attention
(Perry, 2022). In fact, a study conducted by Dr. Nadine Burke Harris and colleagues found that
children with 4 or more ACEs were 32.6 times as likely to be diagnosed with a learning or
behavioral problem (Burke Harris, 2018; Perry, 2022). Another study following approximately
5,000 youth from birth through age nine found that children with one adverse childhood
experience (ACE) had 2.5 times the odds of demonstrating externalizing behavior to a degree
that warranted professional attention, children with 2 ACEs had 3.4 times the odds, children with
3 ACEs had 4.7 times the odds, and children with 4 or more ACEs had 9.3 times the odds
compared to children who had never experienced any ACEs (Hunt et al, 2017; Perry,
2022). Additional data on the effects of childhood adversity also suggest that following multiple
traumatic events youth demonstrate significant increases in attachment issues, sexual
exploitation, running away from home, criminal activity, suicidality, and self-injurious behavior
(Layne et al, 2014; Perry, 2022). Recognizing the prevalence of ACEs and related potential
detrimental effects is an important step towards understanding the problem and identifying the
correct approach to intervene (Perry, 2022). Understanding the biology of why this occurs is the
next critical component.
Neurobiology of Trauma
To understand the neurological impact of trauma, it is important to recognize the
distinctions between acute, chronic, and complex trauma and the impact of each (Perry, 2022).
Acute trauma occurs from a single event, whereas chronic trauma is repeated and occurs over a
prolonged period, such as with domestic violence and abuse (earlyconnections.mo.gov, n.d.;
Perry, 2022). The activation of the body’s stress response system in response to a singular
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traumatic event is both normal and protective (Burke Harris, 2018; Perry, 2022). Both adrenaline
and cortisol are produced under normal circumstances and help prepare the body for coping with
stressors (NSCDC, 2014; Perry, 2022). When the body’s stress response system is subjected to
prolonged activation due to chronic or frequent stressors, it can disrupt brain development, as
well as increase the risk for stress related disease and cognitive impairments well into adulthood
(Burke Harris, 2018; Perry, 2022). The hippocampus, corpus callosum and cerebellum are all
noted to be of decreased volume in multiple studies of adults who were maltreated during
childhood, which has a significant impact on learning and memory, arousal, emotion, and higher
cognitive abilities, including executive functioning (childwelfare.gov, 2015; Perry, 2022).
Abnormally high cortisol levels can also have negative impacts on learning and energy levels
and are also linked to social skills deficits and externalizing behavior disorders
(childwelfare.gov, 2015; Perry, 2022).
Given the complexity of trauma’s impact on both the psychological and physiological
responses, one can see how traumatized youth are easily misunderstood. Even in the absence of a
formal diagnosis of post-traumatic stress disorder (PTSD), traumatic life experiences are
particularly impactful during developmental years and can be drivers for serious emotional
disturbance and externalizing behaviors in youth. As a result, chronic exposure to trauma and
adversity in children may result in progression through adolescence and often into adulthood
with ongoing struggles in self-regulation and emotion management, even if participating in talk
therapy, receiving medication management, or both (Perry, 2022). If providers are overly
focused on the behaviors exhibited by the youth, and do not spend enough time exploring the
“why” behind the behaviors, therapeutic interventions may not even be targeting the underlying
trauma (Perry, 2022). This concern has been validated by studies involving foster care youth,
11

where available data suggests that outpatient therapy alone does not significantly improve mental
health outcomes for these youth who have experienced chronic stressors (Bellamy et al, 2010;
Perry, 2022). Further, given that behavioral outbursts may be coming from a physiological
reaction based on changes in brain chemistry, therapeutic and behavioral interventions focused
on processing trauma, or the teaching of coping skills is not well connected to the idea that when
triggered, a traumatized brain having a physiological response does not have access to logic and
reasoning capabilities that would allow them easily to pause and consider using those skills in
the crisis moment.
The lack of consensus on how to define trauma response and traumatic events is also
reflected in an ongoing debate regarding whether additional trauma diagnoses or more expansive
criteria for post-traumatic stress disorder are needed in the Diagnostic and Statistical Manual
(DSM), The DSM is used by American mental health professionals for the classification and
diagnosis of mental health conditions and is revised every 5-7 years to reflect new research and
changes in understanding of illness. Advocates propose that the adoption of additional trauma
diagnoses is critical for survivors in order to have their condition appropriately understood and
treated with interventions most appropriate for their symptoms and disease etiology (Maercker,
2021; Carr, 2023).
Trauma experts as far back as Judith Herman in the early 1990’s have been calling for a
differential diagnosis for trauma victims who have suffered chronic or repeated trauma, due to
reports that the clinical presentation for chronic trauma victims may be different. Dr. Herman
first proposed a ‘complex trauma’ diagnosis related to her observations from work with domestic
violence and sexual assault victims (Herman, 2022). Later, Dr. Bessel Van der Kolk, along with
a team of child psychiatry and psychology colleagues, developed the concept of ‘Developmental
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Trauma Disorder’, citing that the impact of chronic trauma during developmental years presents
differently in youth, requiring an alternative to post-traumatic stress disorder to better reflect
observed symptomology for this group (Van der Kolk, 2014). To date, the DSM has not added
any alternative or additional trauma diagnoses, citing a lack of clarity on the necessity, as well as
a lack of agreement for adoption, a critical element of the DSM revision process (Maercker,
2021). Although the International Classification of Diseases version eleven (ICD-11) has added
‘Complex Trauma’, the condition requires individuals meet the criteria for traditional PTSD,
with the addition of three further symptom groups to be classified as complex: emotion
regulation difficulties, relationship difficulties and negative self-concept (Maercker, 2021).
Without agreement on what additional diagnoses or criteria are needed, it is unlikely we will see
changes to the DSM that reflect these varied presentations of trauma response. Ultimately, it may
not matter how we label it, but rather that we know the role trauma plays in clinical presentations
beyond PTSD so as to target the concerns with optimal interventions.
Hospitalization for Trauma-Driven Behaviors
When externalizing behaviors raise safety concerns and a traumatized child appears to
others to be out of control and unable to self-regulate, inpatient psychiatric hospitalization may
be determined necessary (Perry, 2022). Inpatient psychiatric care, however, is intended to be
short term in nature and focused on stabilization, making it unlikely their trauma histories will
be, or perhaps should be, explored in this setting (Perry, 2022). Given the nature of inpatient
mental health treatment, other stabilizing elements of a child’s life, such as home and school
environments and routines, and the concepts of connection and autonomy, are disrupted (Ewers
& Ewers, 2022; Perry, 2022). If trauma cannot be effectively addressed in this environment, one
wonders the value of removing other supports that aid in trauma recovery (Perry, 2022). This
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misunderstanding contributes to a significant societal problem: the institutionalization of
traumatized youth.
When youth continue to struggle maintaining behavioral control and functioning in the
community post-hospitalization, a harmful pattern of frequent psychiatric hospitalization can
occur (Perry, 2022). A policy brief published by The Future of Children reports that 25% of
foster care youth are in hospitals, residential facilities, or other settings at any given time (Laub
& Haskins, 2018; Perry, 2022). This statistic is demonstrative of the prevalence of mental health
disorders amongst maltreated youth, which is reported to be as much as four times as high as the
general population of youth (Bronsard et al, 2016; Gallitto et al, 2017; Perry, 2022). It is also
indicative of the cyclical nature of inpatient psychiatric treatment where externalizing behaviors
are the primary concern and trauma is an underlying factor. Multiple studies identify predictors
of repeat admission. One retrospective review identified that children and adolescents who had a
prior history of psychiatric rehospitalization, lived in a residential treatment facility, had a
childhood sexual abuse history, or had a diagnosis of oppositional/defiant or conduct disorder
were more likely to be readmitted to inpatient psychiatric care within the same year (Chung et al,
2008: Perry, 2022). Another study reviewing psychiatric admission lengths for youth in the
1990s identified that length of stay for organic psychiatric concerns such as psychosis, mood
disorders and depression related intentional self-injuries decreased during this time, while length
of stay for adjustment and behavioral disorders increased (Case et al, 2008; Perry, 2022). These
patterns may suggest that inpatient psychiatric settings are well suited for their original design:
short term stabilization of traditional psychiatric concerns (Perry, 2022). There may be less value
in attempting to hospitalize youth for behavioral concerns that are the result of psychosocial
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factors and traumatization, resulting in prolonged or repeated stays due to lack of improvement
(Perry, 2022).
Lengthy or repeated placement in institutional settings can disrupt other critical elements
of healthy development as well, including the establishment of healthy attachments and
developing a sense of belonging in relationships and community (Mota et al, 2016). This is a
significant concern given the prevalence of repeat admission. Among previously hospitalized
youth, as many as 20% are readmitted within less than one year, and nearly 40% of all youth
presenting for emergency psychiatric evaluation had a history of inpatient psychiatric
hospitalization (Gallagher et al, 2017; Perry, 2022). These findings suggest that not only is this
intervention insufficient for a subset of youth receiving inpatient psychiatric treatment, but
amongst traumatized youth, we must further be concerned that the shuffling in and out of
facilities reinforces negative beliefs victimized youth hold about themselves and their worth,
further diminishing motivation towards positive change (Trivedi, 2020; Perry, 2022).
It is important to acknowledge the disproportionate impact of these concerns on minority
youth (Perry, 2022). It is widely known that racial and ethnic minority groups are
overrepresented in the child welfare system, but there are notable disparities regarding mental
health diagnosis as well. When black or brown youth demonstrate maladaptive coping strategies
to emotional distress, they are diagnosed with substance use disorder or disruptive behavior
conditions such as conduct disorder and oppositional defiant disorder than with anxiety, mood
disorders or ADHD at rates disproportionate to their white peers (Liang et al, 2016; Perry, 2022).
This is particularly concerning given that systemic racism and oppression are chronic stressors
experienced by many black and brown youth, regardless of whether they experience other
traumatic events in their childhood.
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Racial bias may also play a role in the alarmingly high prevalence of prescription of
antipsychotics to youth in foster care. One large multi-state found that almost half of foster care
youth on psychotropic medication received an antipsychotic as part of their care (PolicyLab,
2019; Perry, 2022). Given the low prevalence of psychosis in young children, these numbers
suggest the use of antipsychotics for foster youth is primarily to manage behavioral outbursts due
to its sedating effect (Perry, 2022). The role of racial bias in diagnostics and treatment risks
labeling marginalized youth in ways that further impede upon their development.
Factors Driving Reliance on Hospitalization
Stakeholder interviewees identified insufficient and inconsistent training of mental health
professionals in understanding and treating trauma as a major contributing factor to this problem
(Perry, 2022). Interviews revealed a consensus that many mental health providers have only a
cursory knowledge of trauma with a focus on post-traumatic stress disorder (PTSD) and trauma
informed care practices. However, this research also highlighted the lack of consistent definition
of trauma informed care or any universal certification in trauma informed programming or
approaches as a barrier to these concepts being credible (Perry, 2022). In other words, outside of
specific evidence-based practice interventions like trauma focused cognitive behavioral therapy
(TF-CBT) or eye movement desensitization and reprocessing (EMDR), agencies or providers
saying there are “trauma informed” or “trauma aware” in their practices is minimally meaningful
(Perry, 2022). It was also noted that many mental health providers lack a robust understanding of
the impacts of trauma on brain development and how trauma histories may be linked to
significant behaviors and conduct issues, making it less likely for patient facing providers to
approach behavioral escalations in ways that are truly trauma aware and well matched to
deescalating behavioral concerns linked to a traumatic response (Perry, 2022). This is significant
16

given research that indicates that the presence of appropriate or adaptive emotion regulation is
noted to be a critical skill and having a distinctly mediating relationship between cumulative
childhood trauma and behavioral health concerns in children (Haselgruber et al, 2020; Perry,
2022). If providers are not well equipped to understand the origin of dysregulation in traumatized
youth and intervene accordingly, patient outcomes may be negatively impacted.
Additionally, stakeholder interviews indicated that teaching youth directly about trauma
responses seems to be lacking from current treatment interventions, and perhaps could play an
important role in feeling understood, reducing shame and being open to trying healing practices
(Perry, 2022). Finally, the reluctance to talk about the uncomfortable topic of trauma due to
existing social norms was noted to be potentially holding the problem in place by getting in the
way of widespread understanding of the problem and adoption of practices that may mitigate
related issues (Perry, 2022). Negative perceptions of the legitimacy of integrated health
interventions and a lack of knowledge of the data demonstrating their critical role in stabilizing
the nervous system also were noted to contribute to a lack of adoption of meaningful and
evidence-based interventions that work to address the neurobiology of trauma (Perry, 2022).
Theoretical/Conceptual Framework
The proposed solution makes use of the existing system design and focuses on
maximizing the efficacy of the system by increasing knowledge of crisis mental health providers
on the neuroscience behind trauma response and adding learning on targeted interventions to
address the physiological impacts of developmental trauma as a tool to support stabilization of
mental health crisis events. Use of the concepts of the Triphasic Model by contemporary trauma
theorist Judith Herman offers clear steps for how one might intervene to appropriately address
trauma in crisis settings.
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Safety and stabilization, as noted above, are identified as necessary first steps of trauma
recovery that must occur before moving on to further exploring and processing the trauma and
working to repair healthy attachment and connection. The Safety and Stabilization phase begins
first with insuring real any real danger is resolved. Following this, survivors can move on to
begin work on distinguishing between real and perceived danger, as well as developing skills in
self-regulation, relaxation, grounding, and containment (Zaleski et at, 2016). These key activities
are where the gap is in the current system of care that a proposed solution must fill to keep youth
out of crisis and inpatient psychiatric hospitals and able to move on to the next two areas of the
Trauma Recovery model in an outpatient trauma therapy setting (Zaleski et al, 2016).
Specifically, the concept of distinguishing between real and perceived danger is not well
understood by many crisis mental health clinicians, as it requires a strong understanding of the
neurobiology of trauma, and the idea that a sensitized nervous system may over-respond to
minor stressors, perceiving true danger where it doesn’t exist. Behavioral activation to perceived
danger can be easily mistaken for other mental health concerns, such as mood lability, poor
impulse control, or general defiance. The fact that this is not well understood is a major
contributing factor to widespread beliefs that youth who act out aggressively are most often in
control of their choices and willfully acting. Understanding behaviors as a part of an involuntary
fear and self-preserving nervous system response is a significant paradigm shift that must be
understood first by mental health providers if they are to provide this education to youth and
families.
Once this perspective change has occurred, a natural transition towards learning how to
regulate a dysregulated nervous system can occur. This would include easy to implement brief
integrated health interventions, like box breathing and progressive muscle relaxation (PMR), as
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well as psychoeducation about wellness interventions, including sleep hygiene, exposure to
nature, the importance of play and other regulating lifestyle changes. As Dr. Herman explains,
we cannot delve into our traumatic memories in hopes of moving forward in a positive way
towards healing if the brain and body are still responding as though they are under siege
(Herman, 2022).
While even survivors well along their healing journey may occasionally become
activated by memories or sensations associated with traumatic memories, understanding that
response and having the tools to respond when activated are critical to being able to participate in
longer term therapies to process trauma histories in a present and meaningful way, as well as to
rebuilding trust and connection with others. Given that the current crisis mental health system
does not incorporate these ideas into mental health assessment and intervention, it is easy to see
why even repeated stays in acute inpatient psychiatric settings are minimally helpful, as they are
not targeting the right problem. Teaching providers this important information so that they may
approach care with traumatized youth differently is a potentially transformative intervention for
youth, as well as families who are desperately searching for an understanding of how to support
their child at home.
Proposed Solution
An appropriate and novel intervention towards preventing cycles of psychiatric
hospitalization for externalizing behaviors borne out of chronic trauma needs to be inclusive of
psychoeducational material for both caregivers and children focused on understanding the
connection between trauma and behavioral challenges in children and employing integrative
health interventions known to target the physiological impacts of trauma. These interventions
would need to be available quickly in order to support stabilization while longer term services to
19

resolve underlying trauma are identified. These targets make crisis mental health workers ideal
candidates to intervene and interrupt the cycle of crisis. This kind of intervention can only be
successfully employed as an alternative to psychiatric hospitalization, however, if crisis mental
health clinicians are offered specialized training on understanding childhood trauma and
incorporating trauma history into crisis mental health assessments and short-term crisis
interventions. Opportunities exist to improve the crisis evaluation and intervention process to
better identify the role of trauma in behaviors and the families who would most benefit from the
psychoeducation and brief stabilization exercises described above.
These goals can be met through the development of a training curriculum for children’s
crisis mental health workers, aimed at providing an enhanced understanding of and ability to
consider the potential role of trauma in crisis mental health evaluation. The curriculum should
also include psychoeducation on trauma and targeted integrated health interventions that can be
provided to patients and families to improve their understanding of the role of trauma in
behavioral concerns and to empower them with more effective ways in which to respond to
behaviors associated with trauma response.
Pilot Activities
To ensure effectiveness of products developed, a pilot study was held with 10 Emergency
Department Social Workers at a pediatric hospital in the Philadelphia suburbs. Social Workers in
this role serve as mental health evaluators for youth presenting with a chief complaint of
behavioral health crisis. This group began by receiving a knowledge assessment on childhood
trauma to objectively measure their current understanding of key items within the intended
curriculum content. Survey results (located in Appendix A) demonstrated anticipated learning
needs around advanced trauma concepts such as interoception, attunement, and epigenetics. The
20

survey also identified an inconsistent understanding of trauma informed care concepts, which is
in line with stakeholder feedback indicating that a lack of consistent definition of trauma
informed care leads to a lack of clarity around what the concept means and how to apply it.
Further, respondents indicated that even when it is evident that behaviors are related to trauma
history, they are not clear how to best address this for those presenting in behavioral crisis.
Once the curriculum outline was updated to best meet the learning needs identified in the
survey, group members participated in an orientation to a proposed training curriculum as the
final step in the preparation phase. The group was provided an opportunity to ask questions about
and provide feedback on the curriculum. The goal of this exercise was to obtain end user
feedback to determine whether the intended content is well suited to expand their knowledge
base on trauma informed crisis assessment and their ability to teach patients and families about
the impact of childhood trauma and targeted wellness interventions to help with stabilization
when patients become activated. Focus group participants validated that the planned curriculum
was well aligned with their self-identified learning needs and indicated an interest in having
access to intended training content.
Theory of Change
To create systemic change in a particular community’s response to the
management of escalating behavioral concerns born out of traumatic life events, a phased
approach must be employed. This is important as it allows both users and beneficiaries to receive
the training and education required to initiate a system wide shift in thinking around
understanding behaviors and childhood trauma, their role in mental health crisis episodes and
how best to intervene. Use of the concepts of Transformative Learning Theory provides an
optimal tool to facilitate this kind of shift in thinking.
21

Transformative learning is described as “the process of effecting change in a frame of
reference (Mezirow, 1997). Adult learners have acquired a body of experience that shapes their
perspectives and creates a lens through which they process information. This can include
concepts, values, feelings, and conditioned responses that all contribute to the frame of reference
through which we experience the world (Mezirow, 1997). Once developed, individuals tend to
reject information that doesn’t fit their frame of reference. An existing frame of reference can be
transformed however through critical reflection on the assumptions upon which interpretations,
beliefs and points of view are based (Mezirow, 1997). Once a new understanding of a belief or
situation is developed, learners move towards exploring options for new behavior by acquiring
new knowledge and working to apply it (Kitchenham, 2008).
Applying Transformative Learning Theory towards the goal of changing the way that
mental health professionals understand and interact with traumatized youth, one must begin with
working to change the frame of reference through which they understand a young person’s
behaviors. Teaching the neuroscience of trauma allows individuals to understand youth
behaviors differently and opens the door to considering other options for best supporting
patients. Once the frame of reference shift has happened, learners are more apt to be open to
learning different intervention tools and techniques that can be utilized, because they now
understand such tools as more appropriate and effective. A detailed description of steps to be
taken can be found in the attached logic model (Appendix B).
Solution Landscape
There are several well-known treatment modalities specifically geared towards
addressing trauma. Trauma-focused cognitive behavioral therapy (TF-CBT) is considered the
gold standard in treating trauma amongst children (Perry, 2022). Still, some studies demonstrate
22

that CBT interventions have been shown most effective in addressing internalizing behaviors and
is less effective towards improving externalizing behaviors, supporting earlier presented data that
some types of traumas and symptomology are less responsive to talk therapy interventions alone
(Lindebø, 2020; Perry, 2022).
Several other trauma interventions for children are designed for both the parent or
caregiver and the child to engage in together due to the importance of attachment in trauma
recovery (Perry, 2022). The KEEP intervention is a 16-week course is typically offered in group
settings with material centered in concepts from parent management training and designed to
support foster parents in understanding behavior challenges and learning parenting strategies to
intervene (Price et al, 2012; Perry, 2022). Another approach, Child–parent psychotherapy (CPP),
was developed to improve psychological and relational functioning in trauma-exposed young
children and their primary caregivers and shows promise as an early intervention approach and
towards the development of healthy attachment (Hagan et al, 2017; Perry, 2022). Still, none of
the aforementioned interventions specifically address the neurological changes and physiological
responses that result from trauma experienced during the developmental years (Perry, 2022).
A growing body of research suggests that integrative health treatments may increase
brain plasticity, allowing targeted behavioral interventions to redirect brain and body functions,
and ultimately behavior, in healthier directions (McEwen, 2017; Perry, 2022). There are a few
examples of how integrative health might be used to assist in healing childhood trauma thus far.
Mindfulness Based Stress Reduction (MBSR) is an 8-week evidence-based therapy intervention
originally designed for stress management that has since been adapted for the treatment of a
variety of illnesses, including depression, anxiety, and PTSD (Niazi, 2011; Perry, 2022). Though
studies on the effectiveness of mindfulness interventions with child and adolescent trauma
23

victims while still in their youth remains limited, some available data does demonstrate that
mindfulness interventions improve mental, behavioral, and physical outcomes (Ortiz & Sibinga,
2017; Perry, 2022).
A few emerging interventions combine several modalities to provide a more
comprehensive approach. The Center for Youth Wellness (CYW) in San Francisco is a pediatric
health center that uses ACEs screening to identify at risk youth, and to understand how trauma
and toxic stress may be influencing behavioral or physical health concerns youth present with
(Burke Harris, 2018; Perry, 2022). The CYW has a child psychologist on staff who provides
child-parent psychotherapy and wellness interventions for individuals identified as high risk
(Burke Harris, 2018; Perry 2022). Social workers and pediatricians provide psychoeducation on
the importance of wellness to many more families (Burke Harris, 2018; Perry, 2022). The
Vermont Family Based Approach also leverages the primary care health system to offer family
wellness coaching to all, focused family coaching to children and families screened and
identified to be at risk, and family based therapeutic intervention for youth and families deemed
to be exhibiting signs of poor emotional or behavioral regulation currently (Hudziak, 2022;
Perry, 2022). Both approaches emphasize the idea that brain health is critical to all health,
including emotional and behavioral health, and that there are several key wellness activities that
research supports improve the overall health of the traumatized brain: sleep, nutrition,
mindfulness, exercise, healthy relationships, and music (Burke Harris, 2018; Hudziak, 2022;
Perry, 2022).
A review of the above interventions demonstrates one of the key issues holding the
problem in place. These interventions require that youth maintain a level of stability that allows
them to participate in outpatient therapeutic services. Youth who struggle to maintain that
24

stability and cycle in and out of crisis and inpatient psychiatric settings may never be able to
complete a course of TF-CBT or other therapies that are intended for outpatient settings (Perry,
2022). This may also highlight the disconnect between therapies focused on cognitive processing
of the trauma endured and newer neuroscience that tells us that physiological impacts of trauma
require a different approach, and one that can be accessed when a survivor is actively in crisis
(Perry, 2022).
Of note, there have been increased efforts towards psychoeducation on childhood trauma
in recent years. Through the National Child Traumatic Stress Initiative, the National Child
Traumatic Stress Network (NCTSN), in partnership with the Substance Abuse and Mental
Health Services Administration (SAMHSA) and the Administration for Children and Families
(ACF) has developed print and video materials for parents/caregivers, educators, and healthcare
professionals to support their understanding of the impact of childhood trauma in school and
community settings (SAMHSA.gov, n.d.). These materials are accessible on the SAMSHA and
NCTSN websites and while this is a helpful tool to introduce broad strokes trauma concepts,
there is further room to expand the knowledge of professionals working with traumatized youth
that would equip them with practical skills that support de-escalation in a crisis moment. A full
review of the solution landscape is included in Appendix C.
Prototype Description
The Trauma Responsive Assessment and Crisis Intervention (TRACI) for Kids
Curriculum is comprised of six modules designed to provide an in depth understanding of trauma
and trauma response to crisis mental health professionals, as well as teach practical ways to use
this new knowledge during the crisis evaluation and brief intervention processes. Though the
intent is to decrease the need for inpatient psychiatric stays over time, these modules are also
25

very appropriate for training of staff in acute psychiatric settings towards the goal of improving
management of behavioral outbursts and equipping youth and families with the skills to remain
in the community safely upon discharge home.
The program features the following six topic areas in two parts:

Part 1 Foundational Trauma Concepts
Unit One History and Evolution of Childhood
Trauma and Traumatic Stress
Unit Two Understanding Childhood Trauma
and Behaviors
Unit Three Assessing for Trauma in Crisis
Mental Health Evaluation
Part 2 Interventions for Behavior Change
Unit Four Understanding Nervous System
Regulation
Unit Five Integrative Health
Unit Six Psychoeducation for Patients and
Families

Each unit is approximately one hour long and can be delivered independently or in
tandem with other units, depending on the preference of the training organizer and recipient
group. All six hours of training content meet criteria for continuing education credits for licensed
clinical social workers, professional counselors, marriage and family therapists and
psychologists. Units 2 and 5 are appropriate to be delivered as stand-alone products for other
roles in crisis mental health settings, such as psychiatric nursing and psychiatric technician roles
and non-mental health professionals, such as law enforcement and educators, who interface with
children in crisis but do not have an evaluating or treating role. Upon request, recommendations
for other combinations of units and content can be provided to best tailor content to the roles of
participants.
26

TRACI curriculum content is in line with the teachings of the National Child Traumatic
Stress Initiative. NCTSN and SAMHSA materials can be used in tandem with the TRACI
curriculum, with its live delivery format providing additional opportunity for active review of
case examples, as well as discussion of real scenarios faced by educators, mental health
professionals and other training attendees. Additionally, the detail provided on the neurobiology
of trauma in the TRACI curriculum provides further depth of understanding of behavioral
challenges towards the goal of increasing empathic response. A full curriculum outline, program
fact sheet and sample modules can be found Appendix D for a more detailed view. Curriculum
content has been developed in partnership with community stakeholders and content was tested
with one team of pediatric emergency mental health evaluators to ensure alignment of content
with learning needs.
By using transformative learning practices to shift the shared mental model of crisis
mental health professionals, the curriculum works to address the root causes of externalizing
behaviors more effectively in traumatized youth. In doing so, cycles of institutionalization can be
broken, disparities reduced, and mental health outcomes improved, making this solution well in
line with the goals of the Grand Challenge ‘Healthy Development for Youth’, with its focus on
early intervention to improve mental health outcomes for youth (Fong et al, 2018; Perry, 2022).
Following implementation, participating health systems and agencies can consider
monitoring a number of metrics to evaluate the program’s effectiveness, including representation
rates to crisis evaluation centers for youth having received the intervention, restraint episode
volumes, and staff injury rates due to patient behavioral events in crisis and acute care settings,
as a team’s ability to deescalate traumatized youth should increase once their interventions are
more appropriate for the root cause of behaviors. These metrics are all demonstrative of whether
27

a full shift in perspective has occurred that allows staff to not only complete crisis assessments
differently, but to also understand and respond to behavioral escalations with an improved
understanding and skill that allows for more therapeutic and safer intervention.

M e thod ology
Using the principles of human centered design, the approach taken in this capstone was to
take a deep dive into understanding people and their context (interaction-design.org, n.d.). In this
case, that meant understanding the target patient population, and the treatment providers in the
crisis mental health system who care for them. Rather than focusing on the concerning behaviors
of patients, understanding the root of the problem proved critical to identifying an innovative and
meaningful solution. Further, human centered design acknowledges that everything is a complex
system with many interconnected parts (interaction-design.org). Considering the person in
environment and the complexities and limitations of the mental health system are critical to
developing an appropriate solution. By continuing to prototype and refine the final product with
feedback from key stakeholders and end users, the solution could be tailored for maximum
impact.
The design criteria developed to guide this process is available in Appendix E. Through
academic and community based participatory research, the design goal of identifying a different
crisis assessment and intervention pathway for traumatized youth was identified. The design
required components to evolve crisis provider approach, as well as enhancing patient and family
knowledge and skills to meet all of the identified needs. Further, ensuring that information and
skills to be taught to families were low difficulty and high impact were important given that
28

when families are in crisis, they need tangible interventions quickly. The design also needed to
consider the constraints of crisis-based interactions, where time to complete assessment and
connection to next steps is very brief. Considering how to spread this module through a crisis
mental health system in a community felt important for continuity of care, which is often lacking
in crisis settings.
Though other trauma trainings are available for crisis based behavioral health settings,
none of them include this combination of material or depth. Many behavioral health
organizations consider their care trauma-informed and provide some kind of trauma informed
care (TIC) curriculum or training to their staff. As previously mentioned, there is no one
definition of trauma informed care nor standardized training for what it entails. These training
courses are generally focused on the conceptual level and do not provide tangible skills for
understanding or managing patient behavioral escalations. Behavioral health crisis settings also
routinely offer crisis intervention and de-escalation training. These curricula generally have two
components. First, teaching verbal de-escalation skills to be used with patient’s experiencing
behavioral escalation and coupling this with training on safer strategies for physical intervention
when required. These curricula typically have a greater emphasis on teaching safe physical holds
than on understanding behaviors and de-escalation training. The proposed capstone solution
therefore fills a need to train staff in crisis behavioral health settings towards the goal of deeply
understanding behaviors, which requires coverage of neuroscience that is lacking in these other
curricula, so that staff can be better equipped to avoid the need for physical intervention
altogether. Further, none of these curricula provide training on tangible interventions that can be
taught to patients and families returning to the home to keep them out of future crisis episodes.
As noted in the solution landscape, all of the evidence-based trauma treatment interventions are
29

designed for outpatient or community work, and thus require a reasonable amount of stability on
the part of the youth to participate. The proposed solution takes a novel approach to applying
evidence-based integrative health interventions in crisis settings to support stabilization that
would allow youth to fully engage in outpatient treatments where trauma histories can be further
processed and explored.
Successful implementation will involve improved skills and confidence of crisis
intervention staff. Over time, a decrease in crisis representations, physical restraints and staff
injury would also be able to be tracked. Change over time across the latter would demonstrate a
true shift in the culture of an agency towards being not just trauma-informed, but trauma-
responsive. Development of a product website and social media platforms will be essential to
sharing and spreading important information on the neuroscience of trauma on an ongoing basis
to reach a broad community audience and offer ways for those who have completed training to
stay engaged with key concepts and ideas.
Stakeholder feedback has been critical to the development of this product and will
continue to be essential as implementation begins. Ongoing feedback from crisis staff and
leadership will be solicited, as will feedback from patients and families who have received the
intervention so that adjustments can be made as indicated. This intervention is only successful if
it improves understanding, connection and stabilization and feedback from all involved will be
critical to determining if this is the case.
One of the program’s strengths is its ability to be adapted for the receiving audience and
delivered anywhere, keeping the financial impact moderate at agencies who choose to use the
product. Costs for agencies administering are trainer’s time and print materials. As described
below, implementation will be done in a phased approach. In the first year, a total of 4 training
30

sites would be targeted for completion of the 9 total sites in the identified county of
implementation. Though the initial plan is focused on one Pennsylvania county, stakeholders in
other counties will be engaged to share information and gauge interest towards the goal of
scaling over time.

Implementation Plan
Using the EPIS framework to guide the innovation and implementation process, the
process began with exploration of the existing landscape within which this innovation is intended
to be implemented. Currently, much attention is being given to the youth mental health crisis,
including additional state and government funding to programs that support youth wellness,
particularly with the effects of the pandemic years the staggering increases in youth mental
health crisis in mind. The culture and climate amongst crisis mental health responders and
workers is ripe for additional support as well. With many crisis workers voicing overwhelm and
burn out, stakeholders are voicing the need to identify new supportive interventions to alleviate
some of the burden at this entry way into the mental health system, and to better equip staff with
tools to manage levels of acuity and complexity that have increased significantly.
This may open the door for agencies to allocate dedicated funding, or to explore grant
opportunities that could support implementation at either a particular organization or across an
entire county mental health system. Additionally, the county of initial implementation has just
completed a needs assessment on mental health crisis services and findings are forthcoming. The
recommendations made in this assessment may also allow for additional funding to be allocated
at the county level to cover the expense of the program.
31

A per trainee cost of $325 was set for the full 6-hour course to cover trainer time,
knowledge, and materials. Expenses for the business during the first year primarily include
professional development, technology, and marketing. With an average group size of 12
participants, this yields a $3600 average cost per training for receiving agencies. With a projected
4 trainings provided in the first year and the low overhead despite start up costs, this results in a
$6850 profit in year one to be used to compensate for the trainer’s time, with residual amount
placed back into the business. In subsequent years, additional trainers may need to be employed
as contractors to assist with delivering the training. Following the first year, the possibility of a
train the trainer option will be explored to support sustainability and fidelity to the model at
agencies over time. A full line-item budget for year one of the operations can be found in
Appendix F and implementation action plan in Appendix G.
Once the full curriculum is complete, the implementation phase can begin. Formal
training and related tools will be provided to the pilot group of social workers. Social workers
completing this pilot activity will be given and pre and post-tests on their knowledge of
childhood trauma, and two follow up focus groups will occur at two and six months post training
to receive feedback on the utility of the interventions in their day to day practice, any gaps they
have identified in the training content, and to discuss any feedback received from families on
their learning of the brief stabilization exercises.
Finally, upon funding streams being identified, the sustainment phase can begin, and the
training can be made available to all clinicians working in crisis mental health roles across the
county. This will include additional emergency department mental health evaluators and the
county mobile crisis response team. The ability to train providers across all county-based crisis
mental health evaluation roles will work to increase consistency of evaluation outcomes as well
32

as create a shared mental model so that providers are able to build off one another’s interventions
over time, creating maximum progress towards stabilization of the patient’s symptoms and
ability to stay out of crisis settings.
Challenges & Limitations
It should be noted that the solution discussed does assume a relative level of safety for
youth to be effective. Crisis mental health evaluators tasked with assessing the types and severity
of trauma endured are also responsible for assessing for any acute safety concerns, and before
any other treatment intervention can be employed, making relevant child welfare reports and/or
notifying any other necessary authorities. Still, crisis mental health evaluators do not have
control over the outcomes of child welfare investigations, and it remains possible that children
who score high on trauma assessments may continue to live in an environment where trauma is
ongoing. For the purposes of evaluating this intervention, only youth who do not require child
welfare or police referral at the time of assessment will be included in data collection and are
recommended for the model. Further, it is important to acknowledge that some youth live in
settings rife with trauma due to the effects of systemic racism, poverty and community violence.
For these youth, and their families, regardless of the additional information and skills provided to
understand and cope with trauma, these interventions cannot eliminate the traumatic stressors
that exist. There is value, however, in raising awareness of the health impacts of their lived
experiences so that individuals may be better equipped to manage the effects towards the goal of
minimizing impact.
The proposed implementation plan does require buy in from multiple institutions and
system leaders. This writer’s employment at the initial pilot site and pre-existing working
relationships with many of the agencies required makes this implementation plan plausible. If
33

successful there is room to adapt the curriculum for other stakeholders who play a supporting
role in children’s mental health, including educators. This plan would also be easily replicable
for expansion to other community mental health systems by contracting to offer the training
directly, or by offering train the trainer certification opportunities. The latter may be required to
maintain fidelity to the model at sites over time as staff turnover occurs.
Ethical Considerations & Application of Design Justice Principles
It is important to acknowledge both the importance of this work and the unique
challenges that will exist when applying this solution in settings where racial justice issues and
systemic racism play a role in the chronic trauma endured by youth and their families. Though
the pilot is taking place in a suburban county, the county is vast and there is a wide range of
socioeconomic status and life experience throughout. Design justice principles were utilized in
the development of this intervention, which aims to acknowledge disparities and the impact of
lived experiences. Though this solution alone cannot change the lived experiences of those who
are oppressed, it seeks to bring to light the role of systemic oppression in behavioral health crisis
and remove blame from youth and families, instead empowering them with a deeper
understanding of the physiological impact of what is endured and how to cope, in hopes of
creating opportunity for change at individual, family, and systemic levels. Further, creating
greater understanding of the impact of lived experiences for staff in behavioral health crisis
settings is hoped to reduce stigma and disparities in health care delivery.
Conclusion and Implications
This intervention provides a novel approach to the children’s crisis mental health
assessment process and short-term crisis intervention services. In the current solution landscape,
34

addressing childhood trauma is largely reserved for interventions in the outpatient treatment
service arena. This may be because current trauma specific modalities are heavily reliant on talk
therapy and the use of trauma processing narratives to address developmental trauma. This is
problematic in that the available options all require a high level of clinical stability, which
contributes to the institutionalization of childhood trauma as youth who cannot stay out of crisis
can never access these interventions and are instead frequently hospitalized. Further, if
psychiatric hospitals are also poorly equipped to fully understand and address the role of trauma
in externalizing behaviors, hospitalizations are prone to being unsuccessful and, in many cases,
additionally traumatic due to use of restraints and medications to control behavioral outbursts.
The proposed interventions are not intended to replace any existing services or training
within the system of care, but rather to supplement and fill the current gap. Psychoeducation on
trauma response and integrated health interventions for youth and families in crisis are meant to
help achieve the stability required to remain out of the hospital and able to participate in longer
term evidence-based treatment, including trauma focused cognitive behavioral therapy (TF-CBT)
or child parent psychotherapy (CPP).
Perhaps most importantly, the need to raise community awareness and grow provider
competency in the neurobiology of trauma is critical to radically changing the way we
understand the effects of trauma, and to the care provided to survivors. When many of the
previously inexplicable reactions and responses associated with significant trauma now have
rational, science-based explanations, there is an opportunity to shift the narrative away from
blaming individuals for maladaptive coping strategies that were critical to their survival at
another time. Additionally, having a greater understanding of the ‘why’ behind behaviors will
help reduce shame for traumatized youth and increase understanding between the child and
35

caregiver, and between the family and crisis professionals. Empowering youth trauma survivors
and their families with tools that help regulate the nervous system gives them agency to move
forward in far better control of their healing and the opportunity to develop into young adults at
their full potential.

36

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APPENDIX A: CHILDHOOD TRAUMA KNOWLEDGE SURVEY PILOT RESULTS

APPENDIX A: CHILDHOOD TRAUMA KNOWLEDGE SURVEY PILOT RESULTS

APPENDIX A: CHILDHOOD TRAUMA KNOWLEDGE SURVEY PILOT RESULTS

APPENDIX A: CHILDHOOD TRAUMA KNOWLEDGE SURVEY PILOT RESULTS

APPENDIX A: CHILDHOOD TRAUMA KNOWLEDGE SURVEY PILOT RESULTS

APPENDIX A: CHILDHOOD TRAUMA KNOWLEDGE SURVEY PILOT RESULTS

APPENDIX A: CHILDHOOD TRAUMA KNOWLEDGE SURVEY PILOT RESULTS

APPENDIX A: CHILDHOOD TRAUMA KNOWLEDGE SURVEY PILOT RESULTS

APPENDIX B: LOGIC MODEL
Inputs Outputs Outcomes (short/med/long
term goals)
Phase 1: Development of
training curriculum for
enhanced trauma assessment
& psychoeducation in crisis
mental health evaluation.
-Pilot study of curriculum
content with end users
Phase 2: Pilot training and
enhanced crisis mental health
evaluation with Emergency
Department Social Workers
in one Montgomery County
Emergency Department.
Phase 3: Expand training to
all county mental health
evaluators in child serving
settings on inclusion of
childhood trauma in crisis
evaluation process.

Phase 1:
-Training curriculum
-Pilot study and knowledge
testing with 12 Emergency
Department Social Workers
Phase 2: -Training of 12
Emergency Department
Social Workers
-Data collection post training
Phase 3:
Training of all emergency
mental health evaluators in
Montgomery County, PA-
100+ staff members across
multiple institutions
Short Term: Development of
a training that equips Crisis
MH evaluators to identify the
role of trauma more
effectively in behavioral
crisis as evidenced by
knowledge assessment results
and draft curriculum
feedback.
Medium Term:
Children/families receiving
enhanced trauma crisis
assessment &
psychoeducation will
experience and will
experience greater success
managing moments of
behavioral health escalation
at home as demonstrated by
fewer MH crisis visits and
inpatient psychiatric
hospitalizations.
Long Term: County mental
health system will move to
unified trauma focused crisis
intervention model, resulting
in fewer MH crisis visits and
mobile crisis calls system
wide.

APPENDIX C: SOLUTION LANDSCAPE MATRIX
Solution #1 Solution #2 Solution #3 Solution #4 Solution #5 Solution #6 Solution #7 Solution #8
Description
of Solution
Trauma
Focused
Cognitive
Behavioral
Therapy
Child Parent
Psychotherapy
KEEP
Fostering
Mindfulness
Based Stress
Reduction
Center for
Youth
Wellness
Vermont Family
Based Approach
Behavior
Management
Training
Programs
(Crisis
Prevention
Institute (CPI)
& Handle
with Care)
Sanctuary
Model Training
Feature 1 Hybrid
treatment
model
utilizing
both
cognitive
behavioral
and social
learning
theory
principles
Therapy
intervention
for young
children and
parents with
focus on safe
behavior, limit
setting,
establishing
appropriate
attachment
and child-
parent roles
Therapy
intervention
for foster and
kinship
parents with a
foster child in
the home.
Designed to
help with
understanding
behaviors and
parenting
strategies.
Secular
program using
a combination
of
mindfulness
meditation,
body
awareness,
yoga and
exploration of
patterns of
thinking,
feeling,
behavior and
actions.
Routine
trauma
screening is
conducted in
primary care
to identify at
risk or
affected
youth.
Services
include
wellness
coaching for
all and
therapy for
some.
Families
screened in
primary care
and assigned
wellness
coaching, family
focused coach,
or family-based
psychiatrist
depending on
risk level.
Training
programs
teaching
verbal de-
escalation
and physical
restraint or
“hold
techniques
for escalated
patients.
Training and
consultation
services
designed to
transform the
culture of an
organization to
trauma
informed and
healing
focused.
Feature 2 Provided in
outpatient
therapy
settings
Provided in
outpatient
therapy
settings
Provided in
outpatient
setting via
group
sessions
Provided in
outpatient
setting via
group
sessions
Provided in
pediatric
medical
home
Provided in
pediatric
medical home
Used most
commonly in
institutional
care settings
such as
behavioral
health or
medical
Not a textbook
or manualized
protocol, but
an ‘organic
process’ that
happens over
time. Full
implementation

APPENDIX C: SOLUTION LANDSCAPE MATRIX
hospitals,
residential
treatment
facilities and
partial
hospital
programs.
plan and
certification
takes three
years.
Feature 3 Duration of
treatment
is typically
4-6 months
Duration of
treatment is
typically 10-12
months
Duration of
program is 16
weeks
Duration of
program is 8
weeks
Services are
connected to
routine care.
Outpatient
therapy
length is
decided by
provider.
Services are
connected to
routine care.
Psychiatry and
Family Focused
Coaching
duration at
provider
discretion.
Typically
provided to
all staff who
work in
pati ent facing
roles in the
above
settings.
First phase is 5-
day intensive
leadership
training ending
with directions
about next
steps of
implementing
at organization.
Feature 4 Session
length is
approx. 1
hour each
Session length
is approx. 1
hour each
Sessions are
90 min each
Weekly
sessions are
2.5 hours with
one full day
retreat
Trauma
screenings
are given to
all youth
seen in
practice via
the
expanded
ACES
assessment
created at
CYW.
All
youth/families
in practice
receive wellness
psychoeducation
designed to
improve
population
health.
Training
occurs over
1-2 days with
certification
at
completion.
Re-
certification
is required
annually.
Content is
focused on
theoretical
framework,
creating shared
language and
tools to create
systemic
change,
focused on care
team meetings
and planning.
Feature 5 May
temporarily
worsen
symptoms
and thus
requires
Intended for
children ages
0-6 who have
at least some
memory of
Intended for
children ages
5-12.
Adaptation
for older
Primarily used
with adults.
Research on
efficacy with
children/teens
is limited.
Psychologists
see youth in
need of
therapy.
Social
workers and
Program intends
to shift the focus
of service
delivery from
individual to
family level as
Skills can be
used with
any age
group.
Training also
includes
Full
implementation
may be cost
prohibitive to
some agencies,
with the 5-day

APPENDIX C: SOLUTION LANDSCAPE MATRIX
some
amount of
distress
tolerance
on part of
patient
trauma
endured.
teens has
been created.
pediatricians
provide
wellness
coaching and
education on
topics like
sleep,
nutrition,
activity as
important
tools for
regulation.
family is
influential to
health
promotion.
safety
techniques
for staff
safety.
leadership
training charge
of $3000 per
person.
Additional costs
for next two
levels of staff
training apply.
Feature 6 Evidence-
based
treatment
Evidence-
based
treatment
Evidence-
based
treatment
Evidence-
based
treatment
Evidence-
informed
care
Evidence-
informed care
Not evidence
based. Not a
treatment
intervention.
Evidence
informed. Not a
treatment
intervention.

Prototype Curriculum
1
st
Edition
April 2023

Table of Contents

I. Introduction
II. Curriculum
a. Course Content (Units 1, 2, 3)
b. Course Visuals (Units 1, 2)
III. Appendices
a. Knowledge Survey
b. Findings from Knowledge Survey Pilot
c. PEARLS Trauma Screening Tool

I.Introduction
Program Description
The Trauma Responsive Assessment and Crisis Intervention (TRACI) for Kids Training was
developed to expand crisis mental health worker’s understanding of developing research on the
impact of trauma during the developmental years on child and adolescent mental health and
behaviors. As new research takes many years to become common practice, many of our current
mental health providers have not yet received adequate training on how trauma may be
impacting the clinical presentations of the clients presenting in mental health crisis or what our
best options are for helping traumatized youth and their families stabilize in the community. As a
result, many young people with ‘out of control’ behaviors are referred to inpatient psychiatric
hospitals that are poorly equipped to stabilize behavioral concerns that are driven by trauma
response.
This training is designed to provide an in depth understanding of how trauma manifests in the
behaviors of traumatized youth, guidance on providing a more comprehensive trauma assessment
during the crisis evaluation process, and concrete interventions and psychoeducation for patients
and families to increase understanding of the ‘why’ behind behaviors and opportunities to
manage them at home. After completing this training, participants will have a deeper
understanding of the role trauma may be playing in behavioral challenges displayed by children
and adolescents. With the support of strategies and tools provided, participants will be better
equipped to evaluate for the presence of trauma during assessments and have practical
interventions that can be utilized with patients in distress to calm down or shared with patients
and families to try at home. Additionally, participants will be able to identify referrals to trauma
specific treatment options in the community. In sharing this expanded skill and knowledge with
clients presenting in crisis, youth and families have an improved opportunity to remain stable at
home and in the community and reach their full potential.
In this manual, you will find course content to be presented by the trainer, and activities to guide
learning. Corresponding slide decks are included for each unit. The manual also includes a
Childhood Trauma Knowledge Survey to be used as a pre/post test for evaluating the program’s
intended purpose of increasing crisis provider knowledge and confidence in understanding the
role of trauma in behaviors, and connecting youth to interventions and treatment services that
can help. We have also included the data from our pilot use of the survey to demonstrate how
even well trained behavioral health providers in crisis evaluator roles are not getting this specific
content knowledge in their training programs at this time. Finally, we have included the PEARLS
trauma screener for trainer and trainee convenience. While we will share information about
several trauma screening tools during training, we believe the PEARLS may be most appropriate
to use in crisis evaluation settings. This tool can also be accessed on the web here and is free to
use.

IIA.Course Content
Part One: Foundational Trauma Concepts
Unit 1: History and Evolution of Childhood Trauma and Traumatic Stress
History of Traumatic Stress
o Trauma was first understood as an illness following WWII but was described as a series
of symptoms for combat veterans returning home from war much earlier on [Review
slide 6-8 content].
o Veteran’s symptoms included: demonstrating irritability, distress, poor functioning, and
intrusive memories. Originally dubbed ‘combat neurosis’ or ‘shell shock’, victims were
noted to fare better or worse depending on the length and severity of combat exposure,
the amount of social support they had available to them on return home, and how many
qualities demonstrating resilience veterans held. (Herman, 2022)
o When Post Traumatic Stress Disorder was first added to the DSM in 1980, traumatic
events were described as ‘outside of the rage of usual human experiences’. This
highlights the pervasive belief still held at that domestic violence, child abuse (child
protection laws and agencies had only been developed a few years prior in the late
1970’s) and other kinds of assault and battery was uncommon experiences, which we
know now to be an inaccurate understanding of the pervasiveness of trauma. (Herman,
2022)

ACEs Study
o Conducted 25 years ago by CDC and Kaiser Permanente asked about 10 life experiences
related to family or origin (abuse, neglect, and household challenges) found that of
17,000 adult participants- 67 percent of participants had at least one ACE.
o Well established research on Adverse Childhood Experiences (ACEs) demonstrates
increased risk for long term physical and mental health concerns with each adverse event
experienced (CDC, 2019). Since the original ACEs study was published in 1998, 39
states and Washington, D.C. have published population data on the prevalence of ACEs.
Data shows that between 55 and 62 percent of the population have experienced at least
one adverse childhood experience, while between 13 and 17 percent of the population
have an ACE score of four or more (Harris Burke, 2018)
o More recent data shows that while the ACEs are still relevant, they do not account for
traumatic experiences beyond family of origin trauma, including discrimination based on
race, gender or gender identity, bullying, and natural disasters. (Harris Burke, 2018)
o Philadelphia had its own ACES study which found that over 80% had at least one adverse
childhood experience. Data from 11
th
St family health center showed that 49% had 4 or
more ACEs.
Activity: Facilitate discussion on what contributes to high ACE scores in Philadelphia,
then review the ‘Pair of ACEs’ graphic and slides 11-13

Neuroscience of Developmental Trauma
o The literature draws important distinctions between acute, chronic, and complex trauma
and the impact of each. Acute trauma occurs from a single event, whereas chronic trauma
is repeated and occurs over a prolonged period, such as with domestic violence and abuse
(earlyconnections.mo.gov, n.d.). Complex trauma refers to situations where someone has
multiple sources of trauma. This may occur because a person experiences chronic
discrimination (whether discreet or systemic in nature), foster care placement etc., and
other hardships and traumatic events, such as abuse.
o A growing body of research demonstrates repeated exposure to adverse events during
childhood creates notable impacts to brain development and functioning
(childwelfare.gov, 2015). Frequent or sustained high levels of stress, often referred to as
“toxic stress” in the literature, has the potential to cause significant changes to the brain,
particularly when experienced during the critical developmental phases of childhood
(childwelfare.gov, 2015).
o When the body’s stress response system is subjected to prolonged activation due to
chronic or frequent stressors, it can disrupt brain development, as well as increase the risk
for stress related disease and cognitive impairments well into adulthood (Burke Harris,
2018).
o Two hormonal systems have received extensive attention for their role in this. First, the
sympathetic-adrenomedullary (SAM) system, which produces adrenaline in the central
part of the adrenal gland (NSCDC, 2014). The other critical system is the hypothalamic
pituitary adrenocortical (HPA) system, which produces cortisol in the outer shell of the
adrenal gland (NSCDC, 2014). Both adrenaline and cortisol are produced under normal
circumstances and help prepare the body for coping with stressors (NSCDC, 2014).
However, these systems are not meant to be activated continuously. When this occurs,
various areas of the brain can be affected. The hippocampus, corpus callosum and
cerebellum are all noted to be of decreased volume in multiple studies of adults who were
maltreated during childhood, which has a significant impact on learning and memory,
arousal, emotion and higher cognitive abilities, including executive functioning
(childwelfare.gov).
o Another area of the brain commonly noted to be affected by trauma is the amygdala. The
amygdala is responsible the release of hormones known as the “fight or flight” response,
and when healthy, triggers this reaction as a protective measure in response to a
perceived threat (Rowden, 2021). When activated too frequently due to toxic stress
situations, it can become overactive, triggering what is known as “amygdala hijack”, a
phenomenon where the “fight or flight” response is activated when it is not warranted,
and the person is not able to come to a rational conclusion about how to react, which can
result in emotional outbursts or aggression (Rowden, 2021).
o Finally, chronic exposure to abuse during childhood is noted to cause abnormal cortisol
levels, which can have negative impacts on learning and energy levels, as well as cause
social skills deficits and externalizing behavior disorders (childwelfare.gov, 2015). These
changes help to explain some of the behavioral, cognitive, and social impairments
demonstrated by victims of abuse, but are not well accounted for in traditional treatment
interventions that are more reactive to symptoms than they are to the root cause
(childwelfare.gov, 2015).

Epigenetics
o Emerging science that shows how environmental influences, especially during early
childhood, affect the expression of genes. During development, the DNA that makes up
our genes accumulates chemical marks that determine how much or little of specific
genes are expressed, meaning whether and how genes release the information that they
carry. (developingchild.harvard.edu)
o This explains how children from the same family, even identical twins, can exhibit
different behaviors, skills, health and achievements. Also answers the age old argument
about nature v. nurture- now we know the answer is definitely ‘both’
(developingchild.harvard.edu)
o Also important to note that gene expression is then passed down for up to three
generations. So the trauma endured by grandparents can still be affecting gene expression
in the grandchildren. This helps us to understand why even children who have no known
trauma history may exhibit traumatic stress markers in behaviors and connection to others
(Atlas, 2022).

Evidence-Based Interventions for Trauma

Activity: Play video on Slide 21, discuss supplementing with below content
o There are several well-known treatment modalities specifically geared towards
addressing trauma. By many standards, trauma-focused cognitive behavioral therapy (TF-
CBT) is considered the gold standard in treating trauma amongst children, but there are
many variations of cognitive behavioral therapy that have been evaluated for addressing
trauma in children over time. Studies have concluded that individual CBT with parent
involvement, individual CBT, and group CBT are all considered well established,
evidence-based interventions (Dorsey et al, 2017). Available evidence shows that TF-
CBT is suitable across different age groups and can be an effective treatment for youth
with a range of traumatic experiences and additional comorbid symptoms (Lindebø,
2020). Still, some studies show that about 20% of treatment recipients are non-responsive
to the intervention (Lindebø, 2020). Additional evidence suggests that participants with
the highest levels of pretreatment post-traumatic stress symptoms were in the non-
responder group (Lindebø, 2020). Further, other data demonstrates that CBT has been
shown most effective with some forms of trauma, such as sexual abuse victims, and in
addressing internalizing behaviors and is less effective with physical abuse victims and
towards improving externalizing behaviors supporting earlier presented data that some
types of trauma and symptomology are less responsive to talk therapy interventions alone
(Lindebø, 2020).
o Eye movement desensitization and reprocessing (EMDR) is another trauma specific
modality. During EMDR treatment, the client revisits emotionally disturbing material in
brief doses while simultaneously focusing on an external stimulus (EMDR, n.d.) This is
believed to facilitate the accessing of the traumatic memory network, so that information
processing is enhanced, and new associations forged between the traumatic memory and
more adaptive coping responses (EMDR, n.d.). Research conducted on the efficacy of
EMDR has yielded mixed but moderately positive results, and this intervention is now
deemed evidence based and likely at least somewhat effective in addressing trauma
(Dorsey et al, 2017).
o Several other trauma interventions for children are designed for both the parent or
caregiver and the child to engage in together due to the importance of attachment in
trauma recovery. One intervention developed specifically for youth in foster care is the
KEEP intervention. This 16-week course is typically offered in group settings and the
material is centered in concepts from parent management training and designed to
support foster parents in understanding behavior challenges and learning parenting
strategies to intervene (Price et al, 2012). Outcomes from available data showed a
decrease in externalizing behaviors over the course of the intervention, and also some
positive effect on successful transitions out of foster care (Price et al, 2012).
o Another approach that has been well studied in biological mother-child dyads is Child–
parent psychotherapy (CPP). CPP was developed to improve psychological and relational
functioning in trauma-exposed young children and their primary caregivers (Hagan et al,
2017). This shows promise towards an early intervention approach and towards the
development of healthy attachment. Treatment options in this area are still developing,
but existing research suggests an integrative health approach may be the most optimal
way to heal the brain.

Trauma Informed Care
o Trauma informed care is an approach in human services fields that assumes an individual
is more likely than not to have a history of trauma. It recognizes the presence of trauma
symptoms, or that behaviors, attitudes, and actions COULD be trauma symptoms and
acknowledges the role that trauma may play in the life of clients and staff.
(socialwork.buffalo.edu)
o On a systemic level, trauma informed care is a cultural change and commitment requiring
as system to make a paradigm shift from ‘What’s wrong with you?’ to ‘What happened to
you?’ (socialwork.buffalo.edu)
o The intention of trauma informed care is not treatment of symptoms or issues related to
abuse and other trauma but to provide support in a way that is sensitive to the presence or
probably presence of trauma history to avoid further or re-traumatization.
(socialwork.buffalo.edu)
o Some challenges with TIC include no universal model, making it difficult to adopt in a
systemic way across providers or organizations. Also is more of a concept and a way of
approach clients and situations, meaning there is not a specific protocol to follow, but
rather a philosophy to adopt, as though we are providing all care through a trauma
informed lens rather than doing one or several specific things to carry it out.

Activity: Facilitate discussion on Slide 24: ‘What Makes Care Trauma-Informed’, then
review tenets of trauma-informed care on slide 25

Unit 2: Understanding Childhood Trauma & Behaviors

Threat/Stress Response System of the Body
o The body’s stress response system is designed to keep humans out of danger. Consider
the primitive survival needs of early man. The hormonal systems reviewed in unit 1 are
meant to allow the body to be on high alert, perform at maximum capacity, and hopefully
stay alive. Those systems work very effectively and are triggered by other threats to our
safety as well. This is how adverse childhood experiences create responses that look and
feel like aggression and violence but may at their core be linked to a survival response.
Activity: Facilitate Discussion- [Share slide 26 with group] If you encounter this
individual, running alone, looking frantic, screaming, flailing, perhaps trying to strike
you if you get too close…what are you thinking? Feeling? Are you threatened? Worried
he will harm you? That he is unstable? Write down your thoughts. [Share Slide 27].
Understanding the full picture might change our perspective. Does his behavior seem
more rational now? Are you more motivated to help him? People who have experienced
repeated or significant trauma have an overactive stress response system. [Ask for
volunteers to share their impressions out loud] They are all running from a bear you
can’t see. Our job is to learn to understand what’s really happening for them.

Fight, Flight Freeze & Fawn
o The amygdala releases hormones in response to a perceived threat
o “Amygdala Hijack” is a description for a response that typically occurs when stress
response system is over sensitized from chronic or repeated stress exposure.
o Moving out of the ‘thinking’ part of our brain and fully into the ‘survival’ part of our
brain, which means we no longer have access to rational thought that might help us
problem solve is this threat real, is it happening currently or does something about this
feel reminiscent of a past traumatic situation.
o Because of this, it can include what is known as a dissociative response, which means a
feeling of being disconnected from the world around you. At times, we might be able to
tell someone is dissociated because they do not appear mentally present in the moment,
they may be saying things that don’t make sense for the situation that is happening or
appear to be unable to hear you speaking to them.
o Once triggered, the body’s ‘alarm’ system sends message of ‘DANGER!’ and the brain
begins to assess the best option for survival: FIGHT, FLIGHT, FREEZE OR FAWN
o Flight and fight are automatic responses by the brain designed to regain a sense of safety.
Freeze is what happens when the brain feels that flight and fight are not options, and the
best chance of survival is to freeze. *This is an important concept for sexual assault
victims who we may at times say or others may say about them, ‘they didn’t fight back’.
It’s important to realize that the freezing was not compliance, but rather their brain had
assessed this was their best chance of survival and given what we have learned about the
activation of the stress response system, we know that when victims say they could not
move, this is a literal truth. Fawn is a cousin of freeze, wherein a person may appear
actively engaged and compliant, but may also be dissociated and ‘going through the
motions’ of what is asked to preserve their health or safety.

Repeated Activation of the Radar System
o When the body’s stress response system is triggered frequently by high stress and
traumatic situations, there are very real health impacts. Chronically activated stress
response results in chronically elevated blood pressure, digestive distress, repressed
immune function and dysregulated hormones. This is how people become physically ill,
when their body and system is essentially overproducing and responding in order to keep
up with the repeated stress response.
o Once the stress response system is activated, it is critically important to complete the
stress response cycle. Remembering the man running from the bear, when the bear is no
longer chasing him, the stressor might be gone, but do we assume he is immediately
calm? Or will be remain activated and in need of something or someone to help soothe
him? Completing the stress response system is what helps your system return to status
quo, which is needed in order to preserve physical health and to alleviate distress.
o We got stuck in the activated phase of stress response for two main reasons: the stressor
is chronic, thus there is little or no reprieve, and/or because of social appropriateness and
situational expectations. A child who is being verbally abused may have been told they
aren’t allowed to cry, so they hold it in. An adult has a nasty exchange with a stranger or
colleague but knows it’s not the time or place to either run away or fight, and so we sit
with the stress, having not alleviated it even after the stressor is removed. This repeated
activated of the stress response system and the inability to alleviate the residual stress is
what creates an over-sensitized stress response system, which can then lead to
inappropriate reactions when it can no longer be contained.
o The most efficient way to complete the stress response cycle is through physical activity.
For people in frequently high stress situations, 20-30 min several times a week is
necessary (Nagoski & Nagoski). For a singular high stress event, it takes about 30
minutes for the body to process the excess cortisol and return to homeostasis (Gottman,
2021). Physical activity as simple as walking can accomplish this. Other ways to
complete the stress response cycle include: deep breathing, positive social interaction,
laughter, affection, creative expression, and crying (Nagoski & Nagoski)
o We live in a culture where too many visible feelings make people uncomfortable, yet it is
critical to our health that we find ways to move through our feelings (safely) and not
repress them.

Responding to Behaviors through the Trauma Lens
o A shift in focus from compliance to understanding is the most effective way to create real
behavior change. The best way to do this is to begin with understanding the function of
behaviors as one way we will work to understand them.
o The four major functions of behavior are: escape, attention, tangible, sensory.
o Once we understand what we are looking for in terms of function, we can use the ABCs
of understanding behaviors to learn: what was the setting, the antecedent, the behavior
exhibited, and the consequence. Think of consequence less like punishment and more like
result. In some cases, the result will be a consequence, but if we think about it more
broadly we may learn something about what the child was trying to accomplish with the
behavior.
o Societal expectations about what good behavior looks like has made all of us pretty
motivated to resolve any “negative” behaviors as quickly as possible. This is coming at
the situation from the lens of, the child’s behavior is making the adults uncomfortable,
usually because it isn’t socially acceptable, and thus we must make it stop. A shift in
perspective to, the child is behaving this way because something is uncomfortable for
them, and then working to figure out what that is and how to solve that problem makes
children feel more supported and creates longer lasting behavioral change.
o Sometimes children do things that feel unsafe, like throwing an object or banging on the
wall. If we peel back the layers of this, the concern is often that adults involved are
worried that something unsafe is about to happen next, and this is why we feel the need to
physically intervene before that occurs. Though an understandable reaction, the challenge
is that if the behavior is the result of a stress response system activation, the behavior is
telling us that the child feels threatened in some way (whether tangible or not) and going
hands on in that moment is likely only to validate that fear and escalate the situation.
Sometimes we can’t avoid that because the behavior already is at an unsafe level. When a
child escalates, pausing to ask, is this behavior unpleasant or unsafe is a critical question
and decision point.
Activity #1: Pose the questions on slide 35 and engage the group is offering alternative
approaches to responding to a child in escalating crisis.
Activity #2: Review the case examples on slides 36-41 aloud with the group. If group size
permits, consider breaking the group into pairs or small groups to discuss. Have each
pair/group share their answer out loud with the others and process.

Self-Reflection on Trauma
o In reviewing this content on trauma and difficult behaviors, it is important to
acknowledge that it is common for people who have endured hardship and trauma to
enter roles in helping professions.
o It is also important to recognize that we may not even be fully cognizant of our own
‘stuff’. There are ‘Big T’ and ‘little t’ traumas that exist for all genders, races and
backgrounds, and some are more visible to us in the moment as a trauma than others.
Activity: Pass out or share on screen the PEARLS expanded ACEs assessment. Ask each
attendee to review for themselves, and quietly count how many expanded ACEs apply to
them. Assure them that they will not be asked to share their information, this is strictly an
exercise in self-discovery and reflection. Then, share the below guidance:
o If a patient’s story or behaviors leaves you feeling angry or very emotional, pause and
reflect on why. You may know exactly why, if you identify something familiar in a story,
a situation, or even something being said in the moment. You may also not know why
one individual’s situation seems to affect you so much when many other difficult stories
seemingly had not. Maybe it’s because of a trauma you didn’t know was a trauma, or
maybe your stress response system is at max because of all of those other stories you
managed so well. Giving yourself the time and space to regroup and explore further when
appropriate is important to your health and safety, and to the patients you serve.
o Use case consultation with clinical supervisors to explore reactions to difficult scenarios.
We often reserve clinical supervision for diving deeper into the details of a case or
situation, whether trying to problem solve what we could have done differently or to
grow our clinical understanding of cases. It is important that we acknowledge the human
side of us and use this space to look at what is coming up for us in our work as well. If
your own clinical supervisor isn’t a comfortable space to do so, seek outside consultation.
This is a way we can complete your own stress response cycle so that you can continue
the critical work you are doing.

Unit 3: Assessing for Trauma in Crisis Mental Health Evaluation

Mental Health Evaluation: Medical Model v Bio-Psycho-Social Model (And Beyond)
Activity: Ask group participants to share how they ask about trauma during the mental health
assessment/psychosocial assessment process. Record responses on a surface visible to class
participants.
o Traditional biomedical models of practice focus on pathophysiology and other
biological origins of disease, and the treatment of associated presenting symptoms
(URMC, n.d.). For mental health conditions, this has resulted in a standard of care
that is focused on identifying and treating the current symptoms without always
understanding the underlying cause.
o Since developmental trauma does not look the same in every child, a more
comprehensive assessment approach is required to get to the root of the problem.
The biopsychosocial model considers biological, psychological, and social factors
and the complexity of their interactions in the delivery of healthcare services
(URMC, n.d.).
o Though the biopsychosocial model helps us to get closer to the root of the
problem by asking about family make up, dynamics and trauma history, asking
about trauma history and exploring it are not interchangeable concepts. Our
research has shown that current assessment questions about trauma typically
sound like “Do you/your child have any trauma history” or “Do you/your child
have any abuse history or current or previous child welfare involvement”.
Activity: Write the two general trauma history questions above on a surface visible to group
participants (if they are not already accounted for in the earlier activity). Ask group participants:
What are the shortcomings of these questions? What might we be missing?
o There are several issues with questions designed to collect trauma history that are worded
in this way. First, they assume that a child or family knows they have a trauma or abuse
history. It assumes both that there is a universal understanding of what trauma and abuse
are- ie what experiences qualify as traumatic or abusive- and it assumes that it is always
clear to people that they are or have experienced traumatic events or are being mistreated.
This is challenging for children and others who have never known any differently, and it
is not congruent with things we know about the pervasive and insidious nature of certain
kinds of trauma, such as emotional abuse.
o These questions also assume that people will be willing to be honest with us when we use
terms that have a negative connotation to many, particularly individuals of color and
oppressed populations.
o Research conducted in the development of this curriculum indicated that for many crisis
mental health evaluators, when a youth or caregiver indicates ‘yes’ to abuse history, their
primary focus shifts away from understanding the role of trauma and abuse in the
patient’s current clinical presentation, and shifts instead to determining whether a
mandated report has been completed and what their obligations under the law may be.
o Language for more comprehensively collecting and exploring trauma history can be
found in trauma screening surveys. There are a few that are validated and widely used for
this purpose (Review tools via slides).
o The Pediatric ACES and Related Life Events Screener is validated for use in primary care
settings but is free and available for supporting information collecting in any
environment. A unique feature of this screener is that it comes in deidentified versions,
where recipients are asked to count and report how many of the experiences listed they
identify with, but not which ones, unless they choose to self-disclose. Though this may
not tell us the details of what their life experiences have been, by using our expanded
knowledge of the cumulative effect of multiple ACEs, we can consider this likely impact
of trauma on physical and mental health conditions. When we consider this against the
risk of non-disclosure, especially in crisis and emergency settings where there is not time
to build trust and rapport, the benefit of having a more accurate understanding of the
volume of traumas may be the most useful information to inform assessment.

Diagnostic Considerations
o In many short term and crisis mental health settings, what we will call ‘generalist
diagnosis’ is common, and is appropriate to the extent that providers are limited to the
information they have available to them in this brief interaction, which is naturally more
limited than patients seen longer term in outpatient settings. There is motivation to avoid
labeling young people with diagnoses that may be carried forward in an non-discerning
way, and impact their treatment and prognosis over time. For these reasons, when
working with youth with behavioral concerns, it is not uncommon for us to see providers
choose diagnoses that largely describe a cluster of behaviors, such as DMDD, ODD, and
Conduct Disorder. These diagnoses do not contain within their criteria anything that
points to the etiology or the ‘why’ behind behaviors. For this reason, when we encounter
these diagnoses, we should take the diagnosis and the behaviors at face value. In other
words, these diagnoses tell us ‘This is what they are doing’ but also that we have work to
do to understand how these behavior patterns came to be.
o Reactive Attachment Disorder is a diagnosis we may less often, but its criterion are
closely related to much of what we are exploring in this training. Even if we infrequently
encounter this diagnosis, it is important to be familiar with it towards the goal of
understanding behaviors.
o It is also important for us to be informed about the prevalence of racial bias in
diagnostics. When black or brown youth demonstrate maladaptive coping strategies to
emotional distress, they are more commonly diagnosed with psychosis, substance use
disorder or disruptive behavior conditions such as conduct disorder and oppositional
defiant disorder than with anxiety, mood disorders or ADHD (Liang et al, 2016). This is
particularly concerning given that a known trauma history could certainly result in
externalizing behaviors that could easily be misunderstood if minority youth are not
evaluated and treated with the same empathic approach as majority populations.
o This phenomenon may also play a role in the alarmingly high prevalence of prescription
of antipsychotics to youth in foster care. According to a review published by the
Children’s Hospital of Philadelphia’s PolicyLab, almost half of foster care youth on
psychotropic medication received an antipsychotic as part of their care. Additionally,
many children taking antipsychotic medications (65%) were receiving them for diagnoses
lacking regulatory approval for use, such as ADHD and conduct disorder (PolicyLab,
2019). By diagnosing and treating in this manner, the system is essentially putting a
band-aid on a bullet wound by not addressing the underlying drivers for behaviors and
worse, and negatively labeling minority child abuse victims in a way that may further
diminish their self- worth.
Activity: Review case studies included in slide deck. Where possible, ask participants to work in
pairs or small groups to discuss case conceptualization, then share findings out loud and discuss as
a group.

IIB. Course Visuals
The visuals that follow are to be used in conjunction with the preceding content to give training
participants all relevant information. We recommend reading through the content while
advancing the visuals at least one time prior to leading a training to allow for ease of familiarity
with the flow of timing and information.

All human behavior has a reason.
All behavior is solving a problem.
- Michael Crichton
Guiding Principles
Symptoms/behaviors…
- serve a purpose
- are ways patients have learned to adapt and
cope with feelings, memories, and/or
situations in their lives
- help the child in the moment (even if yielding
long-term consequences)
3

Unit 1: History and Evolution of
Childhood Trauma and Traumatic Stress
Agenda
• History of Diagnosis of Traumatic Stress
• Post Traumatic Stress Disorder Overview
• ACEs Study
• Newer Research: Neurobiology of Trauma
• Evidence Based Interventions for Trauma
• Trauma Informed Care: What It Is & Isn’t
History of Traumatic Stress
Disorders
• Civil War Era- ‘Nostalgia’ used to describe soldiers who
suffered from homesickness and despair, as well as
classic PTSD symptoms such as sleeplessness and anxiety
• WWI- Term ‘Shell Shock’ introduced in medical journal
The Lancet (Feb 1915) to describe anxiety, nightmares,
and tremors following exposure to exploding
ammunition on the battlefield
• WWII- British and American forces described traumatic
responses to combat as ‘battle fatigue’, ‘combat fatigue’,
and combat stress reaction’
Modern Day PTSD
• 1952 APA added ‘Gross Stress Reaction’ to the first
edition of the DSM
• Psychological issues stemming from traumatic events
(including combat and disasters)
• Assumed the issues were short lived. If the problem
lasted more than 6 months, it was believed to have
nothing to do with wartime exposure
• 1968 DSM II removed the diagnosis and added
‘adjustment reaction to adult life’.
• This criteria did not sufficiently capture the post-
traumatic stress symptoms of soldiers and thus many
were not able to receive psychological help needed
Modern Day PTSD
• 1980 DSM III- Post Traumatic Stress Disorder added
based on expanded knowledge of traumatic responses
from Holocaust survivors and sexual assault victims
• Diagnostic criteria for PTSD was revised in the DSM-IV
(1994), and DSM-IV-TR (2000), and DSM-5 (2013) to
reflect ongoing research.
• DSM-5- PTSD is no longer considered an anxiety disorder
because it’s sometimes associated other mood states
(depression, anger, reckless behavior)
Adverse Childhood Experiences
Initial ACEs study
• Conducted 25 years ago by CDC and Kaiser Permanente
• 17,000 adult participants- 67 percent of participants had at least one ACE
• Numerous subsequent studies across 30 states showed:
• 55-62 percent have at least one ACE
• 3-17 percent had four or more ACES
Findings
• ACEs are very common
• ACEs are strong predictors of health risks and disease from adolescence through
adulthood
Philadelphia ACE Project
• Philadelphia ACEs Project- 83 percent had one or more ACE
• Practitioners at Philadelphia’s 11th Street Family Health Services found that 49% of their
patients had four or more ACEs
What Were the Original ACEs?
• Physical
• Sexual
• Emotional
Abuse
• Physical
• Emotional
Neglect
• Mental Illness of Caregiver/Parent
• Incarcerated Relative
• Domestic Violence
• Substance Use
• Divorce
Household
Challenges

Why Does This Matter?
The Neurobiology of Trauma
Dose Response Model
• Affects brain development, immune system, hormone systems, DNA
expression
• Triple the risk of heart disease and lung cancer and a 20-year difference in life
expectancy
• 4x the risk of depression and 14x the number of suicide attempts
In high doses:
• Twice as likely to be overweight or obese and 33x as likely to be diagnosed
with a learning or behavioral problem
Physical and emotional
health impacts are
visible in children and
adolescents as well
“Adverse Childhood
Experiences are the single
greatest unaddressed public
health threat of our time.”
Dr. Robert Block, Past President of
American Academy of Pediatrics
Types of Trauma
Acute
Chronic
Complex
Toxic Stress
• Frequent or sustained levels of stress
• Potential to cause changes to brain,
particularly during developmental
years
• Sustained levels of cortisol and
adrenaline production impact
memory, arousal, emotional and
executive functioning
• Abnormal cortisol levels can also
negatively impact learning and
energy levels, cause social skills
deficits and externalizing behavior
disorders
The Body’s Stress Response
System
Prefrontal
Cortex v.
Limbic
System
Epigenetics
• Old Narrative- Genetic Determinism
• A person’s genes and subsequent health are determined
at birth
• Suggests that we are ‘destined’ to have or not have
certain diseases based on the luck of our DNA
• Does not consider the role of family dynamics, trauma,
habits or other factors within the environment
• New Data- Epigenetics
• Genes are influenced by environment from in utero
through the life course
• Choices we make (sleep, nutrition, exercise) alter gene
expression
Effective Treatment Interventions
for Trauma
Effective Trauma Treatment
Interventions
• Trauma Focused Cognitive Behavioral Therapy
(TF-CBT)
• Eye Movement Desensitization & Reprocessing
(EMDR)
• KEEP Program
• Child Parent Psychotherapy (CPP)
Trauma-Informed Care
• Trauma: exposure to an incident or
series of events that are emotionally
disturbing and/or life-threatening
that impact the individual’s mental,
physical, social, emotional, and/or
spiritual functioning and well-being.
• Impacts one’s ability to form
attachments, self concept, behavioral
control, affect and biological
regulation
• Trauma-Informed Care:
understanding of how trauma can
impact an individual’s perceptions
and behaviors
21
What
Makes Care
Trauma-
Informed?
Trauma-Informed Care
23
Safety
• Physical and psychological
setting is safe
• Interpersonal interactions
promote a sense of safety
Trustworthiness &
Transparency
• Decisions are conducted with
transparency and with the goal
of maintaining the trust of the
patient
Peer support
• For empowerment, building
trust, and resilience
Collaboration & mutuality
• Meaningful sharing of power
and decision-making with the
patient
Empowerment & choice
• Strengthen patient and family’s
feelings of choice
• Everyone is unique and requires
an individualized approach
Cultural, historical &
gender issues
• Providing culturally competent
care
• Recognize/address both
historical & recent trauma
Unit 2: Understanding Childhood
Trauma & Behaviors
Agenda
• Threat/Stress Response System of the Body
• Fight, Flight Freeze & Fawn
• Repeated Activation of the Radar System
• Responding to Behaviors through the Trauma
Lens
• Self-Reflection on Trauma
The Body’s Stress Response
System

Fight or Flight Response
• Amygdala releases hormones in
response to perceived threat
• “Amygdala Hijack” occurs when stress
response system is over sensitized
• Includes dissociative response
• Body’s ‘alarm’ system sends message
to get away from the stressor or fight
Freeze or Fawn
Importance of Completing the Stress
Response Cycle
• Activation is first and foremost about survival
• Body needs a signal that the threat is over
• Even when the threat is resolved, need a way
to expel the stress
Safer Alternatives to Completing the Stress
Response Cycle
Physical activity of
any kind
Deep
breathing/meditation
Artistic Activities Play
Emotional Release
(Crying, Laughing)
Understanding Functions of
Behavior
32
Function Purpose Examples
Escape To end or avoid something the person
does not like
- Taking a different route home to avoid traffic
- Tantrum to avoid getting blood drawn
- Eloping from the room
- Dissociating
Attention To receive attention - Raising your hand in a class to answer a
question
- Pressing the call button so that staff comes
to your room
Tangible To gain access to an item or activity - Doing homework to get access to iPad
- Play a game at a carnival to win a prize
Sensory To feel good or feel less bad - Scratching an itchy mosquito bite
- Drinking cold water on a hot day
Understanding Behavior: ABCs
Setting: location,
situation
Antecedent: what
occurs before the
behavior
Behavior: action or
series of actions
which has occurred
Consequence: a
response that
follows the behavior
33
Ask yourself: Is this
behavior unpleasant or
unsafe?
• Unpleasant
• Yelling, pacing, crying,
intermittently gesturing
• Give it more time and space, offer
better choice
• Verbal and non-verbal de-
escalation
• Unsafe
• Harming self or others; property
destruction that begins to target
staff
• Call for help, utilize resources
34
Trauma
Responsive
Considerations
During
Behavioral
Escalation
Consider the role of rapport,
trust and connection
How might you help the child
feel ‘seen’?
What might you ask/say to a
child in distress to help reflect
these concepts?
• How can I help you right now?
• What do you need?
• Can you tell me what’s
bothering you?
• I can see you are upset. Can
we sit and talk about it?
Case Example #1
• 12-year-old female in child welfare custody from residential care
with extended stay
• Initial agitation diminishes in response to support and structure
• Increased comfort on unit and with staff
• Asked to clean up room before playing
• Staff member offers to assist
• Patient declines the help
• Staff member proceeds to move patients belongings and patient
becomes aggressive
What
Happened?
• Patient too comfortable on unit and
with staff due to lengthy stay
• Staff boundaries decreased due to
perceived positive rapport with patient
• Cues/warning sign from patient not
noticed
Case
Example #2
• 8-year-old male with history of volatile
household and domestic violence
• Well behaved, kind, helpful
• During the course of play activity at
recess involving another youth, conflict
over ball occurred and both boys
redirected
• Runs out of play yard, and when staff
catch up to him and grab an arm to stop
him from harm, flails and strikes staff
• Youth reports afterwards that he didn’t
“know what happened”, felt “so mad”
• Staff confirms the youth seemed to be
“elsewhere” mentally
What
Happened?
• Youth perceived himself as “in trouble”
with staff
• Later reported worries that adults
involved were mad at him or wouldn’t
like him any more
• Flight response to flee distress
• Condition of youth described indicated
dissociative response
• Hands on might be
triggering=Grounding activities can help
in these situations
Case
Example #3
• 11-year-old female youth boarding
awaiting inpatient psychiatric bed
• Parent not visiting during stay
• Delays in access leading to increased
agitation and reports of boredom
• Patient appears to be testing limits in
the room, stepping on 1:1 toes
intentionally, refusing to choose a
positive activity
• Patient find opportunity to elope off
unit and out to elevators
• Appears amused and feels “game like”,
until staff set hard limit and physically
intervene
• Difficult and lengthy restraint follows
with patient very agitated, spitting,
swearing at staff
What
Happened?
• Patient testing limits
• May also be testing ability to trust
adults due to attachment issues
• Though it feels game like, extreme
reaction once limit set is an indicator
• Limit testing is warning sign of potential
escalation and good time to huddle and
update the plan
Key Takeaways
“People Will Do Well If
They Can” –Ross Green,
2006
•If they can’t, we need to
figure out why so we can
help
•Behaviors are telling us
something the patient
can’t verbalize
•Behaviors are way of
getting needs met
•Seek to understand
The primary goal during a
trauma response is to
maintain safety and
stabilize
•Focus on how to
reestablish a sense of
safety for patient as an
alternative to limit setting
and before attempting to
process behaviors
Trauma and attachment
are drivers behind many
behavioral concerns
• Establishing trust and
fostering connections with
traumatized youth are
important restorative steps
A Note on
Resilience…
Past Trauma and Helping
Professionals
• Common for people who have endured
hardship and trauma to enter roles in the
helping profession
• Important to recognize that we may not even
be fully cognizant of our own ‘stuff’
Past Trauma and Helping
Professionals
• If a patient’s story or behaviors leaves you
feeling angry or very emotional, pause and
reflect
• Use case consultation with clinical supervisors
to explore reactions to difficult scenarios
Outline of the Course Content
TRACI Curriculum
Trauma Responsive Assessment & Crisis Intervention
Prepared by Erin Perry, LCSW (2023)
UNIT TITLE CONTENT
Part One: Foundational Trauma Concepts
Unit 1: History and
Evolution of Childhood
Trauma & Traumatic Stress
This unit focuses on the history of diagnosis of traumatic stress, including an overview of
Post Traumatic Stress Disorder (PTSD) diagnostic criteria and evidence-based
interventions for PTSD treatment. The unit will also cover the landmark ACEs Study of the
1990's and subsequent developments in research on the neurobiology of trauma, including
exploration of the concepts of developmental trauma and epigenetics. The unit will close
with a discussion on what trauma-informed care is and is not.
Unit 2: Understanding
Childhood Trauma &
Behaviors
In this unit, students will learn the function and parts of the autonomic nervous system and
how this relates to the well-known concept of the 'Fight or Flight' response, and lesser
known 'Freeze or Fawn' responses. This unit will also explore the impact of repeated
activation of the body's stress response system as well as the importance of completing
the stress response cycle. At the close of the unit, a discussion will be facilitated on
provider awareness of their own trauma history, stress tolerance and mindfulness of how
this shows up in the workplace.
Unit 3: Assessing for
Trauma in Crisis Mental
Health Evaluation
This unit concentrates on the mental health evaluation process, with students learning
about gaps in the way we currently collect trauma history and techniques to conduct a
more comprehensive trauma assessment, including review of several trauma screening
and assessment tools. Students will also be exposed to diagnostic considerations beyond
PTSD, including a review of Reactive Attachment Disorder, and connections between
unaddressed trauma and Oppositional Deant Disorder, Conduct Disorder, and Disruptive
Mood Dysregulation Disorder. Unit content will also include a review of racial bias in
diagnostics.
COURSE OVERVIEW
This course expands students' depth of knowledge on the role of trauma in child and adolescent mental health crisis
and behavioral concerns.

Participants will explore the history of understanding trauma response, as well as the concepts of childhood trauma,
developmental trauma, and the neurobiology of trauma, including nervous system dysregulation, common
trauma/stress responses, and expanded incorporation of these concepts into crisis mental health assessment.
Participants will also be exposed to intervention strategies focused on nervous system regulation, integrated health
techniques and psychoeducation activities for youth and families. This full course is intended for crisis mental health
workers in various settings who have previous exposure to conducting mental health evaluations and for those wishing
to further their understanding on the role of trauma in child and adolescent behaviors and mood dysregulation.
Alternative versions of this training are available for other child serving professionals with content modifications to
match role function.

PREREQUISITE
Prior training in conducting crisis mental health assessments is recommended for this course.
...more on next page
Outline of the Course Content Continued...
UNIT CONTENT
Part Two: Interventions for Behavior Change
Unit 4: Understanding
Nervous System
Regulation
In this unit, students will be exposed to Dr. Judith Herman's Triphasic Model of Trauma
Recovery and Dr. Stephen Porges' Polyvagal Theory. Common behavior management
intervention strategies in crisis settings, including behavior modication systems and
medication management, will be reviewed and a discussion facilitated on why these
strategies are poorly effective and potentially harmful when used with traumatized youth.
The unit will close with a review of more effective for regulating a disrupted nervous
system, including a review of self- regulation strategies and relaxation skills. The concepts
of interoception, co-regulation and attachment are also covered in this module.
Unit 5: Integrative Health
Interventions
This unit will begin with a discussion on the difference between completing the stress
response cycle and releasing residual stress, and the importance of doing both. The unit
will cover integrative health interventions effective for completing the cycle and stabilizing
the nervous system, including physical activity, play, breath work, and creative and
expressive arts. The unit will also review data on health and wellness interventions, such
as sleep and nutrition and their role in stabilizing the nervous system.
Unit 6: Psychoeducation
for Patients & Families
This portion of the course focuses on content and strategies for completing
psychoeducation with patients and families. Students will learn ways to approach
discussion on the impact of trauma on children and teens, as well as considerations
regarding trauma impact to the parent/caregiver(s). A review of tools (children's books,
sensory items, etc) to assist in psychoeducation and nervous system stabilization is
included. Students will also learn and practice how they can use the information provided
in Sessions 4 & 5 to complete brief therapeutic interventions during crisis evaluation visits
to support nervous system regulation.
Teaching and Learning Strategies Used in this Course
METHODS STRATEGIES TOOLS
Pre/Post Tests Direct Instruction Power Point Material
Presentations Discussion Screening Tools
Peer Teaching Brainstorming Anecdotal Comments
Role Play Presentation Peer Feedback
Case Studies Group Work
Think – Pair – Share
Observation
The Role of Technology in the Curriculum
1. Visual aids through the use of Power Point presentations, videos, and other images will be used to engage
students.
2. Computers and smartphones will also be incorporated into the class on occasion for screening tool
demonstration purposes.
Overall Expectations
A1. Demonstrate an understanding of the relationship between childhood trauma, toxic stress and nervous system
dysregulation.
A2. Identify and describe some key interventions that support nervous system regulation that can be taught to families
with a child in mental health crisis.
A3. Demonstrate an understanding of how to consider trauma in crisis mental health evaluation and recommendations,
and knowledge of trauma-focused interventions for referral.

Specific Expectations
A1.1 Be able to describe the history and evolution of trauma diagnosis and key outcomes of the landmark ACEs study.

A1.2 Demonstrate knowledge of the impact of trauma on the developing brain, and the neuroscience on intergenerational trauma
and gene expression (epigenetics).

A1.3 Demonstrate an understanding of the autonomic nervous system, sympathetic and parasympathetic nervous systems. Be able
to describe the impact of repeated activation of the body's stress response system and related 'Fight, Flight, Freeze and Fawn'
responses.

A1.4 Be able to describe the impact of repeated activation of the body's stress response system and related 'Fight, Flight, Freeze
and Fawn' responses.

A2.1 Demonstrate an understanding of the concepts of self- regulation, co-regulation, interoception, attunement and attachment.

A2.2 Be able to describe integrative health interventions useful for nervous system regulation, including movement, breathwork and
wellness activities.

A2.3 Demonstrate knowledge of tools that support psychoeducation on trauma response for patients and families, including books,
sensory items for regulation support.

A2.4 Be able to describe key concepts of the Triphasic Trauma Recovery Model

A3.1 Demonstrate knowledge of trauma screening and assessment tools to support mental health evaluation.

A3.2 Be able to describe key criteria for Post-Traumatic Stress Disorder and Reactive Attachment Disorder.

A3.3 Demonstrate knowledge of the connection between childhood trauma history and behaviorally based diagnoses such as
Oppositional Defiant Disorder, Conduct Disorder and Disruptive Mood Dysregulation Disorder and racial bias in diagnosis.

A3.4 Be able to identify evidence-based trauma therapy interventions and accurately describe the concept of trauma informed care.
Learning Goals: At the end of this course, students will be able to…
Understand the role of toxic stress and repeated trauma in mental health conditions and presentations.
Recognize common trauma responses when encountered in mental health crisis situations.
Articulate the role and function of the nervous system as connected to stress and trauma.
Describe key theories guiding the mental health field in understanding trauma response and criteria for stabilization.
Understand the importance of connecting clients with significant trauma histories to trauma specific interventions.
Describe the importance of and rationale for crisis interventions that are trauma-responsive rather than focused on behavioral
control.
Demonstrate an understanding of the role trauma history plays across systems, inclusive of patients, families and providers.
Success Criteria: Students will know they are successful when they can…
Articulate the impact of toxic stress and trauma response on brain development.
Describe potential nervous system regulation challenges following chronic trauma exposure.
Discuss examples of behavioral responses in children, drawing connection to brain and nervous system impacts post-
trauma.
Describe ways to incorporate expanded understanding of trauma response into mental health crisis assessment
process.
Identify evidence-based trauma treatment interventions to be recommended following mental health crisis evaluation.
Describe a series of interventions that help to stabilize a dysregulated nervous system.
Demonstrate how patients and families can be taught to utilize stabilizing interventions at home to stay out of crisis.
Assessment
for/as learning:
knowledge pre-test
teacher observation during all lessons (assessed by teacher)
role play observation
end of course conversation
of learning:
end of course evaluation
end of course post- test

Program Description
The Trauma Responsive Assessment and Crisis Intervention Training was developed to expand crisis
mental health worker’s understanding of developing research on the impact of trauma during the
developmental years on child and adolescent mental health and behaviors. As new research takes many
years to become common practice, many of our current mental health providers have not received
adequate training on how trauma may be impacting the clinical presentations of t he clients presenting in
mental health crisis or what our best options are for helping traumatized youth and their families
stabilize in the community. As a result, many young people with ‘out of control’ behaviors are referred to
inpatient psychiatric hospitals that ar e poorly equipped to stabilize behavioral concerns that are driven
by trauma response.
This training is designed to provide an in depth understanding of how trauma manifests in the behaviors
of traumatized youth, guidance on providing a more comprehensive trauma assessment during the crisis
evaluation process, and concrete interventions and psychoeducation for patients and families to increase
understanding of the ‘why’ behind behaviors and opportunities to manage them at home. Participants
will also be provided a vetted list of providers in the community providing evidence-based trauma
treatment to aid in connecting patients and families to providers and interventions that a re most
effective when assessment identifies trauma as playing a critical role in m ental health crisis.

Curriculum Content
The program features the following six topic areas in two parts:

Part 1 Foundational Trauma Concepts
Unit One History and Evolution of Childhood
Trauma and Traumatic Stress
Unit Two Understanding Childhood Trauma
and Behaviors
Unit Three Assessing for Trauma in Crisis
Mental Health Evaluation
Part 2 Interventions for Behavior Change
Unit Four Understanding Nervous System
Regulation
Unit Five Integrative Health
Unit Six Psychoeducation for Patients and
Families

Each unit is approximately one hour long and can be delivered independently or in tandem with other
units, depending on the preference of the training organizer and recipient group. It is highly
recommended to complete all units in part one prior to beginning training in part two. All six hours of
training content meet criteria for continuing education credits for social workers, psychologists and
family therapists. Units 1 and 2 are appropriate to be delivered as stand-alone products for non-mental
health professionals, such as law enforcement and educators, who interface with children in crisis but do
not have an evaluating or treating role. Upon request, recommendations for other combinations of units
and content can be provided to best tailor content to the roles of participants .

Intended Outcomes
After completing this training, participants will have a deeper understanding of the role trauma may be
playing in behavioral challenges displayed by children and adolescents. With the support of strategies
and tools provided, participants will be better equipped to evaluate for the presence of trauma during
assessments and have practical interventions that can be utilized with patients in distress to calm down
or shared with patients and families to try at home. Additionally, participants will be able to provide
referrals to trauma specific treatment opti ons in the community. In sharing this expanded skill and
knowledge with clients presenting in crisis, youth and families have an improved opportunity to remain
stable at home and in the community and reach their full potential.
Ultimately, TRACI for Kids was created with the goal of transforming systems of care in communities.
Programs such as these are most effective when used across agencies to create a shared mental model
around how to best support kids and teens together. Using the same crisis stabilization strategies allows
professionals at different sites to communicate most effectively about education and strategies being
utilized , supporting positive progress and maintaining momentum in recovery across involved providers.
Additionally , equipping staff in acute and crisis mental health settings with a deeper understanding of
the drivers behind behaviors and strategies for supporting patients more eff ectively has promise for
improving job satisfaction and reducing burnout and turnover in critical roles.

FAQs
Q: We already have a trauma informed care and/or de-escalation skills program that we use. Does this
program replace that or will the content conflict?
A: TRACI for Kids is meant to be a supplement to fill the gaps where traditional trauma informed care or
crisis intervention/de -escalation programs end, but additional opportunities exist to build understanding
and skills for supporting kids in crisis. You can keep using your usual programming and offer TRACI for
Kids to equip your staff even more fully to wards safe and effective crisis assessment and intervention.
Q: My staff have been exposed to some of the ideas included in this curriculum. What makes TRACI for
Kids different than other trainings on trauma?
A: TRACI for Kids combines basic ideas about trauma informed care with a deeper look at how trauma
impacts behaviors. We believe that it isn’t enough to tell staff that sometimes kids display emotions and
behaviors and it’s because of trauma, so please be patient. If we really want people to respond
differently, we have to offer more information on how trauma changes the br ain to create a deeper
understanding of the ways in which emotional reactions and behaviors are beyond the child’s control.
We also believe that once staff understand that, they should be offered practical skills for what to do in
those moments. Don’t get us wrong. Creating trauma awareness is great. Real change happens when we
create true understanding and give people the tools to react differently when faced with kids in crisis.
Q: I see that the full curriculum is written for crisis worker/clinicians. Is this appropriate for non-
clinicians also?
A: Yes! Most of the content in TRACI for Kids is very appropriate for anyone who comes into contact with
kids on a regular basis, including law enforcement officers, teachers, one-to-one aides in classrooms or
on psychiatric units and other psychiatric milieu staff. The units can be bundled together or stand alone,
and we are happy to offer recommendations on which units would be most appropriate for your staff
based on their roles and training.
Q: Can this training be offered all in one day, or over a series of days or months if that works best for
my team?
A: One of the great things about TRACI for Kids is how adaptable the content and format is. Each unit is
approximately one hour long, allowing for the training to be delivered in one business day if desired. The
full curriculum can also be delivered as Part 1 and Part 2 over two half day (three hour) sessions, or units
can be delivered individually over a period of time. We recommend that units are not spaced more than
one month apart to allow for cumulative knowledge building over time, but otherwise will make a plan
that works best for your work environment and team.
Q: Is any of the TRACI for Kids training content applicable to adults?
A: Yes! The neuroscience and nervous system regulation ski lls taught in this training can absolutely be
translated by professionals who work with both kids and adults. Bett er still, the i nformation can be used
by helping professionals to combat their own stress and burnout.
Q: You mention that this curriculum is ultimately designed for transforming full systems of care. Is
there help available to think about how best to implement in our organization, or across providers in a
community?
A: Absolutely! This is our passion. We truly believe that if a large organization, like a school district or
healthcare system, implements this across sites and roles, or a community implements across child
serving agencies, this curriculum is transformative. Consultation services to develop an implementation
and sustainability plan are available upon request.

APPENDIX E: DESIGN CRITERIA
Design Goal • Traumatized youth have different brain development than
others; this impacts their social-emotional health and self -
regulation.
• A design to address this must provide specialized knowledge to
all parties attempting to support youth when experiencing a
behavioral health crisis.
• It is strategically important for there to be both deeper
education on trauma response, as well as tangibl e interventions
for in the moment to increase patient and family comfort with
navigating at home.
User Perceptions • The proposed offering is important towards increasing
understanding, reducing shame, and addressing a gap in mental
healthcare that has the potential to keep traumatized kids out
of cyclical placement in institutional settings.
• This is critically important to the possibility of progress, due to
extensive research that shows the significant risks of long term
institutional care on healthy d evelopment.
• Ease of use means information on high complexity concepts of
neurobiology is presented in a digestible format and brief
interventions are easy to learn, teach, and replicate at home.
Physical Attributes • The solution must capture information that can be taught by a
qualified trainer to users and beneficiaries.
• The solution needs to be designed for classroom/practice lab
teaching environments, and the included interventions must be
able to be delivered in any environment where behavioral
health crisis/outbursts may occur.
Functional Attributes • The design needs to be adaptable to different roles in crisis
mental health care.
• Design also needs to be adaptable to be taught to different
family constructs.
• Optimally design should be able to adapt to a pply to other roles
and environments who may encounter youth in crisis (EMTs,
Teachers, Police Officers, etc.)
Constraints • Considerations for whether interventions need to be billable or
can be encompassed in crisis mental health evaluation charge.
• Crisis mental health evaluation is time limited with pressure to
move on to next client- additions to evaluation process and
psychoeducation need to be brief and easy to employ in this
fast paced environment.

APPENDIX F: BUDGET
TRACI for Kids Training and Consultation
First Full Year (Includes Start Up Costs)
Category $'s (000's) Comments

REVENUE
Training (full 6 hours) $300 per trainee *Average Training Group Size is 12
Training Handbook $25 per trainee
Total Per Trainee Cost $325 per trainee

Total REVENUE $15,600 Assumes 4 training groups in first year

*Cost to train all 9 crisis evaluator sites in pilot
county: $35,100
Operating EXPENSES

Contractors (Indep) *Not necessary during first year
Occupancy/Occupancy N/A
Trainings to be completed onsite at receiving
agencies
Furn & Eqpt N/A Same as above
Tech/Computers 1000
Marketing Materials 400
Training/Prof Dev 1000
Website Dev & Branding 5000
Office Supplies 150
Printing Course Materials 1200 Approx $25 per manual

Total EXPENSES 8,750

SURPLUS/DEFICIT $6,850

APPENDIX G: TRAUMA FOCUSED CHILREN’S CRISIS SYSTEM ACTION PLAN
Action Item Fall
2022
Winter
2022/23
Spring
2023
Summer
2023
Fall
2023
Winter
2023/24
Spring
2024
Notes
Phase
1

Meet with SW
Supervisor at
Children’s Hospital

Meet with
Montgomery County
Mobile Crisis and
Diversion Directors

Develop training
curriculum outline and
key content areas

Develop and share
childhood trauma
knowledge survey

Select enhanced
trauma screening tool

Conduct survey on
curriculum content

Amend curriculum
based on survey
results

Review updated
curriculum outline
with key stakeholders

Conduct focus groups
with intended users to
review curriculum
updated with survey
results

Amend curriculum
outline based on focus

APPENDIX G: TRAUMA FOCUSED CHILREN’S CRISIS SYSTEM ACTION PLAN
group
results/feedback, if
required
Prepare full
curriculum and
content for live
training sessions

Phase
2

Deliver training to first
group of MH crisis
evaluators

Begin data collection
at first trained site

Begin meetings with
SW and BH leaders at
other county hospitals
providing mental
health crisis
evaluation

Provide training to
mobile crisis team
members

Phase
3

Identify training dates
for other county
hospital crisis mental
health evaluators

Provide training to all
county mental health
evaluators

Establish quarterly
meeting for ongoing

APPENDIX G: TRAUMA FOCUSED CHILREN’S CRISIS SYSTEM ACTION PLAN
collaboration and
optimization of county
children’s MH crisis
system

Activity Key
Blue = Pending
Purple= In Progress
Green= Complete

Abstract (if available)

Abstract Though the long-term health effects of adversity and trauma are well documented, our understanding of the impact on children’s physical and mental health is evolving. Developments in neuroscience demonstrate that experiencing chronic trauma during formative years can have impacts on the developing brain that can result in externalizing behaviors largely driven by dysregulation of the body’s stress response system (childwelfare.gov, 2015; Perry, 2022). The origins of behavioral challenges, however, are easily misunderstood, resulting in the use of interventions that do not address the core problem of an overtaxed nervous system. Frequent episodes of behavioral health crisis can then result in chronic institutional placement and an impaired ability to function in home and community environments over the life span.
Opportunities exist to improve crisis assessment and intervention for traumatized youth, including the use of brief interventions that support nervous system regulation. Additionally, providing psychoeducation on the neuroscience of childhood trauma to survivors and caregivers has the potential to remediate chronic behavioral health crisis episodes. The development of a trauma responsive crisis assessment and intervention curriculum works to evolve clinical practice beyond traditional trauma informed care by teaching advancements in neuroscience and tangible interventions. The Grand Challenge “Healthy Development for Youth’ seeks to reduce behavioral health problems and address disparities for all youth (Barth et al, 2022). In line with this goal, use of the curriculum across crisis providers in a community is a scalable intervention that can evolve crisis mental health systems towards a more holistic model of care.

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Asset Metadata

Creator Perry, Erin Kathleen (author)

Core Title Youth interrupted: stopping the cycle of institutionalization for traumatized youth

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Degree Conferral Date 2023-08

Publication Date 08/07/2023

Defense Date 07/25/2023

Publisher University of Southern California. Libraries (digital)

Tag behavioral crisis,behavioral dyscontrol,behavioral health crisis,childhood adversity,childhood trauma,chronic trauma,crisis assessment,crisis evaluation,crisis intervention,crisis mental health clinicians,crisis mental health providers,crisis response,developmental trauma,dysregulated nervous system,emotional disturbance,externalizing behaviors,institutionalization,mental health crisis,mental health system,nervous system stabilization,neurobiology of trauma,OAI-PMH Harvest,psychiatric crisis,psychiatric hospitalization,stress response system,toxic stress,trauma recovery,traumatic life experiences,traumatized youth,Youth

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Manderscheid, Ron (committee chair), DellaCava, Lauren (committee member), Rice, Eric (committee member)

Creator Email ekp0821@gmail.com,ekperry@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113296575

Unique identifier UC113296575

Identifier etd-PerryErinK-12204.pdf (filename)

Legacy Identifier etd-PerryErinK-12204

Document Type Capstone project

Rights Perry, Erin Kathleen

Internet Media Type application/pdf

Type texts

Source 20230808-usctheses-batch-1080 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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