Estrés y trauma: Dificultades relacionadas con la pandemia y lecciones aprendidas

(En inglés)

Stress and Trauma:
Pandemic-related Struggles and Lessons Learned

Steve Shuman: Now we can begin. I am so excited to introduce two very wonderful members of the National Center on Health, Behavioral Health, and Safety. They come from two different partner organizations. Dr. Vilma Reyes is the Assistant Clinical Professor at UCSF, University of California, San Francisco Child Trauma Research Program. Since 2009, she has been providing Child-Parent Psychotherapy services, national training, clinical supervision, consultation, and coordination of community-based mental health outreach services and evaluation.

Dr. Karen Gouze has served as the Director of Training and Psychology at Ann & Robert H. Lurie Children's Hospital in the Center for Childhood Resilience based in Chicago for over 35 years. We're so lucky to have such accomplished women join us today for today's session. I'm going to shut up and let them take it away. Vilma and Karen.

Vilma Reyes: Thank you, Steve. Thank you all for taking the time to be here with us today. Wounding and healing, of course, has always been part of our story as humans. Our understanding of it has grown tremendously over the past few decades. So has the interest, and so many of you today come here to think about stress and trauma with us. We will discuss that today in the context of the COVID-19 global pandemic that has exposed and amplified the racial and economic inequality that has already been here. We will think about the impact of stress and trauma on our children and families and also that outer layer in the context of COVID-19.

As much as we're talking about the impact of trauma, these of course are not deterministic factors. We are spectacularly resilient species. We are capable of overcoming. We're capable of thriving. The neurobiology matches that, supports it. We are wired to heal. We are wired to connect, and through those connections we heal. We will also be talking about those protective factors which lead us to how you can create, expand the buffer the young children and families need to be able to overcome this pandemic and stress and trauma in general.

We are indebted to and grateful for all those who have come before us that have informed our field and supported our work and we acknowledge them here.

You will need your heart for this work, so know yourself well. Offer yourself compassion and care. That is essential to life and to your work. As you're joining us on this journey today and Thursday, please do what you need to stay connected, to stay engaged, and to keep your heart open and healthy.

Let's start with some shared definition of stress and trauma, toxic stress, complex trauma. You might have heard many of these terms. What do we mean by trauma? Trauma is a dynamic relationship between the stressors and the resources. The insult at hand and what you have in terms of internal, external resources to be able to buffer it. When there's a situation that overwhelms our ability to be able to cope with what's happened – generally a risk of life or integrity of life – is what we refer to us as trauma.

They're overwhelmed and unable to cope, and because young children are so dependent on us as adults and their regulatory systems are so immature and not yet established, they're most vulnerable and most at risk for this impact.

Another way to think about in an easy to remember way is to think of the three Es. There's the event, whether that's an acute event or stressor, or whether the event is more what we'll be talking today about is this prolonged stressful exposure, COVID being one of them perhaps in a range depending on the impact as well as other things we'll talk about today. The experience that you have as a result and the effects that happen after.

Most of the time when people think about trauma they're thinking about this inner circle, the individual or interpersonal particular events. You might be thinking about natural disasters or violence. Today, I want to expand that a little bit more. Karen and I will be also talking about the context in which those are embedded.

Honestly, in my 15 years of clinical practice, most of the pain the young children and families present people like Karen and I for, have either … are coming to us because of things that have either been caused or worsened by this outer layer. This often becomes unnamed but it's so loud, and it creates this imprint in young children and families … this imprint of them being fundamentally unsafe or unwelcome. I want to push us a little bit to be thinking about that outer layer both in terms of risk and protective factors. We can also think of that as resilience and strength, which is where you come in.

Again, dynamic relationship between insult at hand and resources you have. Many times the children you've met, the insult that has occurred is out of our control, already has happened. But we have a lot of agency, and being able to expand their resources and the strength that families have access to, to be able to buffer from it. Again, we have the neuroscience behind it. It is the healthy relationship, the strong bonds that those connections that really help young children and families be able to cope from stress like COVID-19 and many others. Think of it as the layers that both have shaped the experience but also the layers in which we have access to be able to create more buffers and protective factors and strength and to build on that.

In all of these layers and in all the roles that you are in or take part in, there is a place for all of us in being able to think about how do we change systems so that they do work better for the young children and families that we serve, and how do we find opportunities in all of these layers to beef up, to buffer, to build up the resilience.

Karen Gouze: Thank you, Vilma. Now we're going to talk a little bit about the impact of trauma on children and families. I just want to do a kind of word of warning here. Language matters. Increasingly, as we talking about these areas, there are several things we want to remember. As Vilma said we want to remember that children and families are resilient. Having experienced trauma doesn't mean that you have a death sentence or that life is going to be terrible. I want you to keep that in mind as we move forward and talk about the ACEs study. But also, how we think and talk about these things matter.

Instead of using terms like traumatized children or at-risk children or minorities, we want to use words that are more person-centered. Children who have experienced the trauma, or children who have experienced a potentially traumatic event. Children who are placed at risk. Again, this gets to those other layers that Vilma was talking about. This is embedded in the individual; it's about how the community treats us. Think about your language. It's evolving. It's reflective of our values of racial equity and resilience, and we want to be very careful not to do harm in the language that we use, especially with young children who obviously are learning a great deal about language.

Most of you have probably heard about the Adverse Childhood Experiences Study. This was a study. I'm not going to spend a lot of time on it. But basically, it was in the context of the Adverse Childhood Experiences Study that people first started to talk about trauma. Our notions about this have expanded dramatically since then. But basically, the ACEs study was a study that was done at Kaiser Permanente in California between 1993 and 1998. Keep in mind that this was with a middle-class sample, and it was started by a physician who was basically noticing that some of his … He was dealing with obesity and other health problems and noticed that where some of his patients got better others didn't no matter what he did even though he was doing the same things with them. He also noticed that some of these patients were starting to talk about events that happened in their childhoods that were of interest.

He basically developed a checklist of events that he had been hearing about, things that maybe accrued to people during their childhood. He basically did this study with 18,000, basically middle-class adults, asking them to check off the number of adverse childhood experiences they had. What he found was that when there were more than four experiences … You can go to the next slide Vilma. When there were more than four experiences of ACEs, people had a great deal of negative health outcomes.

There were many, many outcomes of this study. One, he found that ACEs are very common. Again, keep in mind that this was a very sort of middle-class sample. Sixty-three percent of this sample had had at least one adverse childhood event. Twelve and a half percent had experienced four or more. ACEs occur together, and if you think about the list that you just saw, it makes sense that they put together. I mean, if you have a family with their substance abuse, you're also more likely to have domestic violence potentially, right?

ACEs are powerfully predictive of adult mental health and health outcomes. Just to give you a sense of how powerful it is. ACEs place people at risk for all of the things that you see on the screen, but what you find is that it's predictive of both mental and physical health. You might expect that you would see increases in drug use. You might expect that you would see increases in suicide and alcoholism and those other mental health kinds of things. Also in health habits like smoking. But what was really interesting to this physician was that it also had incredible impact on the physical health of his patients. People who had experienced four or more ACEs were 10 times more likely to have diabetes as adults. They were also more likely to have heart disease, cancer, and stroke. You can click on those, Vilma.

What we see is that there's some downward stream for those childhood events that have implications for how you function as adults and how your health is as an adult.

Just to give you an idea of how this works across the lifespan. This is the cumulative effect over time. Let's say you start with an adverse childhood experience like domestic violence. What we find is that next what happens is that there is disruption in neurodevelopment. Vilma talked about neuroplasticity and the fact that the brains also can heal. But initially, negative ACEs or traumatic experiences can cause neurodevelopmental disruptions, which Vilma will talk about later. Children can become easily startled, more irritable, have difficulty concentrating.

This in turn leads to all the impact that you see in Head Start and Early Head Start. You see children who are less well regulated, who are less able to concentrate, who are more likely to have meltdowns, so you see the social, emotional, and cognitive impairments that then result in school failure. As and that precedes, kids who fail in school, who have poor peer relations, who get into trouble a lot at school are more likely to end up using drugs, maybe have poor eating habits, use other maladaptive coping responses, which in turn leads to poor health behaviors and outcomes like obesity, heart disease, problems with the law.

One of the reasons that we sort of try and emphasize some of the physical outcomes even though we're mental health experts is that, frankly the physical outcomes are what get the attention of the people who give us the money. That's what gets the attention of our lawmakers. OK.

Now, let's talk a little bit about trauma in context because that whole ACEs study was very individual. It was about what's happening to an individual on time. But the truth is as Vilma was saying, we want to expand that view of trauma. Because the cumulative and psychological wounding over the life span and across generations emanating from massive group trauma experiences also has negative outcomes, right? We're talking about things like historical trauma, things like generational embodiment of trauma, if you think about enslavement, if you think about genocide, if you think about the eradication of people's lands. Those are community-based historical traumas which actually have intergenerational loadings and cause problems over time.

If you look at an expanded view of ACEs, you see it's not just the standard ACEs. Growing up in a household with emotional abuse, physical abuse, emotional neglect – those were the original ACEs. But that historical trauma makes this a more cumulative and intense experience and we're talking about things as I said like enslavement, removal of property, colonization, these are the things that go shipping inmates, talk about that basically add to the individual cases experiences – that in communities where there's a lot of historical trauma, these things become exacerbated.

Frankly, as we talk about COVID-19 and the pandemic, what we're going to see is that for certain communities, the effects of the pandemic were much more significant than they were for other communities, and that over time, this is going to feed into the roots of trauma that get promoted through the generations.

If you look at this tree, you see that in the soil are all those adverse collective historical experiences. Things like displacement, the Holocaust, genocide, slavery, right? Through that, that causes these roots to get embedded in community violence, lack of educational or economic opportunity, poverty, racism. That in turn leads to what we typically think of as the adverse childhood experiences, right? Substance use, domestic violence, incarceration, etc., and the outcomes that we're talking about.

When you think about adverse childhood experiences, we don't want you to just think about those individual level experiences but think about the community and collective historical experiences as well. COVID-19 in the pandemic certainly fits into those community environments.

If you think about the pandemic, it was really a collective trauma, right? It was something that everybody shared in our society, and everybody tried to cope with in different ways both collectively and individually. This is a collective trauma in the sense that it affects the population at many levels, both at the community level, the interpersonal level, the individual level. The collective trauma doesn't affect all people the same way.

If you think about COVID-19 and the social determinants of health, you think about the traditional social determinants of health, which include things like education, job status, family social support, income. We know that 50% of health can be traced back to your zip code, OK? Where you live because your zip code encompasses all these other things: where your education is, what your family support is, your income is, etc. In communities where the socioeconomic factors were traditionally more problematic or stressful, COVID-19 had more of an impact, right?

We also see this in health behaviors and access to health care. We all know that people with means had different access to health care around COVID than people who didn't have means. The most dramatic examples of that of course were watching all the politicians who got monoclonal antibodies for their treatment when the average Joe on the street couldn't get those, right? Access to health care was different for people with COVID-19.

In addition, COVID-19 interacted with racism in a way that resulted in many stressors piled on top of one another. Can you flip to the next slide? Done, thank you. This is we call them pancake slice simply because this whole process reminds us of a stack of pancakes. If you've ever sat down to eat a stack of pancakes for breakfast, you realize that if you eat just one you can manage it, you can feel pretty good, but if you start eating lots and lots and lots of them, you start to feel kind of heavy, you don't feel so great. It becomes too much to handle, and that's essentially what happened with COVID-19 and racism.

We have a disproportionate impact of COVID-19 because of its impact on families that were already economically stressed, there was more economic downturn in those populations, and things like racism and brutality exploded. We all experienced the George Floyd murder and everything that went with that. All of that came together with COVID-19 to make a kind of pile of pancakes, so it's just too much to handle.

We know that there was a disproportionate effect of COVID-19 on marginalized communities. We know that the mortality rate for example for Black Americans from COVID-19 was 3.6 times as high as the rate for whites. For Indigenous peoples, it was 3.4 times as high. For Latinos, 3.2 times as high. For Pacific Islanders, three times as high. For Asians, 1.3 times as high as for white populations. We know that in marginalized communities, there was a disproportionate effect.

But keep in mind – it's OK Vilma, you can go to the next slide – that Head Start can make a difference. All of you are here to hear about this and we want to say that in dealing with the pandemic, as kids come back to school, as they come back to your centers, as we start to do all the things that Head Start does so well – providing early learning experiences, providing health opportunities with early screenings, with nutrition and meals and health and mental health intervention, and promoting family well-being to work with parents and families. We know that we can start at the very bottom.

These are kids who have all gone through a very difficult experience. Many of their families have really struggled. We know that children, particularly young children, do only as well as their parents do, right? We know lots of these communities, parents were out of jobs, there was food insufficiency, there was economic insecurity, there was a higher rate of people dying. We just did the mortality figures. People got sick more often. There was a lot of potentially traumatic experiences in these young children during this period. But we know that, if they come back to Head Start, that you can make a difference and we will be talking more about that the next time we meet as well.

Just to sum up. I just want to say that although we're all facing the same storm, we're all dealing with COVID-19, we're not all in the same boat. Some of us are in yachts, and some of us only have dinghies with holes in them. Keep in mind that the populations and kids that we're working with … Many of them are the kids who are in those families that are struggling with trying to get through this pandemic in a dinghy rather than a yacht.

With that, I'm going to turn it back to Vilma. Oh, sorry Vilma. I actually skipped one slide. That's OK. Let me just sum up by saying that the mental health challenges from COVID-19 have been huge. In my hospital, we have 1,800 children on our waiting list for mental health services, and our emergency department has been overrun throughout COVID with children who are engaging in self-harm. Obviously, those aren't the little ones that you deal with, but these could be older siblings of those children.

Things like inequity and structural racism have made the pandemic harder for people. These families have had heightened exposure to stress and trauma more social isolation. Because of COVID, there's been limited access to community programs. The things that sustain families, that help our children, the little ones especially, manage and get positive experiences both through relationships, which Vilma will talk about, and learning experiences that are all those things that are the buffers for stress that they experienced. They didn't have access to those during the pandemic in many cases because of COVID-19 restrictions. It's been a very difficult time, and the return to school and the return to your centers is going to be really, really important time for healing.

On that note, Vilma we'll talk about how neurodevelopment works in trauma.

Vilma: Thank you. Brains are a wonderful marvel of nature. I think that what we want to highlight here is how much brains are shaped by experience. This is an exciting time of life that we're all focused on and working on and not that there's no hope for after five. Our brains continuously are looking to rebuild and heal and make new connections for the rest of our life. But we know that the first five years are critical period in brain development in which both types of neuroplasticity are taking place. What's exciting about that is that in every interaction that you have with the child we're helping them shape their brain. Both for all the things that Karen has talked about that, that was part of what has shaped their brain and honestly we might not see all the effects of COVID in development until years later. Everything that you're putting in place in terms of building resources and connections, that's also shaping their brain.

Humans we come into the world with very immature brains just looking for input, and then most of it, 90% of it is really shaped in those first five years, which makes the field that we all chose so exciting and hopeful. There's so much hope inherent in that, and I hope that that's always part of how we communicate, what we communicate to families and to our work. There is a sense of urgency in this life span, this age span, but there's also so much hope built that and that so much resiliency and recovery. Our brains are responding to the input that we put in them, they're amazing in that. In the way that brains are wired for danger, when there's been trauma exposure, you have the capacity to rewire them for connections.

In every interaction that you have with child whether you're a teacher or in any role that you're in Head Start, whatever capacity you have a place in shaping programs that are holding in mind relationships and brains and healing and mental health. That is really the best shot we can give them, the best protective factor that we can build up.

We all learn to adapt to our worlds. That's one of the marvels of nature and humans. Children, our main task is survival. What we need to do is sometimes adapt to stressful situations by surviving and reacting in these ways. We have a brilliant stress response system that is automatic. It doesn't consult first with all parts of it. It’s automatic, goes in our nervous system telling us survival is the most important thing and therefore the moment we experience threat or perceived threat, even if other people aren't seeing threat. But if you perceive threat because of maybe a reminder of something that's happened to you, that activates a cascade of neurotransmitters and hormones in our body that is equipped to keep us safe.

In even young children and infants, we instantly, the moment we experience threat, go into either a fight, flight, or freeze, which are very responses just to prioritize survival over everything else. Both the blood flowing our brain prioritizes survival at the expense of the parts of our brain that help us learn, so in a sense like fear it blocks learning. In the moment, what's most important is, “What do I need to do to survive?”

Some children adapt by prioritizing and thinking the way: I'm going to survive this is to fend for myself. I can't count on the grown-ups around me to do it for me. Then, those are kids that tend to be a little bit more aggressive when they feel threatened. There are other kids that seem to be more withdrawn and sad, and they think if I can't cope with these feelings: I'm not yet ready for and so I fight for them. These kids tend to fall through the cracks in programs. I'm always putting out for you to be the eyes and ears for kids who their way that they have adapted to danger is by being either immobile or numb, the freeze response, or by being sad and withdrawn.

What you see on the surface might be children having problems learning, trouble concentrating, difficulty managing frustration with peers, but that's what you see on the surface. But underneath it all, it is this a marvel at work. It's the brain doing what it needs to do to survive. It's the brain prioritizing survival over other things.

Another thing I wanted … When I'm thinking about the cost of adaptation for young children is it's not always intuitive but young children, especially when they don't have an adult to help them make meaning and understand the experiences they're seeing, they tend to fill in the gaps and they tend to most often then not assume that bad things are happening because of them, that it's something they did that they were maybe bad or did something wrong. I say this because it's so important that, in whatever capacity we can, foster a sense of meaning for children so that they're not left with that sense of blame.

If you were to summarize all the impact of trauma on our brains – on our ability to relate, on our ability to learn – if you were to sum all that up that we've learned in the last few decades, essentially what it does is that it overwhelms the system that gives us these three things: a sense of control, connection, and meaning. These are three things we all need as people. These are things that are distorted in some way because of trauma. By definition, trauma robs you of a sense of control because it's unpredictable. It robs you of a sense of connection because they let you know that people aren't trustworthy and that you're not protected and cared for.

It robs you of a sense of meaning because unfair, unjust, horrible things happen that the children need assistance, that they can't make meaning of. These three things, when you look at behavior of a child, you don't understand where it might be coming from. Likely, you can understand it as a way that they are trying to restore a sense of control. That kid that is throwing a chair in the classroom feels like out of control and feels like they need to restore a sense of control by taking matters into their own hands and throwing that chair. They need to restore a sense of connection with that teacher or parent and need a sense of meaning.

These three words have been really guiding words for me in both understanding behavior and also healing. They inform programs in a sense, and as you're thinking about your classroom or your program, does it give children back a sense of control? Does it restore opportunities for connection? Does it give a chance for meaning?

I will be very brief with this because we've already presented trauma and stress within a range. Stress is unavoidable, and it's part of being alive. It actually is like a muscle that some normative, typical stressors actually build our muscle and tolerance for stress management and it's unavoidable, all the way ranging to toxic stress which is overwhelming our capacity to cope – COVID-19, likely somewhere in the middle, depending on how it affected you. Depending on your level of privilege and resources, it might have been something that was more tolerable or for some if there was a lot of loss associated with it might have become more overwhelming. Think of it as a range and I hope that that's a helpful way to define it.

Another concept that we wanted to bring up is that children have typical developmental fears that peak at certain months. You could look on their left side, these four fears we all have as humans and honestly we have for the rest of our life, but they peak at these times in which we're really trying to make sense of: a fear of separation, losing love, body damage, fear of being bad – this is just part of typical development. When you're looking at the impact of trauma on a child, something to consider is: When did it happen and what were they already trying to master in that developmental place, in their trajectory and how did the event impact it?

If you're already trying to master a fear of separation and you're already struggling with that, and then you are ripped from the hands of your parent at the border or lose a parent incarceration or separation, then how does that then confirm or compound the fear that you already were struggling with and had? When you're looking at trauma, look at how was development set on a different trajectory class or set awry due to the experience? What do we need to do to return to that developmental trajectory?

We're keeping an eye on time, and we were very ambitious. From here, you'll start hearing some things spoken about in slightly different ways, and we might go a little bit faster. A lot of these are really for your reference. I want to name before I pass it on to Karen that the way we divided it up, a lot of what you can do in terms of strategies is on part two. As you're hearing about the weight of this and the impact of this, I just want you to pay attention, check in with yourself, and go back to that hard slide and see how you're doing. We will talk a lot about what you can do in your program to help children recover and heal and go back to their developmental trajectory. Just wanted to name that as we go through the next set of slides where we look at impact a little bit deeper.

We are – both of us – really holding a really strong attachment lens when we're thinking about impact. Honestly, that is … Trauma impacts every area of development, but the attachment is kind of the highest cost because it tells you a conclusion about who you are, about what you can expect from other humans in the world. Can you expect that people can keep you safe and that you matter? Can they help you manage intense emotions? Can that be in relationship with someone else?

Nothing happens outside of the context of our relationship. All wounding, all healing happens within relationships. That is just how we're wired as mammals. When you're thinking about impact, it's not just specific things but are all within attachment. That is where we can heal as well. Relationships are foundational, and as Karen mentioned, it does also alter physiologically how sensitive you are to new input, how you're able to kind of tolerate and manage that. Your intention, ability to regulate feelings, behavior, senses, all of that is within this lens of attachment.

I'll be brief with this couple of slides, but, we can't talk about early childhood and trauma without talking about their primary relationship and how that is impacted by trauma. Young kids need this myth that their parents are big, strong superheroes to keep them safe in this scary world. A lot of times that myth, if you've been somewhat protected by society, is popped in adolescence when you realize your parents actually don't know everything you thought they did. This myth is often prematurely popped for children of color who time and time again get messages from that outer layer that people that look like them and their parents are not respected, they're not protected by society, that they're fundamentally unsafe in kind of this deep unspoken way. When a child loses their sense of confidence in their parent to be able to keep themselves because they see them scared, they see them scared at a traffic light and they see them scared to go grocery shopping because they heard there would be raped, that is system failure. That is system failure causing ruptures of trust.

When you're looking at families and you're looking about what trauma has done to their relationships, look at that outer layer and think about how has that outer layer done to their relationship and how can we as people live in positions of power restore that sense of confidence and trust, restore and do our part to heal broken systems that have not given parents the sense of agency and respect. With that, I'll pass it to you, Karen. I think this is the last bit of that.

Karen: OK. Thank you. We're going to talk just a little bit about how children might look when they come back to your centers as a function of what they've been through, both in the context of trauma in general so that you understand the effects of potentially traumatic events on kids but also in the context of the pandemic and what they've experienced. Vilma's talked beautifully about attachment, and I just have to emphasize that I also think that this is the critical foundational piece when we're talking about trauma.

Complex trauma, which is the kind of trauma that young children experience in the context of disrupted relationships, is probably the most problematic simply because those early attachments impact all of later development. They impact people's trust, as Vilma said, they impact children's ability to learn, they impact attention … All the other things that we can be talking about are impacted by those attachment relationships. If you think about COVID-19, and you think about the fact that some of the children may have lost loved ones – literally lost loved ones, right? It's just … The other day I was talking to a daycare teacher who was talking about this little boy in her class who had lost his grandfather, and she just didn't know what to do for him because he was so dysregulated and upset about this and kept talking about it. We're going to have kids coming back who have actually lost loved ones.

There are also … We all know that children do only as well as their parents do, as I said earlier. We can have parents who have been unavailable to their children because they were struggling with job insecurity or food insecurity, or felt like they couldn't manage their children home all the time while they were also trying to manage a job or whatever. All that lack of emotional availability that was part of COVID for many people is going to contribute to the disrupted attachment relationships, and you're going to see that in your classrooms, in your centers, because children are going to come back, they're going to be less trusting of adults. Kids who have experienced trauma often … They probably need more love and connection than other kids to heal but they push you away. They push you away through their behavior or they push you away because they withdraw. These are things to be looking for.

The other areas in which we're going to see manifestations of trauma and when kids are coming back are the ways that … As you all know, you all work with little kids all the time. In that zero to five age range, we know that when children are stressed, when they're anxious, when they've experienced trauma, we see it biologically and physiologically, right? They tend to have trouble regulating their bodies. You might see regression in toileting. You might see poor eating or sleeping, and some of those things also might have been exacerbated during the pandemic because of the pandemic experiences, right? You also see somatic complaints. Children manifest with headaches or stomachaches, complain about aches and pains in different parts of their body.

Another place where we see manifestations of … Or do we … I think there was a missed slide. Vilma. One before this? Yeah, thank you. The cognitive manifestations of complex trauma include things like significant learning disabilities. We see children showing up with memory problems. Attentional difficulties are probably one of the most significant.

In a recent study that we just did, actually, where we looked at children's exposure to trauma this is in a couple of neighborhoods in Chicago, the connection between children's exposure to trauma and their adaptive functioning on the behavior assessment for children, so things like functional communication, peer relations, et cetera is very strong but it was mediated by attentional difficulties. Kids with worse attention – those connections were stronger. For kids who had better attention, attention regulation that was mediated. What we're seeing is that for children who have experienced a lot of trauma, especially during the pandemic, who haven't had the benefits of school and learning during the pandemic these things are going to become more problematic.

In addition, children who have experienced trauma often present with poor language development and poor verbal skills. That's very complicated for these children because, often, as Vilma was saying, their behavior is not so interpretable to us, right? That the child who might throw a chair because you need to control for example. When children can use their words, we know that they have better control of their behavior. These children not only are struggling with reactivity behaviorally, but they don't have the verbal skills to help moderate those interactions.

Then, of course, we see all the emotional manifestations of trauma. All of the stresses of the pandemic are going to result in children showing up in our classrooms with more emotional dysregulation, right? For some children, we see more unpredictable and explosive behavior –  things like rapidly shifting moods. The thing to keep in mind is because of the fight, flight, and freeze response that Vilma was talking about … Sometimes we don't really know what children are we responding to, so they might have an explosive reaction to something that seems perfectly reasonable … I mean, not reasonable to us. It seems like an ordinary situation to us, but for them it's really frightening, right? These kids have difficulty coming down. They haven't been taught by the adults in their lives how to emotionally regulate. Emotion regulation and learning to emotionally regulate comes in the context of the coregulation in the attachment relationship. As we were saying, if that attachment relationship is somehow fractured, then they're going to have trouble calming down, right?

You might see sadness and irritability and anxiety. We saw how the neurodevelopmental changes can lead to sadness and irritability, stressors that children are experiencing, feeling unsafe or scared. Situations are fearful for them because they'd also in their lives have been scared during the pandemic. All that gets transmitted not even necessarily consciously, right?

These kids are often guarded with others, they might have trouble reading the emotions of others or understanding the emotions of others so that in a situation. You might think that, for example, a child does something to another child accidentally, but that child automatically reacts with a very powerful behavioral reaction or emotional reaction, right? … and doesn't take the time to say or wait to find out if that was an accident, that's because their brains are overreactive, right?

They're also going to have poor awareness of their own emotions and as Vilma was saying, fear of separation. All these things manifest emotionally and these things are going to be exacerbated post COVID, right? Then, along with the emotional dysregulation we always see behavioral dysregulation in children, right? You might see the oppositional behavior, for example, Vilma was talking about throwing the chair.

Poor impulse control – these children are very reactive. We know that the reactive for example to ambiguous cues because if they've been in a family where there's emotion dysregulation, where people were really stressed out by COVID, with the adults in their lives were reactive and maybe even abusive at times because of their own stress, because of COVID, because of their own historical trauma, because of the racialization in their communities. These children are going to be more aggressive, right? It's not only been modeled for them, but they're also scared. As humans, we lash out to protect ourselves, right?

We're also going to see in some kids withdrawal. As Vilma was saying, these are the kids we worry most about. They show a lack of exploration. They may sit-in the corner. They may not engage with peers or with you. Those things – we're going to definitely see coming back from the current situation, I think.

Regression, we've already talked about it. Then, I just want to put in a comment about sensory manifestations because I think this is a really critical part of what we see in children who have experienced trauma, the kind of over- or under-responsivity – to sounds, to touch, to movement, to visual threat – sent their brains as we've said or overreactive. The stress hormone response makes them overreactive, and they have also been in situations frequently where there's either sensory overload or in cases of neglect, for example. There might be a lack of sensory input, but there's no experience of learning how to regulate and manage their reactions to sensory input.

Then, finally, just like to say that over time, even in our little ones, all of this has an impact on identity and beginning self-concept. Little ones think of themselves as the center of the world, right? We all know that they're pretty egocentric. Along with that comes thinking that everything that happens is their fault, right? Bad things are happening at home because their parents are experiencing problems because of COVID. They are not going to think, “Oh, that's because of COVID” and be able to explain to themselves what's going on, right? They're going to think, “What's wrong with me?” Then, there's continual self- blame and feelings of helplessness and difficulty recognizing what's positive about them, which then over time potentially can move into the negative self-concept.

The important thing to note is that we are in a position right now to break these cycles when children start coming back to Head Start, as we said. Can you in the next slide?

Keep in mind that for all children what their reactions are going to depend on how the adults around them react, what experiences they've had, their own internal resources, community resources, a whole set of things, their developmental ages. As Vilma was saying, what are they dealing with developmentally anyway? Not all children even who have experienced the same difficult situation during the pandemic are going necessarily have the same trauma reactions. But we want you to be tuned in to be looking for these reactions when children come back to school, and we'll talk more next time about what you can do about that.

Vilma: OK. Very briefly we want to introduce context in systems because trauma is not just an individual experience. It's a group experience. It's a system experience. It's a collective experience. When we think about schools as one context and then also systems and institution … Briefly, we want to make sure we maybe give you a little bit of time for questions. We'll have more time for questions on Thursday as well.

I think I'm going to be brief here because essentially all we're doing on Thursday is doing talking about strategies within the context of classrooms, but we … You, as a setting, create your own cultures, spoken and unspoken, about how we think of wounding and healing and how we think about children's behavior and understand that that comes from somewhere. That that has meaning. That that's just the tip of the iceberg.

When you see a difficult behavior like let's go back to the chair throwing, which as a preschool teacher that's happened to me many times … I always go to that one, and you're trying to understand what happened. This kid is throwing a chair. Many times when you're not … When you are maybe in a trigger place yourself, systems can be a little bit more reactive, and they might be going to a place of frustration or be thinking that maybe the kid is like manipulative or he's doing this behavior to bug you or to make things difficult for you in the classroom, we want to shift a little to shifting our perspective that behavior is just the tip of the iceberg. It has meaning.

Children do it as a reaction to a lot of times fear and threat and what they think they need to do to survive, and we want to shift that perspective to what's wrong with you … from “what's wrong with you?” to what's happened to you. I know none of you might explicitly say, “What's wrong with you?” But sometimes it shows in our protocol, in our systems, in our system culture, that we may be more likely coming from this triggered place to blame the child or to be frustrated with the child. We want to shift to like … And I hope part of what today is understanding where that behavior might come from, what it means, and what we as a system and as a culture can do to shift our perspective and be more supportive and healing.

Systems have a life of their own. Trauma … On it on … Just because of what trauma is, it disintegrates. It destroys. It confuses. It fragments. If you do nothing to a system and you're exposed to trauma on some level, it will naturally be trauma-reactive because that's what trauma does. Trauma is the opposite of safety. It's overwhelmed. It's rigid. It's numb. Systems have a culture of their own. If you don't put intentional energy and thought into making the system more reflective and integrated and centered on relationships, it will naturally go to a trauma reactive place.

This slide … When you're looking and reflecting on your system and maybe go back – this is really an introduction – go back to your teams and think together: where are we in this? We're already moving towards being trauma-informed in the past decade or so and have had a lot of training in it. But what does it really mean? In the day in day out and how we speak about families and how we are with each other, are we a system that is reactive and numb and rigid or are we a system that is informing … is being informed by trauma and its effects, and can we go even further than trauma-informed? Can we truly create systems that in itself create opportunities for healing? Systems that are integrated, that are collaborative, that are really giving people voice and choice and power and sense of control? Giving that back to the community, working with them not for them, but with them.

As you're looking at this maybe reflecting on your own team, you're not in any of these boxes exclusively. You can't be a system that is, for the most part on a good day trauma-informed that you're working towards being a safe, supportive healing system, and then COVID hit and you might have been triggered and gone back to being trauma-reactive. The important thing is to be reflective and to notice, “Hey, what happened here? What happened with us? We're talking about this family in this way. We're being reactive with this child or this parent. Let's step back. Let's create a system within us in which we're really collaborating with families and we're truly moving even beyond being trauma-informed and truly be attuned to what families need us. There's an opportunity here that I think is incredible that I hope we can use.

Karen: Just to wrap up. Thank you, Vilma. In the context of healing and trauma-informed care, we call this our hamburger slide. You notice my group is really into food: pancakes, hamburgers. Anyway, there are three primary components to this, the creating a safe environment, building relationships and connectedness and supporting and teaching emotion regulation, and all of those have to happen in the context of an environment that includes provider self-care and community self-care and culture and equity. All of these things are things that we will touch on when we talk on Thursday.

But for now, I just want you to remember that all children are coming back to your centers with an invisible backpack. In that backpack is how they feel, behave, and think. That backpacking through their beliefs, about themselves, about the adults who care for them, about the world, about how they've thought about COVID during this time. We want to think about how we can make children feel safe, capable, and lovable. It's all about building resiliency and throughout the life span across locations of care and development, so across communities and in diverse domains. We will talk more about that next time.

For now, I'm going to hand it over to Steve. Thank you.

Steve: Thank you, Karen. Thank you, Vilma. This was a terrific session. All you people that did send questions, we'd like you to stay tuned. Join us for Thursday. The link has been put into the chat a number of times. You can also go to ECLKC on upcoming events and see part two advertised with a registration link, and we will get to you … Dr. Gouze and Dr. Reyes will get to your questions on Thursday.

I and Lydia have both put the links to the evaluations into the chat. The evaluation is on the screen, and the evaluation will pop up when the session ends. You will then fill out the evaluation. When you select submit, your certificate of participation will appear.

Vilma, can you go to the next slide? Thank you. We want to thank both Vilma and Karen for this incredible session, for Julia and Livia for answering questions, for Kate for making sure that we are able to run this pretty much technology issue-free. We also have a mailing list, and that link is on the handout, and you can subscribe at any point to that. You can always write to health –  next slide, please – to health@ecetta.info, ask for the mailing list. You can ask any health, safety, and wellness question during the course of the year. It doesn't have to be webinar related, but we're happy to address all your webinar questions as well.

I encourage you to tune in on Thursday at the same time that you tuned in today, and we will have more of this great presentation. It sounded like Thursday was going to be a lot more operational, that today was the theory and the foundation, and Thursday is what do you do about it in your classrooms.

Thank you all. We'll keep the Zoom up for about another minute or so. Livia, will you put the evaluation link in the chat one more time? We will make sure that each of you get your questions answered if possible.

Cerrar