... TRAUMA INFORMED CARE IN JUVENILE DETENTION 1 Trauma-Informed Care within Juvenile Detention: Educating Staff on a TBRI and Sensory Approach Paige E. McIntire University of Indianapolis Dr. Christine Kroll, OTD, MS, OTR, FAOTA July 2021 TRAUMA INFORMED CARE IN JUVENILE DETENTION 2 Abstract Literature: Trauma within the juvenile justice system is common, with a high prevalence of Adverse Childhood Experiences (ACEs) (Baglivio & Epps, 2016; Clements-Nolle & Waddington, 2018), resulting in neurological changes negatively impacting sensory processing of those who are a part of the juvenile justice system (Collin-Vezina et al., 2019; Fraser et al., 2017; Pickens, 2016; van der Kolk & MacFarlane, 2007; Wolff et al., 2017). A trauma-informed system would allow youth to develop healthy coping skills (Ford & Hawke, 2012; Pickens, 2016) as well as provide for a safer environment for staff members by providing them with appropriate tools to manage youth behavior. Purpose: The purpose of the study was to educate staff at a juvenile detention center on the impact of trauma on sensory processing and the benefits of sensory interventions to utilize with residents to facilitate trusting relationships and reduce the effect of trauma within the population. Methods: This study utilized a survey methodology to anonymously collect opinions and knowledge from staff members at Johnson County Juvenile Detention Center regarding trauma, sensory processing, and re-traumatization before and after a six-week educational series on the topics. Results: Participants demonstrated increased agreement and acceptance of the educational topics as well as stated that they have a better understanding of all topics after completion of the educational series. Discussion: Findings of the study support the need for educating detention center staff on sensory interventions, as well as show the benefit of occupational therapy for residents of the detention center. Keywords: juvenile justice, trauma, sensory processing, Trauma-Informed Care (TIC), TrustBased Relational Interventions (TBRI) TRAUMA INFORMED CARE IN JUVENILE DETENTION 3 Trauma-Informed Care within Juvenile Detention: Educating Staff on a TBRI and Sensory Approach The impact that childhood trauma can have on youth is multifaceted (Pickens, 2016). When children experience multiple types of trauma or various traumatic experiences during their developmental stages, they have experienced complex trauma (Rapp, 2016), the most experienced type of trauma for children (Parris et al., 2015). Complex trauma is defined as exposure to traumatic stressors at an age or in a context that compromises secure attachment with primary caregivers and the associated ability to self-regulate emotions (Rapp, 2016, p. 493) and can evolve into various forms. Complex trauma is perpetrated on children by a caregiver and includes emotional, physical, and sexual abuse, neglect, and witnessing domestic violence (Parris et al., 2015). Some forms of evolved complex trauma include post-traumatic stress disorder (PTSD), depression, addictive behaviors, and offending behaviors (Childs & Sullivan, 2013; DAndrea et al., 2012; Kilpatrick et al., 2003; Rapp, 2016; Thornberry et al., 2010). Trauma and Brain Development There is extensive literature demonstrating the negative impact that childhood trauma has on the developing brain. Cumulative and chronic trauma during early life disrupts multiple areas of development, including behavioral, biological, cognitive, emotional, neurological, and relational domains (Cloitre et al., 2009; Collin-Vezina et al., 2019; Courtois, 2004; van der Kolk et al., 2005). This disruption can persist into adolescence, and young adulthood and can manifest in many ways, such as sensory processing difficulties, decreased self-regulation, and increased violent behaviors (Dowdy et al., 2020), as well as difficulties with aggression, attachment, anxiety, depression, emotional regulation, and trusting others (Fraser et al., 2017; Ogden et al. TRAUMA INFORMED CARE IN JUVENILE DETENTION 4 2006, van der Kolk 2003). The neurological changes that occur because of trauma lead to the individual living in a constant state of arousal that puts that child on high alert to potential dangers in his or her surroundings (Pickens, 2016; van der Kolk & MacFarlane, 2007; Wolff et al., 2017), and that child remains constantly prepared for either fight, flight, or freeze (Parris et al., 2015). Living in a constant state of heightened arousal impacts impulsivity, concentration, and decision-making (Cook et al., 2005). Living in either a high or a low state of arousal for long periods makes it difficult for individuals to process sensory information, which leads to misinterpretation of everyday situations (Fraser et al., 2017). Researchers call this misinterpretation sensory processing and define it as a regulatory process vital to daily function as it allows a person to perceive, interpret, and appropriately react to the environment (Dowdy et al., 2020, p. 375). This change in sensory processing means that children who have experienced trauma and struggle to process their sensory information will respond more quickly, frequently, and harshly to perceived threats than children who have not experienced trauma (Pickens, 2016). When children become hyper or hypo-sensitive to non-threatening stimuli, they may be diagnosed with a sensory processing disorder. Serafini et al. (2016) define sensory processing disorder as difficulties in registering/modulating sensory information and organizing sensory input in order to carry out successful adaptive responses to situational demands (p. 40). Because there is a wide basis of evidence stating that children who have experienced trauma have sensory processing difficulties/disorders (LeBel et al., 2010; Parris et al., 2015; Ryan et al., 2017; Warner et al., 2013) and a wide basis of evidence stating that juveniles within the justice system have experienced high levels of trauma (Abram et al., 2004: Baetz et al., 2019; Ford et al., 2006; TRAUMA INFORMED CARE IN JUVENILE DETENTION 5 Kerig & Becker, 2010), it is likely to assume that many children who are a part of the justice system have difficulties with sensory processing and self-regulation. Trauma-Informed Care (TIC) To combat the traumatic experiences juveniles in detention have experienced as well as to address the associated sensory processing difficulties, Pickens (2016) proposes utilizing a trauma-informed system of care within detention facilities to reduce the effects of trauma for both the youths residing there and the staff who work in the facility. This system of care involves establishing an environment that can acknowledge the trauma that youth experienced before their incarceration and providing an environment that is both physically and psychologically safe for youth and staff members (Pickens, 2016). The goal of TIC care is to restore these individuals sense of safety as well as help professionals understand and recognize the effects that trauma has on an individuals behaviors, emotions, physical health, relationships, and sensory systems (National Association for State Mental Health Program Directors [NASMHPD], 2009). Specific to the juvenile justice system, infusing a TIC approach requires the education of all staff members to create buy-in and gives staff members alternatives to punitive approaches that could further perpetuate the trauma cycle (Ezell et al., 2018; Pickens, 2016). Rhoden et al. (2019) found that for TIC to be effective, it must include components of education, skillbuilding, and self-regulation for all parties involved. Staff education should include content related to child development, de-escalation skills, self-regulation skills, and self-care (Rapp, 2016). Rapp (2016) and Yatchmenoff et al. (2017) emphasize the importance of the physical space when discussing a successful trauma-informed model of care. Both state that the physical environment must be safe, warm, and nurturing, as well as brightly lit and full of natural light (Rapp, 2016; Yatchmenoff et al., 2017). Yatchmenoff et al. (2017) suggest that juveniles within TRAUMA INFORMED CARE IN JUVENILE DETENTION 6 the detention center play a role in this process, creating artwork and signage to display in the halls, common areas, and bathrooms. Trust-Based Relational Intervention While there are many models of TIC used in the justice system, this paper specifically focuses on Trust-Based Relational Intervention (TBRI). Researchers designed TBRI to use with all children with histories of trauma and in all caregiving environments with various adaptations (Purvis et al., 2013). As opposed to other TIC models, TBRI practitioners can train any nurturing caregiver in the TBRI principles (Purvis et al., 2013), meaning that TBRI is an appropriate model of TIC to implement within a juvenile detention center so long as education about the principles is provided to all staff. Practitioners founded TBRI on three main principles of empowerment, connection, and correction, giving attention to the physical, attachment, and behavioral needs of children of trauma (Purvis et al., 2013). These principles allow both the child and their caregiver to learn healthy interactions so that both parties can play an active role in the process of healing from trauma (Purvis et al., 2013). The empowering principle focuses on the physical needs of the child, with a focus on ensuring the child is safe but also feels safe (Purvis et al., 2013). This feeling of safety is created through smooth transitions for children both in daily life and across the timespan, the meeting of sensory needs, and adequate sleep and nutrition. By meeting the safety needs of children with trauma histories, the children can learn to trust others and develop healthy emotions and behaviors instead of relying on their typical fear-driven behaviors (Knight et al., 2004). The connecting principle focuses on the attachment needs of the child by giving voice to the children so that they can better self-regulate. This increase in regulation is done through training caregivers to be aware of signs of stress and anxiety, giving and seeking care, and attunement TRAUMA INFORMED CARE IN JUVENILE DETENTION 7 between child and caregiver. Activities to achieve this include bonding, physical touch, and playful engagement to create a foundation for trusting relationships. The connecting principle improves the relationship between child and caregiver to reverse the effect of stress, stressrelated behavior and improve psychosocial functioning (Fisher et al., 2006). The last principle, correcting, focuses on the behavioral needs of the child through proactive and responsive strategies (Purvis et al., 2013). The objective of this principle is to build the childs social competence (Miltenburg & Singer, 1999), which is a strategy based in cognitive behavioral therapy (CBT) (Purvis et al., 2013). Staff and caregivers implementing proactive behavioral training has long been shown to improve social problem-solving and conflict management skills (Webster-Stratton & Hammond, 1997). Proactive strategies include verbal reminders, behavioral reversals, role-playing, and demonstrations of appropriate behaviors and can result in a decrease of negative behaviors (Purvis et al., 2013). While over time, behaviors will reduce, it will take time, and caregivers will also have to engage in responsive strategies after a behavior has already occurred. Through the three principles of empowering, connecting, and correcting, TBRI assists caregivers in understanding trauma and its effects on youth, recognizing behaviors that result from trauma, and knowing how to help children regulate their behaviors in times of stress (Parris et al., 2014). Purvis and Cross (2007) found that children who attended a summer camp based on TBRI principles demonstrated significant decreases in aggressive behavior, attention problems, cortisol levels, depressive symptoms, negative mood, and thought problems as well as improvements in attachment behavior and interpersonal relationships. Parris et al. (2014) found that implementing the TBRI principles in a residential charter school resulted in decreased TRAUMA INFORMED CARE IN JUVENILE DETENTION 8 physical aggression, profanity, and restraint use, as well as students being more likely to discuss their problems with staff members. Occupational Therapy in Juvenile Justice Due to the history of trauma and its negative impacts on daily life functioning through PTSD and sensory processing, it seems only fitting that occupational therapy plays a role in evaluating and treating the individuals within the juvenile justice system. The practice of occupational therapy exists to enhance or enable participation in everyday life occupations, such as roles, habits, and routines in any given setting (American Occupational Therapy Association [AOTA], 2020). Occupational therapists in the juvenile justice setting can address both physical and mental health, education, and social relationships, as well as smaller aspects of the individuals such as emotional regulation, coping skills, and self-control (De Ruigh et al., 2019). Occupational therapists within the United States have designed interventions suitable to address a wide range of areas to support occupational functioning within the justice system (Munoz et al., 2016). Sensory Approach to Trauma Specific to trauma and its impacts on the brain, occupational therapists can play a role in the sensory needs of juvenile offenders. According to Dowdy et al. (2020), occupational therapists are well-positioned to meet this need due to their knowledge and training in sensory processing and client-centered care (AOTA, 2020; Schoen et al., 2018; Warner et al., 2013). Dowdy et al. (2020) also states that the sensory interventions for self-regulation used with patients with mental health diagnoses would apply to the individuals in a detention center due to their similarities with experienced trauma. In addition, sensory approaches are non-invasive, self-directed, and empowering, supporting a recovery-oriented and TIC practice (Scanlan & Novak, 2015). TRAUMA INFORMED CARE IN JUVENILE DETENTION 9 Within the sensorimotor frame, occupational therapists can address not only the occupation but also the person and environment. Specific to the person, occupational therapists can assist in developing individualized sensory diets (Fraser et al., 2017) and educate on mindfulness (Wolan et al., 2015) to assist with self-regulation and relaxation. Champagne and Stromberg (2004) define a sensory diet as the preferred sensorimotor experiences that help individuals function optimally within their environments (p.38), stating that developing a sensory diet includes identifying activities or experiences that help ground, calm, or center an individual. Using their skills and knowledge of sensory processing, occupational therapists can create safe and calming environments within juvenile detention centers. Skills learned in these safe and calm spaces increase self-awareness of sensory responses and facilitate regulated reactions to overwhelming sensory input (Champagne & Stromberg, 2004; Lebel & Champagne, 2010; LeBel et al., 2010). These spaces, often called sensory rooms, offer various sensory experiences to users, with activities both for calming and alerting each of the sensory systems (Champagne & Stromberg, 2004). Champagne and Sayer (2003) found that implementing a sensory room within a psychiatric unit had a positive impact on 89% of its users, which resulted in decreased use of seclusions and restraints within the facility. Specific examples of sensory equipment that can be included in a sensory room include aromatherapy, fidget toys, relaxing music/sounds, rocking chairs, weighted blankets or vests, crash cushions, and body socks (Koomar, 2009; Scanlan & Novak, 2015), all of which assist the individual to become more organized and regulated. Sensory-based interventions that address trauma and support self-regulation positively impact an individuals engagement and participation in occupations (Champagne et al., 2010), increasing coping skills, resiliency, and post-traumatic growth (McGreevy & Boland, 2020). Dowdy et al. (2020) found that 89% of youth who participated in occupational therapy services TRAUMA INFORMED CARE IN JUVENILE DETENTION 10 while in a correctional facility reported an improvement in their ability to recognize and appropriately cope with negative emotions rather than relying on their previous reactive responses to stress. Participants in the study also reported that occupational therapy served as a consistent and predictable space in which they could be themselves (Dowdy et al., 2020), demonstrating that participants had an increased sense of felt safety. Occupation-Based Model and Frame of Reference To fully and successfully address occupational performance within the juvenile justice population, practicing occupational therapists within this setting must use an appropriate model and frame of reference to guide evaluation and assessment. The Person-Environment-Occupation (PEO) model would be beneficial when looking at youth in the juvenile justice system, whether they be a part of juvenile detention, community corrections, or on probation. This model assumes that the person is dynamic and always developing based upon their environment and their occupations (Law et al., 1996). The focus of this model is the occupational performance fit, which is formed by the interaction of the person, the environment, and the occupation (Law et al., 1996). This performance fit can change as time goes on and be a better fit at various points in life. When this population is a part of the justice system, their occupational performance fit is small. Through proper occupational therapy interventions, including habilitation and rehabilitation, interventions can increase this fit and lead to a more successful occupational performance fit in their given environment. Both the applied behavioral and sensory integration frames of reference apply to evaluation and intervention within the juvenile justice population. The applied behavioral frame of reference would help to frame evaluation and intervention with this population, as it focuses on the modification of current behaviors, facilitating desired behaviors, and learning new TRAUMA INFORMED CARE IN JUVENILE DETENTION 11 occupational skills (Cole & Tufano, 2008). The applied behavioral frame of reference addresses undesired behaviors and maladaptive occupational performance and would be applicable to this population, as research shows that they tend to revert to prior functioning upon release (De Ruigh et al., 2019; Eggers et al., 2006; Hutcherson, 2012; Ristad, 2008). The sensory integration frame of reference applies to this population due to the neurological brain changes from experienced trauma, resulting in difficulties with sensory processing. The sensory integration frame of reference focuses on the ability of an individuals brain to organize sensory information and produce an adaptive response in relation to that information (Cole & Tufano, 2008). As previously mentioned, children in juvenile detention often have difficulty with their sensory processing (LeBel et al., 2010; Parris et al., 2015; Ryan et al., 2017; Warner et al, 2013), meaning that the sensory integration frame of reference would serve as an informative guide to providing appropriate intervention to assist in regulating the processing of sensory information for these individuals. In addition, a large aspect of the sensory integration frame of reference focuses on the processing patterns of individuals, which includes sensory-seeking, sensoryavoiding, sensory sensitive, and low registration behaviors (Cole & Tufano, 2008). Once the juvenile offenders gain a better understanding of their own sensory preferenes, they will be better equipped to self-regulate and respond appropriately to sensory input in the environments. The Current Study In line with the foundations of TIC and TBRI, the first step of this felt safety includes education of staff members at juvenile detention facilities on trauma and its impact on development to avoid re-traumatization. Denison et al. (2018) provided education to staff members at a residential treatment center on these topics with the goal of reducing restraints and seclusions. Denison et al. (2018) found that older staff members, staff members with more than TRAUMA INFORMED CARE IN JUVENILE DETENTION 12 four years of experience at the facility, and staff who had completed a college degree initially agreed more with the principles of TIC than younger staff members, those with less than four years of experience, and those without a college degree. After education on trauma, restraints/seclusions, and sensory interventions, Denison et al. (2018) found that staff members who have spent the most time in the setting are more open to alternative strategies, such as sensory interventions, in place of restraints/seclusions, also finding increased acceptance and understanding of TIC and sensory interventions across the population. This study supports the teaching of TIC and sensory interventions within juvenile justice settings, indicating that these strategies can impact the individuals within the setting as previously mentioned and on the staff members at the facility. Through educating staff at juvenile detention centers on the impact of trauma, sensory processing, and proper sensory interventions, occupational therapists can play a role in increasing safety within the detention center and increasing self-regulation, coping skills, and executive functioning of the children who spend time within the facility. Ideally, staff members will have a more positive attitude towards sensory strategies and the reduction of restraints/seclusions once they have a better understanding of the neurobiology that underlies behavior (Barkowski, 2016). The purpose of the current project is to educate staff members at Johnson County Juvenile Detention Center on trauma, its impact on brain functioning, and how sensory interventions can assist in behavioral management as well as to assess change in their view and use of TIC before and after education on the topic. Methods This study utilized survey methodology to anonymously collect opinions from the staff at Johnson County Juvenile Detention regarding knowledge and opinion about trauma-informed TRAUMA INFORMED CARE IN JUVENILE DETENTION 13 care, sensory strategies, and the use of restraints and seclusions within the facility both before and after a six-week educational series on the topics. Researchers created the survey from components of surveys by Abdoh et al. (2017), Denison et al. (2018), King et al. (2019), and Multnomah County Defending Childhood (2016) to address all relevant demographics and questions relevant to the previously mentioned topics. Researchers omitted some questions from each of the original surveys due to a lack of relevance to the current research. Participants The participants for this study consisted of 19 staff members at Johnson County Juvenile Detention. Researchers made the survey available to all 32 staff members via paper or online format, with a response rate of 59.4%. Of these participants, eight were female, nine were male, and two preferred not to disclose their gender identity. All participants had a minimum of a high school diploma, with seven participants holding a bachelors degree and an additional six participants having some post-high school education. shows responses for the highest levels of education for participants. Table 1 Highest level of education Level of Education n Percentage High School 4 21.1 Trade School 1 5.2 Some college 4 21.1 Associates degree 1 5.2 Bachelors degree 7 36.8 TRAUMA INFORMED CARE IN JUVENILE DETENTION Prefer not to answer 2 14 10.5 Note. n= Total participants with highest level of education. Respondents between 40 to 59 years of age accounted for 42% of the sample size. Four participants ranged between 20 and 29 years of age, two participants ranging between 30 and 39 years of age, and two participants ranging between 60 and 69 years of age. Three participants preferred not to say their age. Length of time working at the detention center ranged from less than 6 months to more than 20 years, with the highest representation from those who have worked at the facility for more than 20 years (26.3%), with an additional 15.8% working at the facility for both 3-5 years and 5-10 years. Three participants (15.8%) had worked at the facility for less than three years, while two participants (10.5%) had worked there between 10 and 20 years. Three participants (15.8%) preferred not to disclose the length of time they had worked at the facility. A majority of participants (73.75) had no previous experience working in the justice system, while 36.8% of participants did have previous experience working with children who had experienced trauma. Two participants preferred not to disclose their previous work experience in relation to working in the justice system or with children who had experienced trauma. Procedures The researchers submitted the proposed project to the Institutional Review Board at the University of Indianapolis, with the proposed study not requiring approval from the board. Researchers formed the sample through convenience sampling of all staff members at the facility. All digital communication with participants was completed via email through the Juvenile Detention Director, where the researchers did not have direct access to participant emails. TRAUMA INFORMED CARE IN JUVENILE DETENTION 15 Researchers initially provided paper surveys to all 32 staff members at the detention center, including youth care managers across all four work shifts, teachers, kitchen staff, and other administrative roles. Due to low response rates (12 of 32 participants), researchers sent an electronic form of the survey to participants via email, resulting in an additional seven participants. All responses from participants in this study remained anonymous to minimize the chance of researcher and participant bias. Each participant was asked a series of questions to create a unique identifying code that would assist researchers in matching pre-and post-surveys and ensure no participant completed both the paper and electronic forms of the survey. Researchers collected data for the pre-survey between April 20, 2021, and May 1, 2021, via paper survey and between April 28, 2021, and May 1, 2021, using an online survey created on Google Forms. Researchers verbally reminded staff members to complete the survey through informal discussions at the site. Researchers provided participants with the post-survey beginning on June 7, 2020, until June 25, 2020. The post-survey was provided in both paper and electronic forms for ease of completion by all willing participants. Twenty completed the postsurvey, two on paper and 18 through the online format, with only eight of the same participants from the pre-survey. The first part of the pre-survey asked participants five questions, such as what is the first letter of your mothers name? so that each participant could create a unique identification code consisting of letters and numbers to ensure anonymity during the pre-and post-surveys. The second part of the survey asked questions about demographics and their previous work experiences relevant to the justice system and children who have experienced trauma. The next part of the survey asked participants to respond to 30 statements relating to their knowledge about impacts of trauma, re-traumatization, and knowledge and opinions of TBRI and sensory TRAUMA INFORMED CARE IN JUVENILE DETENTION 16 interventions using a Likert scale ranging from strongly disagree to strongly agree. An optional prompt was provided for participants to share feedback regarding the survey or their personal opinions/experiences with the topic and ask questions regarding the topics on the survey. The complete survey can be found in Appendix A. The post-survey contained identical sections for creating the identification code, as well as the 30 statements about their knowledge about impacts of trauma, re-traumatization, and knowledge and opinions of TBRI and sensory interventions. An additional seven Likert scale statements were added to assess participants feelings about knowledge gained from the educational series. Lastly, researchers asked four open-ended questions about the impact of the educational series and how they plan to utilize the information provided. The post-survey can be found in Appendix B. Researchers provided the educational material for the program to participants via an online presentation as well as in PowerPoint format with a voice-over component. Table 2 shows the title of each weeks educational module, when it was sent to participants, and how many participants completed each educational component. After each weeks education, researchers asked participants to complete a small post-education survey of two to three questions to track the number of participants completing each weeks education. Questions on the post-education survey consisted of knowledge assessment questions as well as an open-ended prompt for feedback from participants. Table 2 Educational Topics Title Trauma and Sensory Processing Sensory Processing and the Sensory Systems Sensory Interventions The Sensory Room Date 4/28/21 5/5/21 5/12/21 5/19/21 n 20 22 23 23 TRAUMA INFORMED CARE IN JUVENILE DETENTION The R's of Trauma-Informed Care 5/26/21 Staff Self-Care 6/2/21 Note. n= number of participants each weeks educational component 17 20 20 Sensory Room In addition to providing an educational component to staff members at the detention center about the use of sensory interventions and a sensory room, the researchers also engaged in creating a sensory room and sensory paths for residents of the center. The sensory paths were designed using TBRI principles of relation and connection and were placed in two spaces in the detention center and one space in the accompanying probation office. One of the detention paths was placed in the hall, between the classroom and gym, while the other was designed to serve as a regulation tool as residents go up the stairs and into the courtroom. The space for the sensory room was located between two pods that previously served as a storage space for equipment. Researchers allowed residents to assist in painting an underwater mural scene on one of the walls in the room. Prior to the residents assisting in painting, the researcher outlined various underwater creatures on the wall to assist in breaking down painting tasks for the residents. Researchers allowed each resident to engage in painting the wall for a 30-minute time period, pulling one resident from their cell at a time. All residents were offered the opportunity to paint before allowing residents to engage in additional painting time. All but one resident stated that they would like to paint the room. The researcher was present with each resident as they painted, and the detention center provided all supplies for painting the room. Painting the room occurred over seven evenings and included 18 detention residents. Residents ranged in age from 14 to 18, with 15 boys and three girls engaging in the painting tasks. Results TRAUMA INFORMED CARE IN JUVENILE DETENTION 18 Of the 30 statements on the pre-survey, a majority of participants either agreed or disagreed in some capacity on 23 statements. Figure 1 shows the remaining seven statements that did not achieve a majority of responses in either agreement or disagreement. There was minimal agreement for two statements, with each of the Likert options being chosen at least once by a participant. Those statements were, I believe that all residents should be treated the same, regardless of the individual resident and their behavior and A resident who already received a punishment (such as catwalk) should not be permitted to engage in recreation time. While a majority of participants disagreed with the statement Giving options to an out-of-control resident can be dangerous, 10.6% of participants agreed, and 36.8% of participants were neutral. For the statement Exposure to trauma is common, a majority of participants (57.9%) agreed, but two participants disagreed in some capacity, while 31.6% were neutral. Figure 1 TRAUMA INFORMED CARE IN JUVENILE DETENTION 19 Non-Majority Agreement/Disagreement Statements Strongly disagree Disagree Neutral Agree Strongly Agree # of participants 14 12 10 8 6 4 2 0 Classroom Giving a resident For an individual disruptions an ultimatum who becomes and/or behavior can effectively quiet and problems are resolve an withdrawn is related to escalating response to trauma. situation. stress, engaging in physical activity can be helpful. I believe that all Once a resident's residents should behavior be treated the escalates past a same, regardless certain point, of the individual there is no resident and choice but to their behavior. restrain and/or seclude them. Engaging in an A resident who activity such as already received basketball or a punishment rapping can (such as catwlak) improve selfshould not be regulation skills. permitted to engage in recreation time. Statement Nine of the 30 statements on the pre-survey had an average level of agreement of 3.9 or higher on a five-point Likert scale, while five statements had an average level of disagreement of 2.4 or less. The remaining statements had an average level of agreement equaling a neutral response. Additional information regarding percentages of participants in agreement or disagreement and averages for each statement can be found in Appendix C. In week one of the educational component, researchers focused on basic definitions and statistics of trauma with the juvenile justice population, including ACEs, as well as giving a basic introduction into sensory processing and the importance of coping and resilience within the population. After completing week one, participants completed two post-education questions. When asked what drew them to working within the juvenile justice system, nine participants (45%) mentioned helping others, whether that be the juveniles themselves or their families. An additional three participants stated that their personal histories made them want to work with the TRAUMA INFORMED CARE IN JUVENILE DETENTION 20 juvenile offender population. Three respondents stated that there was no reason behind pursuing their job, and they were not sure why they worked within this setting. One participant specifically stated, I ended up here by chance but have learned to enjoy what I do. When asked what surprised them from the first week of education, 35% of participants stated that none of the information was surprising. In contrast, three stated that they were surprised about the high prevalence of trauma that staff experienced during childhood. The second weeks education focused on sensory systems and sensory processing styles. Participants learned about the eight sensory systems, hyper- and hypo-responsiveness, and the four sensory processing styles. Figure 2 and Figure 3 show the participants self-believed sensory processing styles and if they have experienced situations where sensory interventions would have been beneficial. Figure 2 Staff Sensory Processing Style Figure 3 Perceived Sensory Intervention Benefits Have you experienced a situation within the detention center where a sensory intervention would have been beneficial? Staff Sensory Processing Style Sensory Sensitive Sensory Avoiding Low Registration 3 2 15 10 10 6 5 0 Yes No Maybe Researchers focused specifically on preparatory and sensory interventions during week three of the educational series, which included a video on what it feels like to have sensory processing difficulties. After watching the video, 39.1% of respondents used words like stress, anxious, or overwhelmed to describe how they felt while watching the video. Four participants TRAUMA INFORMED CARE IN JUVENILE DETENTION 21 stated that the video made them feel more educated or informed about the experiences of those within the juvenile justice system. A large part of the preparatory interventions included the importance of offering choices to residents of the detention center. After the education, 69.6% stated that they were comfortable or extremely comfortable offering choices to residents, with only three participants stating that they were uncomfortable or extremely uncomfortable. The sensory interventions included research supporting the use of music and physical activity as sensory modulation and TIC activities to help reduce stress and anxiety in residents. Figure 4 shows what participants use to deal with their own stress or anxiety. Figure 4 Staff Coping Strategies Figure 5 Liklihood of Reccommending Sensory Room What do you use to help deal with your stress or anxiety? How likely are you to recommend a resident use the sensory room? Extremely Likely Music 2 2 Physical Activity Both Neither 16 3 Likely Neutral Unlikely Extremely Unlikely 0 2 4 6 8 10 Week four focused on creating the sensory room at the detention center, including why it would be beneficial and what sensory interventions and tools would be included. Figure 5 shows how likely participants stated they would recommend that a resident use the sensory room. Participants also described items they would enjoy having in a sensory room or relaxation space designed specifically for them. Nine participants stated they would enjoy having access to music or calming sounds, and three mentioned exercise or physical activity options. Additional options mentioned include smells and comfy seating, with four participants noting each item. Lastly, in the optional comment box, two participants stated that they were concerned about residents 12 TRAUMA INFORMED CARE IN JUVENILE DETENTION 22 manipulating or taking advantage of the sensory room, also stating that the room would be good for some residents. However, they would like to see detailed policies placed in the facility handbook about using the space. The focus of week five was on general trauma-informed care and how to implement the concept more easily into daily interactions within the detention center. When asked what the most difficult part of trauma-informed care was, five participants mentioned having difficulty with the punitive versus rehabilitative approaches, not knowing when to use which approach. One participant specifically stated that the most difficult part was how to hold kids accountable for their actions when sometimes their actions are a result of their trauma. Four participants stated that being empathetic and relating to residents was the most difficult part due to not having the same lived experiences. One participant, a shift leader, stated the following: I think time is our biggest challenge in detention. The responsibility of keeping everyone safe and making sure tasks get completed is daunting with only a few people to do it. Its very difficult to give individual attention and sometimes impossible when we are trying to get basic needs met. Being a supervisor its hard for me to help a resident process through what they are feeling when Im constantly getting interrupted or pulled away to the next situation. I think this leads to frustration for both parties. Prioritizing leaves some residents at the bottom of the list which can make them feel their issue is not worthy of time. Supervisors are sandwiched between resident and Youth Care Managers and there is never enough time for both. Researchers also asked how participants build connections with residents. Nine participants stated that they simply listen to what the residents have to say, while an additional four TRAUMA INFORMED CARE IN JUVENILE DETENTION 23 participants state that they engage the resident in conversation about preferred topics. Other strategies included playing games with residents, rewarding good behavior, and overall respect. The last part of the educational series focused on the staff and the importance of self-care and overall wellness. Of the 20 participants that completed the education, half stated that their go-to self-care activity involves some type of exercise or physical activity, with three participants specifically mentioned taking a walk. Four participants stated that their go-to self-care activity involved music, and one participant mentioned weekly therapy sessions. Seventy-five percent (15) of the participants stated that they had tried at least one of the mindfulness activities explained throughout the education, including mindful breathing, tai chi, yoga, body scan, guided imagery, affirmations, and meditation. After completing the six-week educational series, participants once again reached a majority of either agreement or disagreement for 23 of the 30 statements. Of the seven remaining statements without a majority, only three were the same statements from the pre-survey. These statements were Classroom disruptions and/or behavior problems are related to trauma Giving a resident an ultimatum can effectively resolve an escalating situation and A resident who already received a punishment (such as catwalk) should not be permitted to engage in recreation time. Three of the 30 statements received at least one participant answering with each of the five Likert options, two of which still received a majority decision in agreement or disagreement. Four statements had 90% or more of participants in agreement. For 14 of the statements, participants reached an average level of agreement of 3.9 or higher. Appendix C shows this in more detail, along with percentages and averages for all 30 statements on the postsurvey. TRAUMA INFORMED CARE IN JUVENILE DETENTION 24 Overall, participants showed increased agreement on 13 of the statements when looking at pre-and post- outcomes. Of these 13 statements, four statements were regarding their knowledge of the impact of trauma, six were regarding their knowledge and opinions of TBRI and sensory interventions, and the remaining three were related to re-traumatization. For five of these statements, none of the participants stated that they disagree in any fashion after the education. Despite minimal overall changes in response, no participant stated that they agreed with two of the statements they previously agreed with on the pre-survey. These statements were Residents can use higher level thinking (such as cause and effect) when they become upset, and Restraints and/or seclusions are the more effective way to control behavior. For an additional two statements, participants stated that they now strongly agree with the statement, as opposed to simply agreeing. The statement with the most change from the pre to post-survey was, Residents can benefit from routines and rituals to support them during transitions or difficult time periods. Prior to education, 21.1% of participants strongly agreed with this statement, as opposed to half who strongly agreed after education, with an additional 40% agreeing. Only two participants responded to this statement with neutral. Participants varied in their responses, with at least one participant choosing each of the Likert options for eight of the statements, two about knowledge of the impact of trauma, two about knowledge and opinions of TBRI and sensory processing, and four about re-traumatization. Of the 20 participants who completed the post-survey, only eight were the same participants who completed the pre-survey. When looking at these eight participants for pre-post survey changes specifically, they more strongly agreed with or had higher levels of agreement with six statements. Of these six statements, two were coded in each category of knowledge TRAUMA INFORMED CARE IN JUVENILE DETENTION 25 about the impact of trauma, knowledge, and opinions of TBRI and sensory interventions, and retraumatization. All eight participants stated that they agreed in some capacity with the following statements: Residents can benefit from routines and rituals to support them during transitions or difficult time periods, and Residents can benefit from opportunities for helpful participation, such as leadership or a designated job. Participants responded with each of the Likert scale options for two statements, meaning that all responses had a least one participant agreeing at that level. The statements with the most change in agreement from pre-survey to post-survey for these eight individuals were Re-traumatization can occur in both the community and in institutional settings, and Constant stress can impact a persons ability to make new memories. Eighty-seven and a half percent of participants agreed in some capacity with each of these statements on the post-survey, with an average level of agreement of 4.4 out of 5. See Appendix D for answer percentages on all items for the eight participants completing both the pre-and post-surveys. Along with the post-survey statements, participants also responded to seven statements regarding their gained knowledge about the topics presented during the educational series. A majority of participants agreed with all statements, except for I have a stronger belief in and support of trauma-informed care (TBRI), with 45% of participants agreeing in some way and 10% of participants disagreeing in some way. The most strongly agreed with statement was I have a better understanding on the impact of trauma, with 70% of participants stating that they agree or strongly agree. However, at least one participant disagreed with three of the seven statements. Table 3 shows percentages for all responses. Table 3 Statements about Gained Knowledge TRAUMA INFORMED CARE IN JUVENILE DETENTION Statement Strongly Disagree (1) 26 Disagree (2) Agree (4) Strongly Agree (5) 30 55 15 35 50 15 10 35 40 15 5.3 36.8 47.4 10.5 45 40 15 30 40 30 45 25 20 I have a better understanding of the impact of trauma I have a better understanding of sensory processing I have a better understanding of sensory interventions to use with residents during stressful times I have a better understanding of why residents would benefit from a sensory/calm down room I have a better understanding of trauma-informed care (TBRI) I have a better understanding of why it's important to take good care of myself I have a stronger belief in and support of trauma-informed care (TBRI) 5 5 Neutral (3) Sensory Room Feedback During the time spent painting the sensory room, residents engaged in conversation, discussing a wide variety of topics. Topics brought up by multiple residents include discussing their time spent at a residential treatment center, their parents going to jail/prison or doing drugs, their desire to get a job or go back to school upon release, their previous self-harm or suicide attempts, and their relationships with their parents. One resident specifically discussed how during his time in detention, his father was also going to jail and was to serve a long sentence. Other residents mentioned how they grew up in a broken household, witnessing or experiencing abuse, and seeing their parents do drugs. Multiple residents stated that they enjoyed their time painting and were surprised at their painting abilities. Discussion TRAUMA INFORMED CARE IN JUVENILE DETENTION 27 Ezell et al. (2018) and Pickens (2016) stated that to fully implement a TIC approach into the justice system, the staff members would have to buy into the principles and practices of TIC, specifically TBRI for the given setting. In line with this, after completing the six-week education, 55% of participants stated that they had a better understanding of TBRI and 45% of participants stated that they had a stronger belief in and support of the practices relevant to their facility. An additional 45% of participants felt neutral regarding a stronger belief in and support of TBRI, with the possibility that some of these participants had already bought into the principles and did not require any additional education or buy in to implement practices into their daily interactions with residents. The implemented education included all components of education suggested by Rhoden (2019), including education, skill-building, and self-regulation for all parties. Educational components addressed trauma, its impact on development, and sensory processes, with a majority of participants stating that they have a better understanding of all mentioned topics. Along with this, participants were given skill-building opportunities through examples of both proactive and reactive strategies of interaction with residents that support felt safety and build connections in line with TBRI. Self-regulation was addressed with participants by providing sensory interventions to utilize with residents or for themselves during high times of stress. The current education also included education relating to self-care, as supported by Rapp (2016) with the idea that those who work with this population must first take care of themselves to take of individuals with such high amounts of trauma. In accordance with this idea, 70% of participants stated that they now have a better understanding of the importance of self-care. The post-survey results also support Barkowski's (2016) findings. Staff report a better understanding of the neurobiology related to trauma and have more positive attitudes towards TRAUMA INFORMED CARE IN JUVENILE DETENTION 28 sensory interventions and the sensory processing approach. Findings of the current study also support that participants are more open to alternative strategies, as found by Denison et al. (2018), with one participant explicitly stating, I am much more open to alternative types of consequences when asked about the impact of the education. An additional participant stated, I will not be so quick to judge things and how things will be impacted on a kid, with other participants stated they now have increases levels of awareness and more perspective into the experiences of these individuals. Overall, participants agreed more strongly with 14 statements after being educated on the topics, six of which related specifically to sensory processing, which falls within the scope of practice of an occupational therapist within this setting. In addition, the statement with the most change in agreement from pre- to post-survey relates to routines and rituals, which are occupations (AOTA, 2020) and supports the notion of occupational therapy working with the residents at the facility in order to create more defined routines and rituals in line with a TIC approach. Additionally, as Yatchmenoff et al. (2017) suggested, residents at the facility were involved in the painting and creation of a sensory room within the detention center. Residents who participated reported feeling less stressed and more relaxed after working on the painting, suggesting that the activity helped with self-regulation, as Champagne et al. (2010) explained. One participant stated that painting let my stress out without breaking something or hurting others or myself and aided with his anxiety. Painting in the sensory space had additional benefits for residents, such as giving them hope for a better future and making them feel good about doing something that could help others in the future. For example, one resident stated, Painting made me feel like there is still stuff in the world that I can do, and It made me feel confident that I still have a good life ahead of me. TRAUMA INFORMED CARE IN JUVENILE DETENTION 29 While not explicitly stating that they felt safe, these residents could be honest and vulnerable due to feeling safe within the space, which supports the findings of Dowdy et al. (2020), where residents reported that OT was a consistent and predictable space in which they could be themselves. The current study's findings suggest that educating staff members at juvenile detentions centers on trauma, sensory processing, and the use of restraints and seclusions can benefit both staff and residents. Through this education, staff can gain an increased knowledge about alternative practices that may assist in creating stronger bonds with residents and result in fewer exhibited behaviors. In contrast, residents will benefit from being offered alternative methods to meet their sensory needs and cope with their stress and anxiety. These findings suggest that occupational therapy is deserving of a role within the justice system to assist with implementing TIC and implementing sensory interventions within the setting. Limitations Limitations of the current study include a small sample size with little participant retention between pre and post-survey due to high turnover rate at the facility. 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Before the educational series begins, I am conducting an anonymous survey to assess your current knowledge and opinions regarding trauma and its associated factors within the detention center. You will complete an additional survey at the end of the educational series. The survey consists of 3 parts. The initial part of the survey is to create a unique identification code to ensure anonymity. The following part will ask demographic information, while the last part of the survey consists of 30 statements. There is an additional prompt at the end of the survey regarding questions you may have or topics you would like to see covered. Each survey will take approximately 15-20 minutes to complete. Your identity will remain anonymous throughout both surveys. You are free to quit the survey at any point without penalty. You are free to omit answers on any question you feel uncomfortable answering. Your participation and answers on this survey will in no way impact your employment status at Johnson County Juvenile Detention and will not be shared with any of your fellow Youth Care Managers. If you have any questions, please feel free to contact Paige McIntire at the contact information below. Once you have completed the survey, please place it inside of an enveloped and seal the envelope. Please then place your sealed envelope into the basket for collection. Please do not write your name on the survey or the envelope. Please only complete this survey if you are 18 years of age or older. Please tear off the cover page of this survey and keep it for your records. Thank you for your participation. Sincerely, Paige McIntire Paige McIntire, Occupational Therapy Student Department of Occupational Therapy University of Indianapolis, Indianapolis, Indiana 46227 (317) 642-7685 mcintirep@uindy.edu TRAUMA INFORMED CARE IN JUVENILE DETENTION 40 Pre survey Please answer all identification questions. These questions will assist you in creating a code to ensure anonymity while taking the survey. This code will be used on both the pre- and posteducational surveys. What is the first letter of your mothers name? ________ Example: Jennifer (J) What is the second number of your current age? ________ Example: 24 years old (4) What are the last 2 digits of your cell phone number? _________ Example: 798-9862 (62) What is the first letter of the month you were born in? _____________ Example: August (A) What is the first letter of your middle name? ________ Example: Marie (M) Your identification code: _______________________ Example: J462AM Demographics: Please circle your answer, choosing only one answer per question. 1. What is your preferred gender identity? a. Female b. Male c. My preferred gender is not listed here d. Prefer not to answer 2. What is your age range? a. Less than 20 years b. 20-29 years c. 30-39 years d. 40-49 years e. 50-59 years f. 60-69 years g. 70+ h. Prefer not to answer 3. What is the highest degree or level of education you have completed? a. Some high school b. High school c. Trade school d. Some college e. Associate degree f. Bachelors Degree g. Masters Degree h. Ph.D. or higher TRAUMA INFORMED CARE IN JUVENILE DETENTION 41 i. Prefer not to say 4. How long have you worked at Johnson County Juvenile Detention? a. Less than 6 months b. 6 months-1 year c. 1-3 years d. 3-5 years e. 5-10 years f. 10-20 years g. More than 20 years h. Prefer not to answer 5. Before working at Johnson County Juvenile Detention, did you have experience working within the justice system? a. Yes b. No c. Prefer not to answer 6. Before working at Johnson County Juvenile Detention, did you have experience working with children who have experienced trauma? a. Yes b. No c. Prefer not to answer Statements: Please respond to the following statements using a scale of 1 (Strongly Disagree) to 5 (Strongly Agree). Circle the number that best describes how you feel about each statement. 1 2 3 4 5 Statement Strongly Disagree Disagree Neutral Agree Strongly Agree Substance use can be indicative of past traumatic experiences or adverse child experiences (ACEs). * 1 2 3 4 5 There is a connection between mental health and past traumatic experiences or adverse child experiences (ACEs). * 1 2 3 4 5 Listening to music can make a persons body feel calmer. 1 2 3 4 5 TRAUMA INFORMED CARE IN JUVENILE DETENTION Giving options to an out-ofcontrol individual can be dangerous. 42 1 2 3 4 5 Statement Strongly Disagree Disagree Neutral Agree Strongly Agree Residents can use higher level thinking (such as cause and effect) when they become upset. 1 2 3 4 5 Re-traumatization can occur in both the community and in institutional settings. * 1 2 3 4 5 Re-traumatization can occur unintentionally. * 1 2 3 4 5 Classroom disruptions and/or behavior problems are related to trauma. 1 2 3 4 5 1 2 3 4 5 Distrusting behavior is indicative of past traumatic experiences or adverse childhood experiences (ACEs). * 1 2 3 4 5 Stress can negatively impact residents cognitive and physical abilities. 1 2 3 4 5 Giving a resident an ultimatum can effectively resolve an escalating situation. 1 2 3 4 5 Residents can benefit from routines and rituals to support them during 1 2 3 4 5 For many residents, there are no alternatives to restraints and/or seclusions. TRAUMA INFORMED CARE IN JUVENILE DETENTION 43 transitions or difficult time periods. Strongly Disagree Disagree Neutral Agree Strongly Agree Residents can benefit from opportunities for helpful participation, such as leadership or a designated job. 1 2 3 4 5 Trauma affects physical, emotional, and mental wellbeing. * 1 2 3 4 5 For an individual who becomes quiet and withdrawn in response to stress, engaging in physical activity can be helpful. 1 2 3 4 5 1 2 3 4 5 Focusing on a residents negative actions is an effective approach to resolving a situation. * 1 2 3 4 5 Choosing an activity to do when a resident becomes upset can directly impact their ability to regulate their behavior. 1 2 3 4 5 Statement I believe that all residents should be treated the same, regardless of the individual resident and their behavior. * TRAUMA INFORMED CARE IN JUVENILE DETENTION 44 Experiences in the detention center can be a trigger for residents who have experienced trauma. 1 2 3 4 5 Statement Strongly Disagree Disagree Neutral Agree Strongly Agree Getting involved in a strenuous physical activity makes a persons body feel calmer. 1 2 3 4 5 Individuals are in control of their actions when they are upset. 1 2 3 4 5 Once a residents behavior escalates past a certain point, there is no choice but to restrain and/or seclude them. 1 2 3 4 5 Engaging in an activity such as basketball or rapping can improve self-regulation skills. 1 2 3 4 5 Exposure to trauma is common. * 1 2 3 4 5 Making decisions that consider both logic and emotion can be improved through physical activity. 1 2 3 4 5 Constant stress can impact a persons ability to make new memories. 1 2 3 4 5 TRAUMA INFORMED CARE IN JUVENILE DETENTION 45 A resident who already received a punishment (such as catwalk) should not be permitted to engage in recreation time. 1 2 3 4 5 Statement Strongly Disagree Disagree Neutral Agree Strongly Agree Offering choices to a resident and respecting their decisions is an effective way to resolve a situation. * 1 2 3 4 5 Restraints and/or seclusions are the most effective way to control behavior. 1 2 3 4 5 Survey statements adapted from Abdoh et al. (2017), Denison et al. (2018), and Multnomah County Defending Childhood (2016). signifies verbatim statements from original source; * signifies statements from Abdoh et al. (2017); signifies statements from Denison et al. (2018); signifies statements from Multnomah County Defending Childhood (2016) Please share any questions you would like addressed regarding trauma-informed care, sensory interventions, or occupational therapy: TRAUMA INFORMED CARE IN JUVENILE DETENTION 46 Appendix B Post-Survey Hello, I am conducting an anonymous survey to assess your current knowledge and opinions regarding trauma and its associated factors within the detention center. This survey is to be completed after completing the 6-week educational series on the topic. The survey will take approximately 15-20 minutes to complete. Your identity will remain anonymous. You are free to quit the survey at any point without penalty. You are free to omit answers on any question you feel uncomfortable answering. Your participation and answers on this survey will in no way impact your employment status at Johnson County Juvenile Detention and will not be shared with any of your fellow staff members. If you have any questions, please feel free to contact Paige McIntire at the contact information below. Once you have completed the survey, please place it inside of an enveloped and seal the envelope. Please then place your sealed envelope into the basket for collection. Please do not write your name on the survey or the envelope. Please only complete this survey if you are 18 years of age or older. Please tear off the cover page of this survey and keep it for your records. Thank you for your participation. Sincerely, Paige McIntire Paige McIntire, Occupational Therapy Student Department of Occupational Therapy University of Indianapolis, Indianapolis, Indiana 46227 (317) 642-7685 mcintirep@uindy.edu TRAUMA INFORMED CARE IN JUVENILE DETENTION 47 Post survey Please answer all identification questions. These questions will assist you in creating a code to ensure anonymity while taking the survey. This code will be used on both the pre- and posteducational surveys. What is the first letter of your mothers name? ________ Example: Jennifer (J) What is the second number of your current age? ________ Example: 24 years old (4) What are the last 2 digits of your cell phone number? _________ Example: 798-9862 (62) What is the first letter of the month you were born in? _____________ Example: August (A) What is the first letter of your middle name? ________ Example: Marie (M) Your identification code: _______________________ Example: J462AM Statements: Please respond to the following statements using a scale of 1 (Strongly Disagree) to 5 (Strongly Agree). Circle the number that best describes how you feel about each statement. 1 2 3 4 5 Statement Strongly Disagree Disagree Neutral Agree Strongly Agree Substance use can be indicative of past traumatic experiences or adverse child experiences (ACEs). * 1 2 3 4 5 There is a connection between mental health and past traumatic experiences or adverse child experiences (ACEs). * 1 2 3 4 5 Listening to music can make a persons body feel calmer. 1 2 3 4 5 Giving options to an out-ofcontrol individual can be dangerous. 1 2 3 4 5 TRAUMA INFORMED CARE IN JUVENILE DETENTION 48 Statement Strongly Disagree Disagree Neutral Agree Strongly Agree Residents can use higher level thinking (such as cause and effect) when they become upset. 1 2 3 4 5 Re-traumatization can occur in both the community and in institutional settings. * 1 2 3 4 5 Re-traumatization can occur unintentionally. * 1 2 3 4 5 Classroom disruptions and/or behavior problems are related to trauma. 1 2 3 4 5 1 2 3 4 5 Distrusting behavior is indicative of past traumatic experiences or adverse childhood experiences (ACEs). * 1 2 3 4 5 Stress can negatively impact residents cognitive and physical abilities. 1 2 3 4 5 Giving a resident an ultimatum can effectively resolve an escalating situation. 1 2 3 4 5 Residents can benefit from routines and rituals to support them during transitions or difficult time periods. 1 2 3 4 5 For many residents, there are no alternatives to restraints and/or seclusions. TRAUMA INFORMED CARE IN JUVENILE DETENTION 49 Strongly Disagree Disagree Neutral Agree Strongly Agree Residents can benefit from opportunities for helpful participation, such as leadership or a designated job. 1 2 3 4 5 Trauma affects physical, emotional, and mental wellbeing. * 1 2 3 4 5 For an individual who becomes quiet and withdrawn in response to stress, engaging in physical activity can be helpful. 1 2 3 4 5 1 2 3 4 5 Focusing on a residents negative actions is an effective approach to resolving a situation. * 1 2 3 4 5 Choosing an activity to do when a resident becomes upset can directly impact their ability to regulate their behavior. 1 2 3 4 5 Experiences in the detention center can be a trigger for residents who have experienced trauma. 1 2 3 4 5 Statement I believe that all residents should be treated the same, regardless of the individual resident and their behavior. * TRAUMA INFORMED CARE IN JUVENILE DETENTION 50 Strongly Disagree Disagree Neutral Agree Strongly Agree Getting involved in a strenuous physical activity makes a persons body feel calmer. 1 2 3 4 5 Individuals are in control of their actions when they are upset. 1 2 3 4 5 Once a residents behavior escalates past a certain point, there is no choice but to restrain and/or seclude them. 1 2 3 4 5 Engaging in an activity such as basketball or rapping can improve self-regulation skills. 1 2 3 4 5 Exposure to trauma is common. * 1 2 3 4 5 Making decisions that consider both logic and emotion can be improved through physical activity. 1 2 3 4 5 Constant stress can impact a persons ability to make new memories. 1 2 3 4 5 A resident who already received a punishment (such as catwalk) should not be permitted to engage in recreation time. 1 2 3 4 5 Statement TRAUMA INFORMED CARE IN JUVENILE DETENTION 51 Statement Strongly Disagree Disagree Neutral Agree Strongly Agree Offering choices to a resident and respecting their decisions is an effective way to resolve a situation. * 1 2 3 4 5 Restraints and/or seclusions are the most effective way to control behavior. 1 2 3 4 5 Survey statements adapted from Abdoh et al. (2017), Denison et al. (2018), and Multnomah County Defending Childhood (2016). signifies verbatim statements from original source; * signifies statements from Abdoh et al. (2017); signifies statements from Denison et al. (2018); signifies statements from Multnomah County Defending Childhood (2016) Statements: Please respond to the following statements using a scale of 1 (Strongly Disagree) to 5 (Strongly Agree). Circle the number that best describes how you feel about each statement. Each of the statements will begin with the following phrase: After this education, I 1 2 3 4 5 Statement Strongly Disagree Disagree Neutral Agree Strongly Agree have a better understanding of the impact of trauma. 1 2 3 4 5 have a better understanding of sensory processing 1 2 3 4 5 1 2 3 4 5 have a better understanding of sensory interventions to use with TRAUMA INFORMED CARE IN JUVENILE DETENTION 52 residents during stressful times Strongly Disagree Disagree Neutral Agree Strongly Agree have a better understanding of why residents would benefit from a sensory/calm down room. 1 2 3 4 5 have a better understanding of traumainformed care (TBRI) 1 2 3 4 5 have a better understanding of why its important to take good care of myself 1 2 3 4 5 have a stronger belief in and support of traumainformed care (TBRI). 1 2 3 4 5 Statement Please answer the following questions. Feel free to use the the back of this page or a blank piece of paper as additional space if needed. Be sure to include the additional paper in the envelope with the survey. Describe the impact this educational series had on the way you think about the residents that you work with. TRAUMA INFORMED CARE IN JUVENILE DETENTION How have you used (or plan to use) the information you learned in this educational series? Is there an example of a time when you saw physical activity impact a residents behavior? Please describe. Describe how you plan to maintain your own regulation during times of high stress when working with residents. Please list any other feedback below. Thank you! 53 TRAUMA INFORMED CARE IN JUVENILE DETENTION 54 Appendix C Pre-Post Survey Results for all Participants Strongly Disagree (1) Statement Substance use can be indicative of past traumatic experiences or adverse child experiences (ACEs). There is a connection between mental health and past traumatic experiences or adverse child experiences (ACEs). Listening to music can make a persons body feel calmer. Pre Residents can use higher level thinking (such as cause and effect) when they become upset. Neutral (3) Agree (4) Average Strongly Degree of Agree (5) Agreement 15.8 42.1 42.1 4.3 Post 5 15 45 35 4.1 Pre 5.3 21.1 31.6 42.1 4.1 Post 5 10 35 50 4.3 21.1 57.9 21.1 4 5 5 45 45 4.3 Pre Post Giving options to an out-of-control individual can be dangerous. Disagree (2) Pre 5.3 47.4 36.8 5.3 5.3 2.6 Post 5 25 60 5 5 2.8 Pre 10.5 63.2 15.8 10.5 Post 25 50 25 2.3 2 TRAUMA INFORMED CARE IN JUVENILE DETENTION Re-traumatization can occur in both the community and in institutional settings. Re-traumatization can occur unintentionally. Classroom disruptions and/or behavior problems are related to trauma. For many residents, there are no alternatives to restraints and/or seclusions. Distrusting behavior is indicative of past traumatic experiences or adverse childhood experiences (ACEs). Stress can negatively impact residents cognitive and physical abilities. 55 Pre 15.8 73.7 10.5 3.9 Post 15 45 40 4.25 Pre 15.8 63.2 21.1 4.1 Post 15 45 40 4.24 26.3 63.2 10.5 Pre 2.8 Post 5 10 65 15 Pre 11.8 41.2 41.2 5.9 2.4 Post 5 50 35 10 2.5 5.3 42.1 42.1 10.5 3.6 Post 35 40 25 3.9 Pre 5.3 68.4 26.3 4.2 Post 15 40 45 4.3 Pre 5 3.05 TRAUMA INFORMED CARE IN JUVENILE DETENTION Giving a resident an ultimatum can effectively resolve an escalating situation. Residents can benefit from routines and rituals to support them during transitions or difficult time periods. Residents can benefit from opportunities for helpful participation, such as leadership or a designated job. Trauma affects physical, emotional, and mental wellbeing. For an individual who becomes quiet and withdrawn in response to stress, engaging in physical activity can be helpful. I believe that all residents should be treated the 56 Pre 10.5 26.3 42.1 21.1 2.7 Post 15 15 35 35 2.9 Pre 15.8 63.2 21.1 4.1 Post 10 40 50 4.4 Pre 5.3 73.7 21.1 4.2 Post 5 70 25 4.2 Pre 10.5 47.4 42.1 4.3 Post 20 30 50 4.3 52.6 26.3 40 40 20 3.8 10.5 10.5 15.8 2.5 21.1 Pre Post Pre 26.3 36.8 3.1 TRAUMA INFORMED CARE IN JUVENILE DETENTION same, regardless of the individual resident and their behavior. Focusing on a residents negative actions is an effective approach to resolving a situation. Choosing an activity to do when a resident becomes upset can directly impact their ability to regulate their behavior. Experiences in the detention center can be a trigger for residents who have experienced trauma. Getting involved in a strenuous physical activity makes a persons body feel calmer. Individuals are in control of their actions when they are upset. 57 Post 35 35 10 5 Pre 15.8 52.6 26.3 5.3 Post 20 40 30 5 Pre 5.3 42.1 52.6 Post 10 45 25 20 3.6 Pre 21.1 73.7 5.3 3.8 Post 20 50 30 4.1 5.6 33.3 50 11.1 3.7 5 3.4 Pre Post 5 5 40 45 Pre 21.1 47.4 21.1 10.5 Post 20 35 30 10 15 2.3 2.2 5 2.4 3.5 2.2 5 2.5 TRAUMA INFORMED CARE IN JUVENILE DETENTION Once a residents behavior escalates past a certain point, there is no choice but to restrain and/or seclude them. Engaging in an activity such as basketball or rapping can improve selfregulation skills. Exposure to trauma is common. Making decisions that consider both logic and emotion can be improved through physical activity. Constant stress can impact a persons ability to make new memories. A resident who already received a punishment (such as catwalk) should not be permitted to engage in recreation time. 58 15.8 36.8 42.1 5.3 3.4 5 30 45 25 3.8 5.3 52.6 36.8 5.3 3.4 25 60 15 3.9 5.3 31.6 47.4 10.5 3.5 Post 5 45 30 20 3.7 Pre 5.3 36.8 52.6 5.3 3.6 31.6 47.4 21.1 3.9 22.2 55.6 11.1 3.7 20 45 35 4.2 Pre Post 5 Pre Post Pre 5.3 Post 11.1 Pre Post Pre 10.5 26.3 36.8 15.8 10.5 2.9 Post 10 15 50 10 15 3.1 TRAUMA INFORMED CARE IN JUVENILE DETENTION Offering choices to a resident and respecting their decisions is an effective way to resolve a situation. Restraints and/or seclusions are the most effective way to control behavior. 59 Pre 26.3 73.7 Post 35 45 5.3 Pre 31.6 47.4 15.8 Post 25 50 25 3.7 20 3.9 1.9 2 TRAUMA INFORMED CARE IN JUVENILE DETENTION 60 Appendix D Pre-Post Survey Results for Eight Participants Strongly Disagree (1) Statement Substance use can be indicative of past traumatic experiences or adverse child experiences (ACEs). There is a connection between mental health and past traumatic experiences or adverse child experiences (ACEs). Listening to music can make a persons body feel calmer. Re-traumatization can occur in both the Agree (4) Strongly Agree (5) Average Degree of Agreement 12.5 25 62.5 4.5 Post 12.5 75 12.5 4 Pre 12.5 25 62.5 4.5 Post 12.5 50 37.5 4.3 75 25 4.3 50 37.5 4.1 Pre 12.5 Pre 12.5 Post Residents can use higher level thinking (such as cause and effect) when they become upset. Neutral (3) Pre Post Giving options to an out-of-control individual can be dangerous. Disagree (2) Pre Post Pre 12.5 50 25 25 75 62.5 12.5 75 25 12.5 12.5 2.4 2.8 12.5 2.3 2.3 75 12.5 4 TRAUMA INFORMED CARE IN JUVENILE DETENTION 61 community and in institutional settings. Re-traumatization can occur unintentionally. Classroom disruptions and/or behavior problems are related to trauma. Post 12.5 37.5 50 4.4 Pre 12.5 50 37.5 4.3 Post 12.5 37.5 50 4.4 75 12.5 3 87.5 12.5 3.1 37.5 37.5 12.5 2.5 62.5 25 12.5 2.5 Pre 37.5 37.5 25 3.9 Post 37.5 50 12.5 3.8 62.5 37.5 4.4 12.5 50 37.5 4.3 12.5 Pre Post For many residents, there are no alternatives to restraints and/or seclusions. Distrusting behavior is indicative of past traumatic experiences or adverse childhood experiences (ACEs). Stress can negatively impact residents cognitive and physical abilities. Pre Post 12.5 Pre Post Giving a resident an ultimatum can effectively resolve an escalating situation. Pre 37.5 37.5 25 2.9 Post 25 50 25 3 TRAUMA INFORMED CARE IN JUVENILE DETENTION Residents can benefit from routines and rituals to support them during transitions or difficult time periods. Residents can benefit from opportunities for helpful participation, such as leadership or a designated job. Trauma affects physical, emotional, and mental well-being. For an individual who becomes quiet and withdrawn in response to stress, engaging in physical activity can be helpful. I believe that all residents should be treated the same, regardless of the individual resident and their behavior. Focusing on a residents negative actions is an effective approach to resolving a situation. Choosing an activity to do when a resident becomes upset can 62 12.5 62.5 25 4.1 Post 62.5 37.5 4.4 Pre 87.5 12.5 4.1 Post 87.5 12.5 4.1 Pre Pre 12.5 50 37.5 4.3 Post 25 37.5 37.5 4.1 62.5 25 37.5 50 12.5 3.8 12.5 Pre Post 3.1 Pre 25 37.5 12.5 12.5 12.5 2.5 Post 25 37.5 12.5 12.5 12.5 2.5 Pre 25 50 25 2 62.5 37.5 2.4 Post Pre 37.5 62.5 3.6 TRAUMA INFORMED CARE IN JUVENILE DETENTION directly impact their ability to regulate their behavior. Experiences in the detention center can be a trigger for residents who have experienced trauma. Getting involved in a strenuous physical activity makes a persons body feel calmer. Individuals are in control of their actions when they are upset. Once a residents behavior escalates past a certain point, there is no choice but to restrain and/or seclude them. Engaging in an activity such as basketball or rapping can improve selfregulation skills. Exposure to trauma is common. 63 12.5 62.5 25 Pre 12.5 75 12.5 4 Post 25 62.5 12.5 3.9 Pre 37.5 37.5 25 3.9 Post 62.5 37.5 3.4 50 25 12.5 2.4 Post 50 37.5 12.5 2.6 Pre 12.5 37.5 37.5 12.5 3.5 Post 12.5 12.5 50 25 3.9 Pre 50 37.5 12.5 3.6 Post 12.5 87.5 Pre 12.5 62.5 25 4.1 Post 37.5 37.5 25 3.9 Post Pre 12.5 3.1 3.9 TRAUMA INFORMED CARE IN JUVENILE DETENTION Making decisions that consider both logic and emotion can be improved through physical activity. Constant stress can impact a persons ability to make new memories. A resident who already received a punishment (such as catwalk) should not be permitted to engage in recreation time. Offering choices to a resident and respecting their decisions is an effective way to resolve a situation. Restraints and/or seclusions are the most effective way to control behavior. 64 Pre 50 37.5 12.5 3.6 Post 37.5 37.5 25 3.8 Pre 25 50 25 4 Post 12.5 37.5 50 4.4 Pre 12.5 37.5 25 12.5 12.5 2.8 Post 12.5 12.5 50 12.5 12.5 3 Pre 12.5 87.5 Post 37.5 50 3.9 12.5 3.8 Pre 37.5 50 12.5 1.8 Post 25 75 25 2.3 ...