The Importance of Addressing Complex Trauma in Schools: Implementing Trust-Based Relational Intervention in an Elementary School

Karyn B. Purvis, Henry S. Milton, James G. Harlow, Sheri R. Paris, and David R. Cross

A significant number of students arrive at school each day, unable to remove the cloak of fear and distrust that has become their only source of protection in their own homes. For these children, the repeated maltreatment they have endured has shaped how they view and react to their world, both inside and outside of their homes. Bath (2008, p.18) states,

The brain-based stress response systems of these children appear to become permanently changed as they focus attention on the need to ensure safety rather than on the many growth-promoting interests and activities that secure children find attractive and stimulating.

Looking at the statistics, approximately 68% of Americans have experienced some type of trauma during childhood (Copeland, Keeler, Angold, & Costello, 2007), and children from urban areas and ethnic minorities experience particularly high rates of recurrent interpersonal trauma, also called complex trauma (for a review see Overstreet & Mathews, 2011; Richards et al., 2004; Sedlak et al., 2010). Complex trauma includes physical abuse, sexual abuse, emotional abuse, neglect, and/or witnessing domestic violence, and is perpetrated upon children by their caregivers (Greeson et al., 2011). The resulting effects of complex trauma include developmental, psychological, and cognitive impairments that can significantly impact school behavior and performance (for a review see Overstreet & Mathews, 2011; Cole et al., 2005). We know that chronic fear obstructs both cognitive and emotional functioning (Anda et al., 2006; Perry, 2001), and when fear is reduced (as evidenced by a reduction in the stress chemical cortisol), there are gains in behavior, cognition, and language (Purvis & Cross, 2006).

With only a limited number of studies thus far exploring how a history of trauma impacts children in school settings, we do know that preschool children exposed to trauma exhibit lower levels of frustration tolerance, flexibility, and problem solving; and higher levels of anger and noncompliance (Egeland, Sroufe, & Erickson, 1983; Vondra, Barnett, & Cicchetti, 1990). Elementary-aged children exhibit lower persistence on, and greater avoidance of, challenging tasks (Shonk & Cicchetti, 2001). Older children and adolescents exhibit problems with attention, abstract reasoning, and executive function (Beers & DeBellis, 2002). In addition, all ages of children with histories of trauma: (a) are more frequently referred for special education and disciplinary action (Eckenrode, Laird, & Doris, 1993; Shonk & Cicchetti, 2001); (b) have lower grades and standardized test scores; and (c) exhibit higher rates of academic failure, grade retention, and dropping out (Boden, Horwood, & Fergusson, 2007; Cahill, Kaminer, & Johnson, 1999; Eckenrode et al., 1993; Kurtz, Gaudin, Wodarski, & Howing, 1993; Leiter & Johnson, 1994). However, studies have shown that schools can play a mitigating role in outcomes and can promote resilience (Crooks, Scott, Wolfe, Chiodo, & Killip, 2007; see Heller, Larrieu, D’Imperio, & Boris, 1999).

Children with backgrounds of complex trauma are often in a persistent state of hyperarousal—geared for fight, flight, or freeze (resulting from a home environment where they do not feel safe). Thus, some maladaptive behaviors may arise from this hypersensitivity and tendency to overreact to, or misinterpret, actions of others or certain elements in their environment that would go unnoticed by someone without a history of trauma. When schools implement measures to ensure that children feel safe, their voices are heard, and their needs are met, these children can begin the process of removing the cloak of fear and self-preservation that they brought from their home environment, and learn to engage with teachers and peers in a productive and healthy manner. Teachers and school counselors can benefit from training about complex trauma, its effects on children, including recognizing the types of involuntary behaviors that result from trauma, and ways to help children regulate such behaviors (O’Neill, Guenette, & Kitchenham, 2010).

Trust-Based Relational Intervention®

This article discusses Trust-Based Relational Intervention® (TBRI®), an intervention designed to address the underlying issues behind persistent unmanageable behaviors for at-risk populations in any setting. In addition, examples of the intervention techniques and activities are also provided. Developed at the Institute of Child Development at Texas Christian University (TCU), this intervention has been used successfully in settings such as individual families, group homes, summer camps, and more recently, school environments. Through TBRI®, educators create conditions to help children succeed behaviorally through strategies grouped into three evidenced-based principles: (a) empowering principles—address biological and environmental issues, and promote a feeling of safety; (b) connecting principles—promote relationships, awareness of self and others, and playful engagement; and (c) correcting principles—teaching self-management. Other publications describe the components of TBRI® in more detail (Purvis, Parris, & Cross, 2011; Purvis, Cross, & Sunshine, 2007; Purvis, Cross, & Pennings, 2009), and empirical evidence supporting TBRI® (Purvis & Cross, 2006; Purvis, Cross, Federici, Johnson, & McKenzie, 2007). A brief summary of each of the three evidenced-based principles is provided below.

Empowering principles. First, the empowering principles address children’s biological needs and provide an environment where they feel safe and nurtured (Bronfenbrenner & Morris, 1998; Lickliter, 2008). Children who know their environment is safe and predictable are able to learn and practice new behavioral skills (van den Boom, 1994, 1995). They also can learn to trust others and develop healthy emotions and behaviors that are trust-driven rather than fear-driven (Knight, Smith, Cheng, Stein, & Helmstetter, 2004).

Because many of these children have not had a responsive parent to meet their basic needs on a consistent basis, having food and water available at school can alleviate their worries and reassure them that they will not go hungry. Also, hydration improves behavior and mental functioning, including attention and memory performance (Bar-David, Urkin, & Kozminsky, 2005; Edmonds & Burford, 2009; Edmonds & Jeffes, 2009; Wilson & Morley, 2003). Allowing children to keep water bottles at their desks can meet this need. Also, regularly scheduled snacks (recommended every two hours) help sustain adequate blood sugar levels, shown to be important in children’s ability to maintain positive behaviors, stable moods, and optimal cognitive functioning including attention and self-regulation (Benton, Brett, & Brain, 1987; Benton & Stevens, 2008; Gailliot et al., 2007).

Establishing predictable daily routines and creating a calm, positive atmosphere can be a great help. Transitions are particularly difficult for students who are fear-driven and struggle with self-regulation (e.g., transitioning from one activity or class to another, or at arrival or dismissal). Facilitating smooth transitions can reduce problem behaviors and wasted time that can occur during these times (Paine, Radicchi, Rosellini, Deutchman, & Darch, 1983). Transitions can be managed by providing children time to mentally adjust to the transition, such as giving more than one notification that an activity is about to change; or allowing children to move freely among available activities (Agler, 1984; Doke & Risley, 1972; Fowler, 1980).

Also, children with histories of trauma often have sensory processing disorders that can negatively impact behavior, social skills, motor skills, and academic performance (Cermak, 2009; Cermak & Groza, 1998). Behaviors that indicate possible sensory issues include breaking pencils or crayons (misjudging tactile pressure), misjudging a touch on the shoulder as painful pressure, reacting in an aggressive manner, intolerance of noisy environments, or many other signs (for more information about sensory processing disorders and symptoms see http://www.spdfoundation.net/about-sensory-processing-disorder.html). Daily schedules that include sensory activities and physical activity can significantly improve sensory issues (Dorman et al., 2009; Kranowitz, 2006; Miller & Fuller, 2007; Purvis & Cross, 2006). In addition, TBRI® teaches calming techniques such as deep-breathing exercises (Peck, Kehle, Bray, & Theodore, 2005; Stueck & Gloeckner, 2005) and use of weighted blankets and neck pads (Mullen, Champagne, Krishnamurty, Dickson, & Gao, 2008),

Connecting principles. Second, the connecting principles promote relationships, including awareness of self and others, and playful engagement. Building relationships can help reverse the adverse effects of early stress on the brain, reduce stress-related behavior, and improve psychosocial functioning (Fisher, Gunnar, Dozier, Bruce, & Pears, 2006). Engaging children with a playful tone of voice (in everyday interactions as well as when redirecting negative behaviors) instills warmth and trust in the relationship (Panksepp, 2000, 2002), disarms fear, promotes attachment, and builds social competence (Brown, 2009; Jernberg & Booth, 1999; Robison, Lindaman, Clemons, Doyle-Buckwalter, & Ryan, 2009).

Correcting principles. Third, the correcting principles are proactive steps that prevent disruptive behavior before it happens, including teaching appropriate behaviors for challenging situations (Colvin & Sugai, 1988; Colvin, Sugai, Patching, 1993). TBRI® proactive strategies are often taught in nurture groups (described below), and include verbal reminders, behavioral rehearsals, and role play with others or with puppets. Life value terms are used to teach social skills and include using respect, making eye contact, using words to replace negative behaviors, being gentle and kind, accepting consequences, accepting “no,” asking permission, and others. While proactive strategies will reduce the number and intensity of behavioral challenges, when they do occur, TBRI® recommends using the IDEAL Response.© With this approach, the adult’s response is matched in intensity to the level of the behavioral challenge, and the relational connection is maintained with the child during correction (for a review of the IDEAL Response©, see The Connected Child; Purvis, Cross, & Sunshine, 2007).

This next part of this article reports how TBRI® was brought to one school in Oklahoma, describing implementation and initial outcomes.

About the School

The school, Eugene Field Elementary School, in Tulsa, Oklahoma, U.S.A., was considered one of the worst schools in the state due to having the lowest state test scores for the two previous years. They had 33 teachers and 428 students in grades PreK – 5 during the first year of TBRI® implementation. Ninety-eight percent of the students in this inner-city school lived in poverty, and 75% had a parent or caregiver in prison. Student ethnicity was approximately 40% African American, 21% White, 20% Hispanic, 8% American Indian, and 1% Asian. These students had not typically responded well to traditional methods of discipline and classroom management. The school had already implemented Positive Behavioral Intervention and Supports (PBIS) to the physical environment as recommended by an occupational therapist, and had installed consistent procedures for transitions throughout the day without tangible improvements in student behavior. The principal and staff had worked to turn the school around over the past eight years with some progress in test scores, attendance, and some individual successes, but the school was still lacking significant progress in the behavioral culture.

Implementation of Training

In June of 2010, TBRI® trainers met with school representatives who stated that their goals were for teachers and staff to obtain appropriate tools to successfully maintain classroom behavior standards and to create a more positive learning environment. Based on the discussion, TBRI® trainers provided school staff with training in (a) TBRI® principles and techniques, including strategies to connect with children and support them physiologically and emotionally; (b) insight into children’s needs; and (c) resources to put TBRI® into practice. TBRI® trainers would conduct schoolwide staff trainings and individual teacher training in classrooms. In addition, a few school representatives would travel to TCU twice for additional training. TBRI® trainers also would be available by phone or email to answer questions.

Nurture group training. TBRI® trainers visited Eugene Field three times during the school year (August, September, and February) for nurture group training in classrooms. During each visit, trainers visited between 8-10 classrooms to demonstrate or assist teachers in implementing nurture groups (about 30 minutes each). Nurture groups are a key component of TBRI® because they are effective vehicles for developing relationships, promoting communication, and teaching self-regulation and social skills. During initial visits, trainers modeled nurture groups for the teachers. In later visits, teachers conducted their own nurture groups while trainers offered feedback. For nurture groups, students were seated in a circle either on the floor or at their desks. Teachers reported that individual discussions with trainers were very helpful in addressing specific questions and concerns about their own students. Also, through nurture groups, teachers were able to address current needs in their classrooms.

The basic structure of nurture groups consists of six steps. Steps 1-3 and 5-6 are Theraplay® activities (Theraplay® for groups; Rubin & Tregay, 1989) that provide a “wrapper” around the 4th step, which is sandwiched between them and provides social skills training. Nurture group steps are as follows:

    Step 1. Review Rules: Participants review the three rules for groups: stick together; have fun, no hurts. These rules set the tone for how group members should treat each other.

 

    Step 2. Check-In: This is a warm-up activity in which children take turns answering a simple, nonthreatening question about themselves. This activity helps participants find their voice and practice being heard in a safe context.

 

    Step 3. Band-Aids®:In this activity, children tell about something that “hurts” on their body or emotionally. This is an opportunity for children to use words to express their feelings, and where they can learn not only to give, but to receive care. Next, partners apply a Band-Aid® on the area of the body that hurts, or over the hear for an emotional hurt.

 

    Step 4. Social Skills: In this portion of the nurture group, children work on social skills such as “respect” and “making choices” through role-playing, puppets, and practice. For example, a social skill is explained to students who are also taught the language (scripts) for that concept. Next, students role-play the concept with puppets, peers, and non-respectful behavior using puppets. “Puppets” who behave disrespectfully would get a “redo” using respectful behavior.

 

    Step 5. Feeding: Before the closing, children take turns feeding each other. Candy is generally used in order to connect a nurturing act with something pleasurable. As a bowl of candy is passed from one child to the next, children make eye contact with their partner and ask, “May I feed you?” The partner can either consent, or politely say, “No thank you,” and feed himself.

 

    Step 6. Closing: This is a time to celebrate the success of the group. The facilitator can make a comment such as, “Let’s give ourselves a hand for being so awesome at _____________ (for example, practicing respect).” The three rules are then briefly reviewed, and children are told about what they will be doing after the nurture group dismisses, to ease transition to the next activity.
    Of critical importance is that nurture groups are loaded with playful interactions and opportunities for success. For the first few nurture groups, any child may be allowed to “pass” on participation if they do so with respectful words (“I’d rather not today”). As they learn that nurture groups are emotionally safe, they will soon become an active participant in the group.

 

Of critical importance is that nurture groups are loaded with playful interactions and opportunities for success. For the first few nurture groups, any child may be allowed to “pass” on participation if they do so with respectful words (“I’d rather not today”). As they learn that nurture groups are emotionally safe, they will soon become an active participant in the group.

Other training. In July, prior to implementation, several representatives from Eugene Field attended our Hope Connection Summer Camp at TCU to observe TBRI® in action. In October, TBRI® trainers conducted a two-day training at the Eugene Field campus for all school staff which included an overview of TBRI® theory and methods, emphasizing practical application for the classroom and including the following topics: attachment; neurochemistry; sensory processing; and the empowering, connecting, and correcting principles. Much of this training was conducted in an interactive format (e.g., role-playing, practicing nurture groups). In November several school representatives attended a weeklong TBRI® training at TCU. Finally, in February, TBRI® trainers provided a two-hour refresher course for school staff at the Eugene Field campus that included a sensory experience workshop to highlight sensory issues that may cause behavioral problems in classrooms, and techniques to help children cope with these issues.

Resources. At the beginning of the school year, TBRI® trainers supplied resources to Eugene Fields such as weighted pads and stress balls, which are effective calming tools, and materials for “engine plates” (these help children learn to gauge their level of alertness and self-regulate). Engine plates are based on the Alert Program for Self-Regulation (Williams & Shellenberger, 1996) and may also be used in TBRI® nurture groups.

Outcomes

In the two years since TBRI® was first implemented, teachers, support staff, and counselors are now consistently using TBRI® to create a more positive learning environment. They report that children have made dramatic gains in developing positive relationships and overcoming various behavioral challenges. For instance, there are fewer violent outbursts and emotional meltdowns, social skills have improved, and teachers are reporting that students are less likely to act out to get their needs met. Children are now using words to get their needs met and making eye contact when talking to peers and adults. These are tremendous gains for children who are learning to control their behaviors and develop positive social skills that will last into adulthood.

The year prior to implementation, 16% of enrolled students had three or more referrals to the principal’s office. During the year TBRI® was implemented, the principal reported they “have fewer children acting out and more doing the right thing.” Several of these students had no referrals and many others had only one to two referrals for minor issues. Also, incident reports decreased 18%, and the number of referrals from the top 10 most frequently referred students decreased by 23%. The principal reported that more referrals were for minor offenses because teachers were able to deescalate many situations by using TBRI® practices. For example, for some students, emotional meltdowns that had previously escalated into violent episodes lasting for two hours were now resolved in 10 minutes.

Also, teachers, support staff, and counselors have created a more positive learning environment, and better understand how addressing basic needs can significantly improve a child’s capacity for self-regulation, focused attention, and relationship building. The school staff have created a sensory-rich environment and daily schedules that now include a physical activity every two hours, and snacks and water are available in classrooms. Classroom rules now include, “Stick together,” “No hurts,” and “Have fun” (developed by Theraplay®). Nurture groups have been added to the school’s morning routines, and teachers are using calming tools, all of which have helped reduce undesirable behaviors and improve students’ attention.

Discussion

Given the promising results of this project, we have begun longitudinal studies implementing TBRI® in a large, urban school district, and also in a secondary charter school. Additional studies are planned. Through our ongoing research in schools, we are developing additional training and support materials to help schools ensure successful implementation of this program. We are encouraged by the preliminary data in the current studies because results are consistent with the positive results seen at Eugene Field. Also, a broader range of student and school outcomes are being assessed in these studies, and publication of these results will be forthcoming.

At Eugene Field, many of the teachers were skeptical about implementing yet another method that promised to help them with behavior issues. However, after the first few months, they could see that positive changes were occurring. Because there are many strategies for helping children at risk for complex trauma, teachers were able to choose a few strategies with which to begin, and then could add more over time; incorporate the strategies that work best for their own students and classrooms; and find ways to adapt strategies to fit specific needs. By giving teachers the information and tools to alleviate the effects of complex trauma, behavioral issues that do not respond to traditional methods of discipline may also be reduced while classroom learning is increased.

Feedback

The following is feedback received from school staff regarding TBRI® training:

As we have been educated about TBRI®, the staff at the school has developed a new level of empathy for our most challenging students. There is a greater awareness of the reasons so many of our kids hang upside down in their chairs, chew on their t-shirts, spin around in circles, or shut down completely in a noisy room. Instead of being punished, we have begun offering sensory experiences to these kids . . . Staff are encouraged to make corrections more immediate and leveled at the problem behavior. We have all reexamined our attitudes about children’s behaviors and the meaning behind them . . . we hope to expand the scope by educating the greater [school] community to use the same practices and language. This will include all staff, volunteers, mentors, after-school programs, etc. . . . I think our environment is more positive, more sensitive to the needs of the children, and more equipped to face the challenges presented by most difficult students. TBRI® has influenced the way I interact with students and has enriched my practice at the school.—School Counselor

The impact I saw in my classroom was almost immediate. No, it did not eliminate severe behavior outburst, but it certainly helped reduce the amount of behavior outburst that would escalate into a child screaming, yelling, throwing chairs/desk, or destroying my classroom. When things like that happened, it meant that learning had to stop. The TCU training helped to equip me with strategies that gave my students choices—which gave them a sense of control. They were much more willing to compromise with me so that learning could take place.—3rd Grade Teacher

[Our staff] became believers in the TBRI® system because it gives us permission to be kind. There is a framework in place that assures the safety of the child and the adult, and the procedures allow us to “re-do” our behavior in an acceptable way. It is ultimately about respect of the child and the adult (in that order). I saw a drastic change in the way our “toughest kids” managed their own behavior. We now always ask—“What need is not being met?” for each child—we feed them, talk to them, listen and offer a “re-do” for success. We loved our book study of The Connected Child by Dr. Purvis and Dr. Cross. TBRI® is the school’s missing link with making all students feel successful, loved, and safe. When you have all those in place all learning is possible.—Principal

Acknowledgments

This project was partially funded by grants from the National Recreation Foundation (U.S.A.), Lesley Family Foundation (U.S.A.), and The Rees-Jones Foundation (U.S.A.).

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About the Authors

Karyn B. Purvis, PhD, is founder and Rees-Jones director of the Texas Christian University Institute of Child Development. Dr. Purvis and her colleague, David R. Cross, PhD, lead the Institute in its triple mission of research, education, and outreach on behalf of at-risk children. She has authored many peer-reviewed publications about issues regarding at-risk children, including those who have experienced early trauma. She also coauthored a feature book for McGraw-Hill titled, The Connected Child: Bringing Hope and Healing to Your Adoptive Family.

Henry S. Milton, MS, is a Training Specialist with the Texas Christian University Institute of Child Development. He conducts trainings, workshops, and consulting on Trust-Based Relational Intervention® (TBRI®) across the country to children’s services organizations and schools that serve at-risk populations. He has over 15 years of experience in mental health care, residential care, and inpatient psychiatry.

James G. Harlow, MA, LPC, and former training fellow for the Texas Christian University Institute of Child Development, is currently in private practice counseling in the Dallas/Ft. Worth area. His learning about children who have experienced chronic trauma came primarily as an adoptive father of five children from the foster care system.

Sheri R. Parris, PhD, is an Associate Research Scientist with the Texas Christian University Institute of Child Development. Her research interests include educational and developmental issues regarding at-risk children, including those exposed to trauma. She has authored many peer-reviewed articles, book chapters, and has served as coeditor of three books in the field of education.

David R. Cross, PhD, is Co-Director of the Texas Christian University Institute of Child Development and Professor in the Texas Christian University Department of Psychology. Dr. Cross and his colleague, Karyn B. Purvis, PhD, lead the Institute in its triple mission of research, education, and outreach on behalf of at-risk children. He has authored many peer-reviewed publications about issues regarding at-risk children, including those who have experienced early trauma.

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