Abordar el trauma en los entornos del aula

(En inglés)

Addressing Trauma in Classroom Settings

Dr. Sangeeta Parikshak: Hello, everyone. Welcome to the seventh event in the Head Start Heals campaign. Today, we're going to be talking about addressing trauma in classroom settings, and I've already seen many people have been chatting in, saying how excited they are to hear the information today. We've already maxed out on the live views. For those who weren't able to get in, if you have colleagues who weren't able to get in at this time, it will be available on demand through the registration link half an hour after the webinar, the live webinar, ends today.

I'm Sangeeta Parikshak, and I serve as the behavioral health lead at the Office of Head Start. And our speakers for today are from the National Center for Pyramid Model Innovations, funded by the Office of Special Education Programs.

I am pleased to introduce Dr. Lise Fox. She is a professor in the department of child and family studies at the University of South Florida in Tampa, Florida, and the co-director of the Florida Center for Inclusive Communities, a university center for excellence in developmental disabilities. Dr. Fox was one of the developers of the Pyramid Model for Promoting the Social and Emotional Competence in Infants and Young Children and is the principal investigator of the National Center for Pyramid Model Innovations, funded by the Office of Special Education Programs, for research interests and publications focused on the promotion of young children’s social-emotional competence and addressing challenging behavior and the supports needed to bring evidence-based practices to early care and education programs and communities.

I am also pleased to introduce Amy Hunter, who I'm sure many of you all know, through our National Center for Early Childhood Health and Wellness. She is a licensed independent clinical social worker and serves as an assistant professor at Georgetown University. In addition to co-directing the mental health section of the Head Start National Center for Early Childhood Health and Wellness, she is also faculty on the National Center for Pyramid Model Innovations. Amy has worked in the field for early childhood mental health for over 20 years. She has provided training and technical assistance on early childhood mental health to a variety of audiences around the country and has maintained a private practice in Washington, D.C. providing consultation to parents with young children.

Before we hear from Amy, I just wanted to do a couple of things where I want to make sure that everybody knows how to ask a question. Please send in any questions that you have, in this top “Ask a Question” section, and if you're interested in downloading the PowerPoint, you can find them in the “Event Resources” section as well. We would love to hear in what capacity you are with us today – what role do you play in Head Start? – so that we know who is so interested in the information today. So, please go ahead and put that in the chat. And with that, I will turn it over to Amy Hunter.

Amy Hunter: Thank so much, Sangeeta it was wonderful to be with you and with all of our audience here today. So, I'm going to talk for just a little bit about trauma, and then I'm going to turn it over to my colleague, Lise Fox, and we’re going to also infuse throughout this webinar time where we can hopefully answer your questions. So, as Sangeeta said, please ask your questions, and we hope to get to as many of them as we can. So, let's get started.

So, the first question is actually, or the first topic, is a question for you all: If someone asks you how you would define trauma, just reflect to yourself for a minute, what you would say. What is – do you have an elevator speech? If you were, you know, in at a different time, not in our current time, but if someone was in an elevator and asked you, “What is trauma?” What would you say? Would you be thinking of a single event, or would you be thinking of, sort of, chronic circumstances or multiple events? Maybe you would wonder about how trauma affects young children differently than adults. If it does, maybe he would have more questions than you would answers. And maybe that's why you signed up for this webinar today.

So, we are using this definition of trauma today so that we're all on the same page: when frightening events or situations overwhelm a child's ability to cope or deal with what has happened. And so, you can see from this definition that it's really less about a specific event, although of course there are events or circumstances that we probably would all agree could potentially, or would be more likely to, lead to trauma. Things that come to my mind are things like physical abuse or severe neglect, seeing something happened to a loved one, a loved one being harmed by violence – something like that. Of course, there are also chronic circumstances that might come to some of our minds like food insecurity or homelessness, chronic family conflict, maybe immigration status, or maybe substance use in the home. Those kinds of things may come to mind. But really, what's key to this definition is this idea that the event or the events overwhelm a child's capacity to cope.

And there are lots of different things that really influence a child's ability to cope, including things like temperament. We all know some children are very sensitive to their circumstances and to the environment around them. And then, some children are much less sensitive and sort of let things roll off. A key piece of what becomes traumatic to one child and not another has to do with the adults around them, who can support a child to understand the experience and help them make sense of it and feel safe and secure. And we also know that...Oops, wrong button. Hold on. There we go ... that young children are particularly vulnerable to trauma because their brains are developing so rapidly. They're particularly sensitive to sensory experiences like really loud noises, or violence that they may see, or frightening scenes. They have less life experience to really make sense of these events, and some part of a developmental progression of children is they don't really understand cause and effect. And so, sometimes we hear children thinking about whether their thoughts, or their fears, or their wishes cause things to happen. Was the hurricane their fault, or was it something they did to have this traumatic experience?

And you didn't know that when we were going to be talking about trauma, you were going to have to have a brain quiz. I'm just kidding. We're not going to have a brain quiz, but I wanted to show you a little bit about the science of the brain related to trauma just to really drive home the point that early childhood trauma does impact the development of the brain and can actually change the brain architecture. And so here we have a picture of, at the bottom of the brain, you see it says the amygdala, and that's really the part of the brain – sometimes it's referred to as the lower brain, or the reptilian brain, the primitive brain – it's really what's responsible for the stress response system. So, when a child – they're, you know – perceives something that might be life-threatening or really scary for adults – it's the same system for adults – it turns on that fight, flight, or flee response. And you can see how close that stress response is to the part of the brain that regulates memory and emotion. And so, when that stress response system in the brain gets activated, the front part of the brain that's really more responsible for weighing out decisions or trying to decide, “Should I do this, or should I do that, or how should I respond?” That part of the brain gets turned off by this more-survival part of the brain that’s saying, “Do I run? Do I hide? Do I flee? Do I fight this experience?” And this has really important implications for the kinds of behaviors that we see. And if we don't have the adults to help support children understand the experience and help them feel safe, and provide nurturing and responsive care, it can have longer consequences in life and how the brain develops over time.

But the exciting thing is – and I think this is probably why we're all here, either on this webinar or choosing the work that we choose to work with young children and their families – is that when we provide that responsive, nurturing care, when we are helping children to feel safe, when we're providing those consistent routines, we can help sort of buffer those potentially traumatic experiences.

So, how do we know? I mean, one way we know children may have experienced trauma, maybe we have – and hopefully we do have – really wonderful relationships with their family, and the families can tell if something has gone on, and we can explore with families about the impact of different experiences they've had on children and have those conversations. But also, we don't know, and so here we have a couple of slides of some signs and symptoms of children who've experienced trauma. This slide is about infants and toddlers, but I just want to alert your attention to the first three bullets there: eating and sleeping disturbance, clingy/separation anxiety, irritable/difficult to sooth. Any of you who have worked with infants and toddlers, I hope will see that all three bullets are part of normal infant-toddler development. So why are they on a list that has to do with signs and symptoms of possible trauma in young children? Well, you really have to take them into consideration with the whole picture, right? You have to look at lots of these other symptoms. For instance, developmental regression. Was the child previously toileting independently, and now they're not? Was the child using more language, and now they're using much less language? Or were they walking or crawling, and now they are no longer doing that? You might look and notice that they've become easily startled. So, when there's loud noises, they seem kind of hypervigilant or hypersensitive to what's going on around them. You may begin to see some aggression in toddlers. And so, the point of this slide and the next one – and you actually have a handout with these on them – is really to kind of put on that trauma lens so that when you see these behaviors, you might ask yourself, “Could this child have experienced something that would be related to these behaviors? Might that be one explanation for something that might be going on?”

And so, let's look at the slide here. We have a very similar list of signs and symptoms related to trauma for preschoolers, so many of the things that are quite similar to the list for infants and toddlers. A couple of the things that are different are related to their increased maturity, so preschoolers might be able to tell you – they might be able to tell you about what they’ve experienced, but they might be able to tell you things like the physical symptoms. You might hear a preschool or talking about, you know, frequent headaches, frequent sore throats, stomach aches related to sort of the anxiety that they’ve experienced. You might see children this age engaging in aggressive behavior or post-traumatic play. So, one example that – I actually was working with a child after 9/11, and they had seen the plane crashing into the tower on TV over and over and over. And so, during playtime, they were using the plane to crash into a block tower to sort of be reenacting that event. Or, another example was a child who had been in a bus accident. So, in their traumatic play area were sort of having the bus crash over and over again, so those would be some examples of different, behaviors that you may see. And again, there could be lots of other reasons for these behaviors, but one – the reason we're sort of showing you is if you want to put on that trauma lens, just to ask yourself, “Might these be the child's attempts to cope with some things that have happened in their life?”

So, the next slide we have before I turn it over to Lise – and actually pause to see if you have some questions for us – is just to show you – and Lise's going to begin to talk about some pyramid strategies – but here you can see that strategies to promote social-emotional development are really excellent strategies that also support a trauma-informed program. So, things like providing that nurturing responsive care, offering consistent and predictable routines that help children feel safe and know what's going to happen next in their environment. Of course, teaching children to identify their feelings, identify feelings of others, begin to express their feelings in age-appropriate ways gives them a lot of skills to be resilient. And not only after a traumatic experience, but later in life as well. And then, responding to challenging behavior, trying to understand not only the function of behavior. But also might the behavior be related to a memory or an experience that they have gone through? And of course, we always want to think about, I know for Head Start, eliminating any kind of expulsion or suspension, really figuring out how do we support children in this setting that they're in. And so, let me take a pause and see, I think you – do we have some questions?

Sangeeta: Thanks, Amy. We do have some questions that are coming in. I think one of the things that came through was just noting that trauma is very complex and that sometimes, you know, the definition that you gave may sounds fairly simple, but there's a lot of different factors that go into it. And so, I know that there are folks in our audience who are wondering, “How do you determine whether a child's symptom may because by trauma?” And particularly when you're thinking about infants.

Amy: Yeah. I'm so glad you asked that question, Sangeeta, and I'm also so glad you said it. I had it in my notes that I didn't say that I was going to be talking about trauma for 15 minutes. [laughter] It’s a topic that really deserves multiple days because it is really complex, but ... So, we're just scratching the surface here and trying to do justice to a topic that is really far more complex than we could ever offer in a short period of time. But your ... the question that someone raised about how do you determine if it's trauma or if it's something else is really a great, great question. And I think it’s particularly relevant right now in the time of the pandemic. You know, if programs are going to be opening, we're going to ... I would anticipate seeing quite a bit of the behaviors. It wouldn't be unexpected, right, to see some of the behaviors that were listed in the slide. And so, I think part of the message that I would give to answer that question is you need – especially in the current time – you want to give it a little bit of time to see what sort of an adjustment ... And that would also apply to, you know, any times infants and toddlers or preschoolers start a new program. I mean, you have to give some time to really get to know the child, and get to know the family, and try to build that supportive, trusting relationship with the family so that you can get a better understanding of what experiences that child has had. The other sort of message I would give in answering that question is every Head Start program and Early Head Start program has a mental health consultant. And so, the mental health consultant, this is really their job is to help consult with teachers to sort of tease this out to, you know, have that question in the back of your mind, like, “Could the behaviors that we're seeing be related to trauma? Might they be related to something else? How do we figure this out?” Let's do some observations. Let's really try to understand the meaning of this child's behavior to make sense of what we're seeing. Lise or Sangeeta, do you that you want to add?

Sangeeta: I think that was a very thorough answer, Amy. Thank you. I have one more follow-up for that before we turn it over to Lise, and I think you started answering it when you mentioned the importance of developing trusting relationships. But I think it's important for us to highlight the role of Head Start staff when it comes to addressing trauma. You know, we had people asking questions around the best ways to help a child stay calm when talking to them about trauma. Do you – who do you recommend is the person that talks about trauma, and how should staff be thinking about their role?

Amy: That's a great question, and I'm not sure if the person who is asking the question ... I mean, I'll try to answer it sort of globally by thinking about one – we were just talking about the mental health consultant – can help all staff be more knowledgeable about the impact of trauma on young children and help parents to understand the impact of trauma on young children. I think the more that the program talks about this and becomes more comfortable talking about it, the more confident and competent staff will feel sort of talking to the parents about it. And then, I think part of your question was staff talking to children about it, and I would encourage teachers, if they know that children have been through certain circumstances, to be able to talk to children about those circumstances. I think particularly in the current time, we know there's specific program who’ve experienced – and this is beyond even the current times – but who've experienced grief and loss, and so being able to acknowledge that and have resources that help teachers be able to talk to children about that. I think the more comfortable we all can get about talking to children, and to parents, and to each other about some of these difficult topics, the better.

Sangeeta: Thank you, Amy. And I do want to, you know, let folks know that we see a lot of the questions coming in about the current pandemic and worrying that it's the – that going through something like this can be the equivalent of trauma. And, you know, I just – I want to say that we want to be careful about making assumptions about what our children and families necessarily are going through during this time. I think we don't want to make assumptions that every child and family is going through a traumatic experience right now, but I do think that we want to continue to emphasize the importance of structure and routines for children that we serve, and to Amy's point, being very transparent about what is going on with children in their language and at their developmental level. We have offered different types of social stories and previous Head Start Heals webinars – you can check that out on the website – and, you know, I'm sure Lise will touch upon some more strategies and things that we can talk about. But I did want to just kind of note there are a lot of questions coming in – totally understandable – and just kind of stay tuned for some more information during the webinar. Lise?

Dr. Lise Fox: Thanks, Sangeeta. I think that's a really interesting dilemma when we learn about trauma, and we know its impact on development, as Amy has pointed out. Then, we want to know what families and children have experienced trauma and our responses. And I think the reality is we don't know who. There are some families we might not know and children, and I think that's a part of this idea of being trauma informed and engaging in trauma-informed care. So, we engage as if any child could be, and that we're ready to be able to support all children wherever they are, as well as the family system. So, as kids and families come back, we want to be responsive, we want to be careful on our interactions, we want to validate the strong emotions children are feeling, and help them navigate it. So, we're not on the pursuit of unpacking it. What we want to do is help restore some predictability and build strong relationships. Again, it feels like ...

So Amy, I've talked a lot about the pyramid model and how it really stages trauma-informed care, and I think if you kind of roll back into some of the things that she shared, including the National Child Traumatic Stress Network of recommendations around trauma-informed educational programs, is this idea of a multi-tiered approach that offers all of these elements to young children. And so, I think that very much, and I know you met – most of you have been exposed to the pyramid model, because it's a multi-tiered framework of practices to support all children, social-emotional learning, and it's been very thoughtful about what those practices look like on our infant/toddler classrooms, within our home programs, and within our pre-K classrooms. It gives us a framework in which we can break in – begin to bring a trauma-informed to how we implement the pyramid model, so I want to point out for you and unpack it a little bit.

Some of what I'll share is like – yeah, I know that. I want you to think about it through the lens of a child who’s been exposed to trauma and how that strategy or practice is particularly important. And think back on what Amy shared about some of the symptoms that we see among children who've been exposed to trauma, but also the amazing opportunity we have with that period of rapid brain development that Amy had pointed out. And so, I walk us through the pyramid model and try to point out some of those things, be thinking about that child who might've been in that's or trauma, or that child who may be experienced same trauma right now during this time of the pandemic.

First off, think that the pyramids are framework. It's not a curricula. It's not one set of materials, but it really is a framework of practices, and it was designed intentionally to make sure that programs and staff could support the full range of children that we are privileged to be able to work with in our programs. And that universal tier – what should we provide to all children in a thoughtful way? – is really critically important to thinking about the supportive children who've been exposed to trauma. So, our ... [silence] ... the trauma really need a solid relationship for resilience, for their ability to feel OK again, to feel safe, to be able to regulate their behavior, that they need strong relationships with a caregiver. And so, as we think about guiding practitioners, or if you are a practitioner, if you think about your work, the child has been exposed to trauma is going to need even more intentional, planful, and persistent – especially for a child who may reject those bids – and initially more persistent efforts at fostering that strong relationship. And that's going to be critically important in the classroom, and we probably couldn't spend enough time really thinking about that, being planful about that, structuring our interactions and our activities so that we're fostering those relationships and promoting child resilience. And the whole reason I'm talking about resilience is because that's what we're counting on. Right? That's what we're counting on that we – that's kind of our role, our role as practitioners and professionals who work within programs is ... We can't erase the trauma that has occurred, but what we can help children do is come back, cope, feel stronger, and that's what we're talking about when we're talking about resilience. We're trying to foster that child's ability to be OK, to bounce back, to overcome the odds. And actually, the literature has indicated to us, there's plenty of evidence that some young children can move through adversity and are resilient, and what we want to do is make sure that we can do everything we can to put the factors in place, the strategies in place, the processes in place to make that happen for a child and for a family system.

Amy pointed out in the chat: bounce forward too. I liked that expression as well. And so, our relationships are really instrumental to doing that. Our peer relationships are also particularly important. We saw on that list of symptoms, children struggle with building relationships with each other. And so yes, children are all in a classroom together – we're talking about the preschool level classroom – and we foster a climate of friendship and community. But for children who've been exposed to trauma, there may be more difficulties with those peer relationships, and so we want to offer them even more practice opportunities and more support to be successful in those relationships. When they have friendships, we want to really honor those friendships and help children hold on to strong relationships that they have with peers and with adults because those are gonna be particularly important to their resilience. And then the other relationship piece in the foundation, the pyramid, is our relationship with families. And of course, that intersects with what we know if a family has been exposed to trauma or not. So, we're thinking about children exposed to trauma, but if we have a child exposed to trauma, that means we have a family system that's experienced trauma. And so, our ability – our capacity to support that family – it really rests upon having a trustful relationship with the family, where were we begin to know some of those things, and then we're able to respond with appropriate resources, or interventions, or services that families may be seeking for themselves and for their child. And so, our relationships with families is way beyond making sure that we're sharing information around how to foster children's development and school readiness, but it really is a broader – let's help families be healthy, feel nurtured, and supported – that they can then help their children be healthy, grow well, be nurtured, and feel supported. And so, investing in that family relationship is so critically important.

Right now, I'm hoping as you offer remote services, if that's what you're doing, that you build strong relationships with your families and trustful interactions, where you can share information with them. At the National Center for Pyramid Model Innovations, where we have put some things on our website, and I encourage you to go and look. One of them, this is our more infographic level. It's just some simple tips for families to help their child because really that's what's going on now, right? Kids are at home with families, and we're relying on families to do these kinds of things, to support their children feeling safe and secure, and engaging in learning opportunities, natural learning opportunities. So, we have a couple of pieces I want you to go and find. This one is really quick and easy and short. We also have ones that offer some tips when kids might have behavior challenges. And of course, as families express their frustration, hopefully these resources are things you can use in a conversation with families so that they can guide their children.

The supportive environments pairs with a relationship in a really important way, and as we think about trauma, I want you to think about how critically important predictability is, how important routines are because they give children predictability, how important it is for the child to know when I come back here, it’s going to be the same, it's been operating the same, and the expectations are the same. And I'm going to know what to do, and I'm going to be able to navigate this environment confidently and receive lots of encouragement and support to do that. And that's really critically important. Of course, for all of our children, but for that child exposed to trauma, it's even more so.

One of the hard things about the pyramid model is that our middle has social-emotional in it, but at the core, obviously, is a robust social-emotional curriculum or learning opportunities. That is something we want all children to have. We want it to be rich and embedded in all our interactions and all of our supports to children. And so, when we think about that middle of the pyramid, we have social-emotional teaching for all kids, but you know we're going to have kids who’re going to need some more support. And it's probably, in particular, those kids who either have delays for this reason or that or could be kids who've been exposed to trauma. So, when we think about all of our kids, we want all of our kids during these years – before they move on to kindergarten to learn self-regulation skills, to be able to understand the emotions of others and express emotions appropriately – have strategies for developing relationships with peers, be able to engage in some problem-solving, and if you think back to the slide that Amy presented with some of the symptoms we see among kids exposed to trauma, we can anticipate that they'll need even more so, some of these things. So, we see kids here might have issues with conflict resolution or kids who might have issues with regulating their strong emotions. And so, those are children who really might need that explicit instruction, and when I say explicit instruction, what I mean is more opportunities for scaffold of learning, more opportunities to practice, more feedback about how they're doing, and being able to do that in partnerships with families because families are going to want to know how to be able to do this too. And in particular, families are going to want to know how to do it too if they're supporting kids at home.

I love the visuals and you’ve – I hope you've discovered them too – that are on headstartinclusion.org, which help us teach something really complex to young children. So, these visual are appropriate for our classroom, helping an older preschooler understand, “What is something I can use personally to calm down?” And children are taught to do that as a group, but individual children might be guided to be able to do that more often, or be scaffolded to do that by the adult in the classroom. We at the National Center for Pyramid Model Innovation are putting ... We just put up – and I didn't have time to get it in the PowerPoint because it just got up this week – a chart that a parent could use with strategies appropriate for home. So, if you've taught this successfully in the classroom, or you know this is a strategy that might be appropriate as we're supporting families in their support of children at home, go to the website and find this chart and suggest that they could make a little poster where they could guide their child to pick a self-regulation strategy to use, or a strong emotion.

We also offered this infographic early on around, from a parent's perspective, how do I help my child get calm? And of course, it starts with calming yourself, reflecting on what's going on. You teachers in the audience have used this strategy a lot, and then how to guide the child and then reconnect with the child. So, if you're supporting a family right now who is expressing a little bit of frustration with behavior or having some difficulty, this “Help Us Stay Calm” may be appropriate to share with them for their use at home.

The “Taking a Deep Breath” is a great strategy for self-regulation, and also for calming down when you have strong emotions – smelling the flowers and blowing at the pinwheel – is that easy way to teach children that. Within the classroom, I know many of you have used that successfully.

So, our either domain is the emotional literacy, so understanding the emotions of others in dealing with your own strong emotion, being able to express your emotions. And if we think about this through the trauma lens, how critically important this skill set is for young children who have been exposed to trauma and may struggle with that. Again, we're going to use visuals to make this really evident to children, to explore the whole range of emotions – for our preschoolers who can actually express their sadness, their anxiety, or their nervousness – is going to be really important, I think, as children return to our classrooms. We'll want to do a really heavy dose of instruction around emotions and emotion expression because all emotions are OK. It's what we do with our emotions and how we use our emotions in the classroom. And so, we'll want to know if children are anxious, or stressed, or sad, and be able to support children with those emotions. So, having the visuals can be super helpful there.

In terms of strong emotions, you may have used “Tucker the Turtle.” He's a really great, kind of iconic figure when you have strong emotions and you want to externalize or push out. And actually, a turtle appears in three of the most popular social-emotional curricula – evidence-based social-emotional curricula – out there for preschoolers because it works so well. So, Tucker learns that he needs to stop and pull in, and then that deep breath, and come out and think of a solution. And we were excited to develop “Tucker Turtle Takes Time to Tuck and Think at Home,” a little story that has been made for home context with ideas for how to support a child to use Tucker the Turtle at home. So again, this might be a resource that you can use as you're helping your families through this period of time and in the future when we're teaming. If you're teaching Tucker the Turtle in the classroom, how great will this be to also be able to have families translate this to a home context.

And then for our kids ... Our next domain is problem-solving, and problem-solving involves resolving conflicts with other children. So, trying to figure – its social problem-solving that we're referring to here – trying to figure out “what should we do?” First of all, that we have a problem. And what are the options, and what should we do about it? And so, that's going to be particularly important for these children who've been exposed to trauma, and we may need to guide them really explicitly and individually through the steps and help them see the sequence of the steps.

We often pair the social problem solving with a solution kit of solutions that are visually represented. It helps us teach children that there are multiple solutions that think about and to weigh, and it also help kids to have limited verbal skills actually use the card to show what they want when they engage in some problem-solving. We are going to have a problem-solving book for home contexts soon as well as a solution kit for use at home, probably in the next month, if you want to stay tuned to our material development work.

And then finally, our domain of teaching peer interactions skills. And so again, these kids who – these children, I'm sorry, I keep lapsing into saying kids – these children who are struggling with how to develop secure and trustful relationships with adults and with others, often that can flow into their relationships with children. And so, for children who really struggle with interactions – social interactions, play interactions – that really calls for an adult to teach them how to do it, to be able to break it down and teach them how to navigate that.

I love these visuals, again from headstartinclusion.org, which are options for how you initiate play. So, you see that this – how can I initiate an interaction – is broken down in very concrete ways that then enables us to teach it in a very explicit manner to children.

So, the last tier of the pyramid is what if a kid presents with challenging behavior and we labeled it intensive individualized intervention? It's intensive because it's intensive on the adult’s heart; it's not intensive about what we do with children. And when it's a child who's been exposed to trauma, it's the same process, although what I think it probably calls for – and we're going to talk about this a little bit more – is it, we're going to need ... We want to support children should be able to be OK in the classroom environment, to be able to navigate the classroom without using problem behavior, right? We're going to want to be able to manage those behavioral symptoms as being exposed to trauma in a manner that allows that child to continue to engage in activities and enjoy relationships with adults and children. And so, the behavior support plan is critical to that. And we have plenty of research evidence ... If we approach the behavior support plan in this manner, it can be effective, but that doesn't preclude other interventions that might be warranted. So, it's not an either-or situation, but ... Tomorrow for a child who's melting down, we want a behavior plan so we can make sure that child can still be a member of the classroom and be able to navigate that learning environment without having problem behavior. And so, developing the plan means convening a team is at the center of the team, and the folks who bring the most knowledge are the family and the teacher. We engage in a functional assessment, and a functional assessment ... I want you to think broadly about that. That's about a child's history. That's about previous records. That's about a child's medical history, as well as social history, as well as what we're seeing happen in the classroom. All of those go into that portfolio that's a functional assessment, and then we develop our hypothesis and the behavior support plan. And what’s fabulous about helping families at the center of that team is that if these issues are popping up in other environments, we can work together around helping a family with strategies for the community environments, as well as home environments. And when we do that, we can really wrap around support to these little ones who have such intensive needs.

So, all of this practices, I think you've been exposed to. I hope that I've helped you kind of revisit them through the lens of – for children exposed to trauma. But what I would say to you, and especially those of you who are operating programs, is these practices aren't “let's train everybody; we'll have a workshop on trauma and a workshop on pyramid practices, and we're good to go.” What we have to do is make sure that we've created the program environment so that these practices can be used, and when ... I'm to segue into Amy's part. She'll help us think about how we use the practices and how we have the implementation support to implement the practices with fidelity, with a trauma-informed lens. And so, in order to implement all of those practices, that takes a leadership team that really thinks about getting staff on board with this, making sure that our family engagement strategies are broad, and comprehensive, and include family – so families who may be exposed to trauma as well as other needs – our expectations, the way that we are helping, the way we're addressing challenging behavior and developing behavior support also is in place – so that when teachers have those issues, we can efficiently and effectively get that to them – the coaching, and the professional development we do, and then how we're making data decisions. All of those things are held by a leadership team, and that leadership team establishes an infrastructure that you could do the pyramid practices, that all teachers can be able to do these and get to fidelity on their use of those. So yeah, Sangeeta, you can ask me some questions. Do we have any questions? And then I’m going to have Amy really reflect on how the team does this with a trauma-informed care lens.

Sangeeta: Thanks, Lise. One of the things that you mentioned at the beginning of your slides, as you said, we don't know who has experienced trauma, and just, you know, thinking about this discussion around the effect of adverse events, such as the pandemic, it's very individual. And it's dependent on a lot of different factors. And so, you mentioned how we approach everyone kind of with that understanding that we just don't know. So, a lot of our viewers are expressing concern about what behaviors they will see when they go back into program. Will they see more fear, anxiety, challenging behaviors? Do we know? And what can we be prepared for? And I'm wondering if you could speak a little bit to that and all of these great resources and strategies that you highlighted ... Can those be – can those be used for something as big as the kind of the pandemic and the effects of that?

Lise: Well, first of all, I think yes, absolutely. And so, yeah, we won't know. But we could expect – we could expect possibly more fear. We could expect increased separation anxiety. You may have children who have experienced grief and loss in the home. You may have children who come from homes that have experienced food insecurity. We're all concerned about hidden – domestic violence that is hidden from us because we're not in homes that are having families in programs, children in programs, so we won't know what happened.

So, what are the behaviors that we often see that are a result of that? And I think most of those behaviors, Amy covered. You know, those are the – some of the behaviors that we'll see and whether or not children can move through that and cope and kind of settle in. I think it's highly reliant on us kind of having a heavy dose of relationship building and a heavy dose of social-emotional teaching. So I want you to think about some of the strategies, you know, I think some early lessons as kids come back will be around emotion, and emotional literacy, and what we do with our strong emotions. We might set up a cozy corner and practice that with children. You might model it as a teacher, if you're a trained practitioner, as well as encourage children to use that. You may need, as the classroom team, as the practitioners in your classroom ... And talk about being vigilant and trying to kind of tune in to when kids are going to need more support, so you're not waiting for the meltdown, but you're helping a child, say, get anxious or unglued. You know, go and seek some way to calm down, either moving to a calm-down corner, or pulling out of an activity, or finding an activity that's more soothing to them. We might offer more of the kinds of activities we know are soothing to the age level of the children that we're with. We might be a little more generous with ourselves about long periods of play and exploration so that kids aren't hurried and we don't increase their anxiety. So, I think what I want to say to pyramid practitioners is you know the practices. I think we need to look through the lens of what has happened to children and what more might they need. We're going to try to develop some social, scripted stories. Of course, every situation is different. But to help kids deal with whatever it is that they're encountering, if we have rules that could be in place, like not sharing toys and not hugging your friend, which is going to be hard for all of us to do when we get the good people again, we might have to give some prevention instruction to children to really remember that. And then we're going to need to be gentle, supportive, and encouraging and not scared as adults if children forget some of those rules.

Sangeeta: Thank you, Lise and there have been a lot of questions around family engagement, and we do have a National Center for Parent, Family, and Community Engagement that did a great webinar for us. It's on the Head Start Heals page that folks can check out. But a lot of the strategies that you've highlighted, people are wondering if they should be or could be shared with parents as well to use with their kids.

Lise: Absolutely, and what we'll try to do is we're trying to keep ahead of you and anticipate some of those needs and tailor them. Because you're gonna want to say, “Oh, this is good, but it's not quite fits with a home context.” So, for those things that don't fit with a home context, we're going to try to develop those for you, and then I think then we'll all be in a better place in the fall for our home-school partnerships in doing this work.

Sangeeta: And then my final question before we turn it over to Amy is that, you know, there are instances where people see in classroom settings one or two kids in that classroom that really disrupts the flow of the entire day, right? The kids who might be biting, or hitting, or spitting, or even destroying school, it's hard to get them to go to the cool-down corner. Is there any advice that you can give about using this model that you've talked about, the pyramid model or the strategy for those kids as well?

Lise: Yeah. So, when we developed the pyramid, it was really designed so that any child who crossed your threshold could belong in that classroom and be supported. And so, if a kid has chronic biting and it's so disruptive, then that's a child that we should initiate the behavioral support planning around. However, what we see is that when people put in place the relationships, the predictable environment, and a really robust and repeated social-emotional learning opportunities and social-emotional teaching, we see very few of those happen in our classrooms. I think we're going to see maybe a pop-up, a little bit more because pandemic – because it's such a whole new situation, although kids could all be so happy to be back with you as we see them settle in. But I think we need to resist the idea that there some better place for a child, because especially for children exposed to trauma, that can be retraumatizing – that's another rejection, that's another adult I can't trust – and could really compound the problem. But you have a mental health consultant that can help you figure this out. You get ... First thing I would just get together as a classroom team and really think about what can we do from a social-emotional prevention and promotion frame to help support that child settle in. And if those strategies don't work, then move to behavioral support planning. Amy? Thank you. Amy?

Amy: All right. Well, I do want to just weigh in on this question a little bit too, in the sense that I love what Lise said around the pyramid was developed for all children to be successful in the classroom. And I was thinking about this question: What we can teach other children by how we react to those children who are having a hard time, right? Like what are we teaching all the children about relationships, and about inclusion, and about compassion, and about tolerance. And, just when we treat that child who's having a hard time managing their feelings, or controlling their behavior, or coping, that we're teaching the lesson that this is not a bad child, but this is a child who's having a hard time. And what can we do for our friends? How do we set limits with our friend? If our friend is hitting us, we can tell them that, I don't like it or maybe the friend doesn't want to be playing with them in that moment, but what are they ... So just kind of pulling out a little bit and broadening the lens to think about, you know, all the awesome strategies that the pyramid model offers and the processes that they offer. And then, the larger lessons that we can teach children about how we treat others when they're having a hard time and what we can do for them in terms of our compassionate selves.

So great questions. These are tough. I mean, this is ... You all are asking some awesome questions. So, I'm going to move us forward just a little bit to take – unless there were any other questions. Sangeeta, should we keep going or were there a couple more questions that you wanted to ...

Sangeeta: No, you can keep going, and then we'll have time at the end hopefully for more, right?

Amy: Yep. Exactly. Perfect. So, just picking up where Lise left off, about thinking about the leadership team and the whole process of addressing this. We can weave into that process the thinking around how do we help our program to be more trauma informed. And here are some strategies that we can think about doing this. These are strategies from SAMHSA, that’s Substance Abuse Mental Health Services Agency, that really helps us think about: What does it mean to be trauma informed? And one of the first things it means is to make sure that all our staff understand the widespread impact of trauma. Again, we did like that five-minutes, scratch the surface here, but you would really want to help your staff in an ongoing way – through training and through ongoing support – to understand the impact of trauma on children and on adults. I think that's a piece that we often forget is: How has trauma impacted, yeah, that was trauma impacted, you know, us? How has trauma impacted families? And so really, really get a sense of understanding that.

And then we talked here today a little bit about the signs and symptoms of trauma, so just having that lens of maybe what I'm seeing is related to experiences that children have had and the signs and symptoms ... Are there ways of trying to cope with the experiences that they have had. And then, taking all of that knowledge and then sort of answering that well ... So what? You know, so now I know this, now what? And really integrating that, as Lise so aptly talked about, into our practices. So, making sure that we are treating all families and also children with an understanding and with a compassion that the experiences that they may have had may be informing the behaviors that we're seeing, making sure that families, all families, feel welcome so that they don't feel like they're being retraumatized by a school experience that they may have had as a child that didn't go very well. And so, that gets to the last bullet of making sure to the extent that we can, that we're avoiding retraumatizing experiences, using harsh voices, or having policies that – as Lise was talking about, expulsion or suspension – that really create much more trauma for children and families. And so here we have a slide that kind of takes the pyramid model and all the wonderful practices and sort of theories behind the pyramid model and overlays, sort of, that trauma-informed approach. So, I think all the effective practices as a pyramid model can be incredibly helpful for children in terms of the social-emotional skills, and the relationships, and the routines, and teaching social skills, all that Lise talked about. And then we also can add in some of those trauma-informed approaches. So, really thinking about how do all of those practices promote resilience? And linking all of those social-emotional skills to really ... Social-emotional development is very much synonymous with children's mental health, helping children feel safe, helping them feel confident and competent, and able to sort of weather the storms that they may have been experiencing, and as Lise said, be resilient to bounce back from adversity. And then, you know, we've heard people talk about actually not just overcome the adversity, but really move even forward more than they may have otherwise. So, understanding where behavior might be coming from in terms of helping them ... Those behaviors may have helped them stay safe or to be safe in traumatic situations. They may not be working as well or not needed in the classroom context, so we can help them learn new ways of communicating or new behaviors and new models of relationships. And I think, yeah, we're going to talk just in a couple of slides to the last bullet is really just a theme that we've talked throughout about the importance of family engagement and really building that very intentional, close, and secure relationship with families in addition to children.

And so, I'm going to animate this whole slide here quickly to show you sort of when we're integrating trauma into that pyramid framework that Lise talks about, we're really thinking about sort of that trauma-informed approach at every level. So, the effective workforce, that's where we would be thinking about how staff have training on the impact of trauma, and how they're using that kind of trauma-informed lens to add on and integrate into the pyramid practices and the pyramid processes. I love the way Lise was talking about, related to pyramid practices already have as their solid foundation related to promoting secure and responsive relationships and creating stable environments and routines. And so, it may be, for children who have experienced trauma, just to be amping that up a little bit and being even more intentional about that. And then, certainly, when we teach children about how to regulate their emotions, and when we're talking about infants and toddlers, we may need to be much more intentional about our coregulation. So, how do we manage our own frustrations so that we can help infants, toddlers, and preschoolers to first coregulate and then be able to regulate their own emotions.

And then I think Lise gave a great example or talked quite a bit about how to integrate this trauma lens into developing behavior plans. That's the top of the pyramid. And the other thing I would say about this top of the pyramid is ... So, developing a behavior plan for a child in the classroom is going to be very supportive of children who've experienced trauma, and it might be that the child would benefit as well, and the family from other interventions, therapy, or that kind of service.

Here is an example of a handout. I don't believe the handouts are available right now, but if you check back, we will have the handouts linked, and you can also find this handout on the PMI website. It is ... There's no way ... And we would never want to have checklists of informed practices, but this gets you thinking about, sort of, the kind of the categories of practices that we've been talking about and some examples of how certain practices might be helpful to children who have experienced trauma and how you can add your own practices. So how, for instance, how do you build those close and secure relationships with children and especially children and families who have experienced a trauma? So, what is it specifically that you do when they enter the classroom or when you're meeting a new child or family? Look for that handout.

And then we have a theme throughout, as it's appropriate, is talking about not just supporting children, but supporting the whole family system, because if a child has experienced trauma, whether or not their family has also experienced trauma, it's impacting the family. And most likely, for young children, it has been family experience. So, making sure that first and foremost we're helping families meet their basic needs. And I think, there's been quite a number of questions related to the pandemic. This may be something where if your programming... I think you are hitting on something very important about individualizing for families, just like we individualize for children. So, we appreciate that point. And the last point I'm going to make before we take more questions ... And if you have a question, please type it in. And before I turn it over to Sangeeta for the questions and Lise to wrap us up, is we've mentioned a couple of times about mental health consultation. We hope that you're – at this point, even more important – to pull that mental health consultant in and think about whether you need more mental health consultation, or how you decide how much is enough of mental health consultation. But the consultant can help support pyramid model implementation and all the awesome strategies. Lise talked about ... They can add to mental health ... I mean they can add to, excuse me, a pyramid model implementation by infusing some of the trauma-informed care pieces we've talked about or staff with wellness pieces that will be really relevant to reduce staffing anxiety around this time, and really sort of getting all hands on deck to think about the importance of mental health during this time. And I think the next slide is for Lise, but we might want to pause to see if we have any questions. Sangeeta?

Sangeeta: Yeah, I think just in general, I'm looking through a lot of the questions coming in, and you know, right now is the time when our staff are trying their best to engage with parents over Zoom, or calls, or over the phone. Are there strategies that you would suggest people can use virtually to engage with families better? Can they be talking about the pandemic when a child is there listening in on the Zoom call? What are some tips that you would give them when all they really have is a virtual platform for engagement?

Amy: Yeah, that's a great question, and I think one thing to keep in mind is that right now, while families are sort of in – and I don't want to make any huge generalizations, and I think this was what maybe you were saying or the person who was on before – is that for every single family, this is going to be a different experience. And each day may be a different experience. There may be some days where you're like, “It's OK.” You know, lots of other days where it's incredibly financially stressful, emotionally stressful. But it may be hard for families to kind of engage with you in a meaningful way, talking about their experience when they're in the experience because it very well be that you're just trying to get by. Like, I'm just trying to survive another day, doing the best I can, and it may not be ... You shouldn't be expected that, if it is a traumatic experience for families – and it won't be a traumatic experience for every family – but if it is for some family that it is not the time to sort of be unpacking it when they're in the middle of it, right? They may need some distance, and some care for their children, and some time and space to be able to, kind of, to unpack it to talk about it, reflect on it. It would not be during the time when it is happening. So that's one piece to think about.

Another piece to think about ... I think part of the question was, “Is it OK to talk about the pandemic with the children there?” I think you can ask the families, “What has the family talked to their children about?” There's some great social stories on the PMI website and as well as in other places that talk about how to talk to children about the virus, and what a virus is, and why we have to wear masks, and why we have to stay home. So, I would encourage you to share those with families and help families have those conversations with their children so that their children can make meaning of what's going on, and why things have been changing, and why maybe the parents are stressed or why people are wearing masks, and all of that.

And then finally, I would say just being your genuine self and asking families: How can I best support you during this time? What's most difficult about the situation for you? Are there things that we can talk about that would help? And then one of the questions that we've been talking about asking families as well is: Are there any silver linings in this experience? Are there any things that are surprisingly small gifts from this experience, in addition to the difficulties? So, those are my thoughts.

Sangeeta: And I think to that ... That's super helpful, Amy. I think to that last point that you made, we don't by any means want to downplay what people are going through, but part of this trauma-informed approach and part of being mentally well is to be able to look at some of the silver linings, right? It's kind of a basic thing that we often forget about as part of the staff wellness strategies that your center sometimes provides. And so, I think even in this situation with all the uncertainty and everything going on, I'm glad that you highlighted the need for that as well. Lise, did you want to add anything, or would you have to continue on with your slides?

Lise: No, I don't know if I have anything to add. We did put up ... Some teachers who are in the classroom and haven't engaged in a lot of working through families, through phone calls, or web meetings to then guide families around learning activities were like, “How do I even start this conversation?” So, we've just put something up on the website that helps you think about the sequence of your conversation and how to have a conversation that communicates with the family the support, nurturance, as well as be focused, because I know when you're having these distance meetings with families ... We're also ... We have a little bit of an agenda, right, around: What can we do to guide your child, and how do I support you? So, you might want to check out that resource as well.

So, we have this final slide here. We'll move right back to questions – because this one was just kind of hanging out here – around professional development and practice-based coaching, and that's really important. And people said, OK, we'll now let's get trained in the pyramid practices, and we'll use practice-based coaching to put those practices in place. And I created this slide because I want people who are thinking about bringing a trauma-informed approach to their pyramid work to know that we're going to need to do more than that. Right? So that we're going to need to make sure, especially if you think about that – what the leadership teams do, and how do we make sure our whole program is trauma informed – that what we'll want to be able to offer is more continuous professional development. Obviously, this is like a touch. You got a window into what's involved in doing this. But for people to have a deeper understanding about the impact of trauma and adverse childhood experiences, it also is important that folks understand bias, and their implicit biases, and the how those intersect with these issues that we're talking about, especially when we talk about children with behavior challenges, that we really work hard on our family partnership and strategies to use. So, of course, every high-quality Head Start program has broad and comprehensive family engagement strategies. When we start talking about trauma, then we might be thinking about adding ways of reaching out and connecting with families and offering family supports that might be different or include more resources or community partners in thinking that through, including community leader who help us think about the needs of the families that we're serving. We'll want to have training and attention paid to equity issues and culturally responsive practices that, of course, intersect with implicit bias as well as intersects with our interpretation of behavior and what we think is challenging behavior.

And then, I think there's a lot of work for us all to do around the notion of integrated services, and community collaborations, and that idea of all hands-on deck that Amy talked about. Bringing this all together and so that we have a really strong system to be able to be responsive to families and children who've been exposed to trauma.

And we can move to questions. I need to thank our funder because ... Because I'm funded, I get to come and share this great information with you, but I also want to acknowledge Head Start and child care, who funded pyramid work so generously in the past, and we're excited to be able to continue to work with you all to bring it. Did we have more questions, Sangeeta?

Sangeeta: Yeah, thanks, Lise. So, we are getting more questions around working with parent’s, right, during this time. And so, one person asked, “Should we ask parents to a private Zoom meeting without their children to have discussions about their concerns and ways to support them?” Wondering if others are wondering how much they should be putting on the parents at this time. It's a fine balance between providing lots of supports, but then also recognizing they have a lot going on, so they may not have time for another Zoom call. How would you ... Are there any other ways that you would support parents during this time? Do you think that private Zoom meeting is a good idea?

Lise: Well, so whether or not it's a good idea for a particular family, I think is up to the family. Offering ... If you have a sense that a family is feeling anxious, overwhelmed, frustrated with a child or reluctant like, “Yeah, I don't think I can do any of that. You don't know how it is here.” You can offer, “Would you like to have a phone call where we can just talk and chat about that? You know, I'm happy to do that for you.” You're going to have to follow the lead of the family. I think Amy was really wise in saying, “We can't force people to unpack.” We're not going to be insistent of that. And I think being there is important, and maybe even just knowing that you're there and willing to listen offers something to a family. So, I think offering it – a phone call or a Zoom meeting – doesn't have to be them ... People are getting pretty tired of them and the stress that’s around ... But Amy, do you have thoughts about that?

Amy: No. Well, my first thought was exactly what you said about asking the family. I think it's a wonderful idea to offer. I don't know if there would be logistical issues if the parent could even sort of arrange that at a time maybe when their child is napping or if they do have a partner that they could step away and have a private call or Zoom. I think it's really up to the family, but the idea of offering it if it's something that would meet their needs, you can talk to them about that. I think being as transparent as we can about things within our scope that we're able to do and whether or not that would be helpful to the families is a great question to ask them.

There are also probably friendly ways, if the child is there, that you can communicate a message. I love the “you need to put on your oxygen mask before you can put on your child's.” So, those are friendly ways that you can get at: I'm hearing stress in your voice, and I know it's overwhelmed, and here's a strategy without getting too in the weeds or making it uncomfortable to have that discussion in front of a child, if a child is sitting there with the parent.

Sangeeta: I think some other questions that are coming ... Oh, go ahead. I'm sorry. I thought you were done.

Amy: I was just going to pick up, Sangeeta, on that other piece of the question that you asked about regarding balancing the added stress to parents versus offering help and kind of finding that balance. I just I've heard that so much from people who are doing this virtual. And I think, you know, it's again a great question that you can ask families directly. Is this helpful or is this an added thing that you feel like you have to do? And are there ways that we could do that to be ... The idea is that we're lessening the burden, and we're being helpful, not adding to your stress. And so, would it be helpful to have a call at a different time, or a different type of call, or take a break, or do you want to send emails, or you know? But really just being as open and transparent with families as you can and letting them decide.

Sangeeta: The last question I'm going to ask has to do with when to refer a child or family to a mental health provider or a mental health consultant. Amy, you started off today by listing off a variety of different symptoms of trauma, and people have been worried about the anxiety part of the pandemic, but when we all return, or children and families return to program, what should they be considering is kind of normal behavior? How long should they wait until they engage the mental health team with their concerns?

Amy: Yeah. Excellent questions. And so, I always encourage, right, like we did in the beginning, use your mental health consultant to sort of help individualize this question for each child and family, and then sort of globally, I think one of the ways we sort of answer this question about when to refer for additional help is, first of all, rule out any medical causes, right? Make sure that the pediatrician is involved – or the medical provider, if that may be a nurse or family practitioner – to rule out any other underlying medical concerns that may be adding to this child's behavior. Do they have ear infection or dental health issues? What else might be going on medically or physically that might contribute to the child's behavior? So, making sure that's part of the overall profile or picture that Lise talked about when you're gathering information. And then we look at: Is this behavior getting in the way of the relationships? Not just necessarily in the classroom and their peer relationships, but their family relationships – is it changing the dynamic of the way that the parents interact with the child? Are the parents really frustrated? And they're sort of really interfering with their family functioning. Is it interfering with the child's progressing in terms of their developmental milestones, and learning, and being on track? Those would be some of the questions that we'd be asking. Are things that we're doing in the classroom with a behavior plan or with boosted strategies related to some of the things the pyramid practices? Are they making a difference? Are we seeing progress over time? So those would be some of the things that I would take into consideration when determining if extra mental health support is needed for the child. And then for the family, I would really sort of take the lead with the family about what their experiences have been, and might it be helpful for them to talk to somebody about their experiences? Lise, do you want to add?

Lise: No. [laughter] No, we covered that thoroughly.

Sangeeta: Well, Amy and Lise I want to thank both of you for all of the wonderful information you provided us and for being willing to try to answer and tackle some of these really hard questions that are coming in.

Just want to take another couple of minutes to let people know other ways they can stay engaged around these discussions. So, we do have a MyPeers community, if you're not a part of it yet, strongly encourage you to join. There's open communities related to mental health, but we'll be having more discussions around trauma and trauma-informed approaches, so please take a look. If you have more questions around the parent and family engagement piece, there is a PFCE Deepening Practice community that we would encourage you to join as well. And then, we do have some upcoming office hours and webinars that you may be interested in. So, we have one this week on partnering with families to address domestic violence. This will be – basically just a Q&A session. PFCE will be joining us, along with Health and Wellness. And so, we encourage you to come with your questions around this important topic. We'll have some office hour on addressing substance use and then one on child welfare. We also have an upcoming webinar on preparing for challenging conversations with families – so a lot of those questions about how to engage families – I hope we can get some more information there. If you want to register for any of these upcoming events, you can go to the link at the bottom of the slide here to register for any upcoming events that are coming up.

And then, many of you asked how to get to the Head Start Heals campaign page. You can go to the main page of the ECLKC, and there's a link for Head Start Heals there. All of our webinars and office hours are recorded in there for you to listen to, and the PowerPoints are available as well. We also have our mental health page on the ECLKC, and there's the link for that. We do have a trauma section there that talks more extensively about trauma-informed approaches, so please check that out.

And also, I know that many of you had questions around the coronavirus, and reopening, and what OHS’ guidance is going to be. We didn't talk about that here today. We do have a separate webinar series. It's called, “Ask the Experts” series. And so, if you go again to the main ECLKC page and go to the COVID page, you'll be able to get more information about those.

Thank you so much for being a part of our discussion today, and we look forward to you attending another webinar office hour for Head Start Heals. Have a good rest of your day, everybody.

Cerrar