Statewide Interagency Approach for Children in Care

1. Children with Special Health Care Needs, Child Maltreatment/Trauma & Foster Care: A Statewide Interagency Approach to Care and Capacity Building

2. University of Tennessee Center of Excellence for Children in State Custody Boling Center for Developmental Disabilities Janet Todd, Ph.D. Melissa Hoffmann, Ph.D. Kristin Hoffman, Ph.D.

3. LEARNING OBJECTIVES 1. Describe functioning of COE and its relevance in a UCEDD 2. Describe collaborations with stakeholders to improve outcomes for children 3. Discuss importance of understanding impact of trauma on child development

4. Tri-Partite Structure for Case Management for Children in Custody and at Risk of Custody Centers of Excellence for Children in State Custody Vanderbilt COE • DCS Health Units: Regional units composed of psychologist, nurse, and case manager who identify and manage health and mental health care for children in custody and at risk. • COE’s: Provide specialty consultative, diagnostic, and clinical services, improvement of the system of care; referrals from Health Units and Implementation Team. • Crisis Management Team: ETSU COE UT-CherokeeCOE Southeast COE UT Boling Center COE Map of COEs across Tennessee

5. Development of COEs Collaboration of multiple stakeholders: - University partners - Commissioners of Child Serving State Departments - Child Advocacy Organizations - TennCare (TN’s managed Medicaid)

6. Staff of UT COE Psychologists Psychiatrists Pediatrician Social Workers Speech Pathologist Training Coordinator

7. CONTINUING COLLABORATIONS - Child Welfare - Community health and behavioral health providers - Schools • TennCare • State Departments • Commission on Children and Youth

8. COEs and Children with Disabilities • Children in or at risk of entering the child welfare or juvenile justice systems are much more likely to be victims of abuse or neglect and to have physical, developmental, or psychiatric disabilities.

9. Characteristics of ReferralsOct. 2012 – Oct. 2014 • N = 165 • Ages ranged from 1 to 17 years • 0 to 5 years = 19% • 6 to 11 years = 38% • 12 to 17 years = 43% • 61% Male, 39% Female • 50% African American, 50% Caucasian

10. Referrals – continued • 60% Resource (Foster) Home • 22% Biological or Adoptive Home • 11% Residential Treatment • 7% Other (kinship/relative care, psychiatric hospital, etc.) • Among those in out-of-home care, youth experienced an average of 2.8 placement changes/moves (range 1-12)

11. Referrals - continued • Average of 3.4 prior DSM disorders (ranged from 0-8) • Most Common Prior Diagnoses • Behavior Disorder (19% of youth) • ADHD (18%) • Mood Disorder (17%)

12. Intellectual Disabilities among Referrals • 10% of referrals (among children 6 and older) had a previous diagnosis of Intellectual Disability • Following assessment, COE diagnosed 28 youth with Intellectual Disabilities (21% of referrals)

13. Youth Diagnosed with Intellectual Disability by COE • Only 13 (46%) had prior diagnoses of Intellectual Disability • Among ages 12-18, 8 out of 16 (50%) had not been previously identified • Among ages 6-11, 8 out of 12 (67%) had no prior diagnosis

14. Pre and Post Diagnoses among Referrals

15. Reporting Requirements • 2010 Reauthorization of the Child Abuse Prevention and Treatment Act (CAPTA) • Requires states to include child disability in their abuse and neglect incidence and prevalence reporting

16. Reporting Requirements • Under 2010 Reauthorization of CAPTA • A child is considered to have a disability based on the definition used in IDEA

17. Victims with a reported disability, 2012 • Data from CHILD MALTREATMENT 2012: • Tennessee Total Reported Disabilities – 160 out of 10,069 • 155 “Behavior Problem” • 5 “Physically Disabled” • No other categories reported

18. Disabilities & Child Maltreatment • Disproportionate rates of maltreatment among children with disabilities • Children with disabilities are 1.7 to 4 times more likely to experience abuse or neglect • 11% to 22% of children who experience maltreatment have a disability

19. Why at Higher Risk? • Increased dependence/demands on caregivers • Lack of personal safety & abuse prevention programs • Communication difficulties • Susceptibility to manipulation

20. Effects of trauma may be increased as well • Reduced protective factors • Belief that people with developmental disabilities cannot benefit from traditional verbally oriented therapies • A lack of trained professionals who are comfortable working with people who have developmental disabilities and trauma

21. Maltreatment and the Developing Brain

22. Not only are people with developmental disabilities more likely to be exposed to trauma, but exposure to trauma makes developmental delays more likely.

23. Abuse and neglect have profound influences on brain development. The more prolonged the abuse or neglect, the more likely it is that permanent brain changes will occur.

24. PET Scans Showing IncreasingBrain Metabolic Activity: Birth to One Year of Age Images: Harry Chugani Science Vol 288, June 23, 2000 Slide modified from Frank Putnam, M.D. PCIT & Trauma presentation

26. By age 7, 93% of brain growth (volume) has occurred • However, children between the ages of 0 and 7 experience the highest rates of abuse and neglect

27. Experience in Adulthood…. • Alters the Organized Brain • Experience in Childhood…. • Organizes the Developing Brain

28. Neural Imprinting The brain develops and modifies itself in response to experience. Neurons and neuronal connections (i.e., synapses) change in an activity-dependent fashion. The more an experience is repeated, the stronger the connections become

29. What Fires Together Wires Together • The more an event occurs, the more a neural path is fired and traveled, and the more permanent the message or new learning becomes • So, when you repeatedly activate specific brain activity you are wiring or rewiring the brain.

30. Normal vs. Neglected Brain As cited by Felitti & Anda, 2003; source CDC

31. Fight, Flight, or Freeze • During traumatic experiences children’s brains are in a state of activation (survival mode). • The neurohormones released are good for short stress periods – but can become harmful when in the system for long periods of time.

32. Young children who are neglected or maltreated have abnormal patterns of cortisol production that can last even after the child has been moved to a safe and loving home.

33. Chronic activation of this adaptive fear response can result in the persistence of a fear state: • Hypervigilance • Increased muscle tone • Focus on threat-related cues • Anxiety • Behavioral Impulsivity

34. Under stress, traumatized children’s analytic capacities disintegrate, and their emotional reactions take over, resulting in uncontrolled emotions and behavior

35. Normal Stress Response • All affective energy mobilized in the limbic system (red). • Higher Cortical areas less active (blue).

36. The Good News • The brain is very plastic and capable of changing in response to experiences, especially repetitive experiences. • Early identification and intervention with abused and neglected children has the capacity to modify development

37. Defining the Problem in Tennessee in 2008 • 8,000 children and youth in custody • Underserved and complex population • No screening/assessment for trauma • Few assessments recognized trauma etiology of externalizing behavior problems in outpatient mental health or residential treatment centers

38. Defining the Problem in Tennessee • Dearth of therapists trained to work with families • Lack of evidence-based practice

39. OPPORTUNITY KNOCKS Governors Office of Child Care Coordination

40. A Building Momentum for Change Nationally • Kaufman Best Practices Report (2004) • National Child Traumatic Stress Network (est. by Congress 2000) • Mission: To raise the standard of care & increase access to services for traumatized children and their families

41. Kaufman Report • Best Practices: • Criteria for clinical utility • Criteria for evidence supporting the efficacy of the treatment • Criteria for transportability • Science of Dissemination

42. Large Gap Between Scientific Knowledge/Front-line Practice • Institute of Medicine has found that it requires 17 years for scientific knowledge generated in randomized clinical trials to be routinely incorporated into everyday medical practice across the nation.

43. Traditional Training Approach • Single Training Event • Passive Learning • Individual Change • Minimal Follow-up • Minimal Accountability • Minimal Consultation

44. Learning Collaborative Model of Dissemination • 9 to 18 months time frame • Develop a learning community • Include key administrators • Pre-Work Phase • Three 2-day Learning Sessions • Action Periods between sessions

45. Learning Collaborative Model of Dissemination • Ongoing phone consultation & coaching • Model of Improvement • Small Tests of Change • Plan, Do, Study, Act • Monthly metrics

46. Dissemination of Trauma-Informed EBPs in Tennessee • 6 Learning Collaboratives (2008 to present) and 27 Booster Trainings • 5 TF-CBT (55 agencies, more than 900 clinicians) • 1 ARC (10 agencies, more than 100 clinicians)

47. TN-TIES • Tennessee Network for Trauma-Informed and Evidence-Based Systems (TN-TIES) • 4-year grant from the National Child Traumatic Stress Initiative and the Substance Abuse and Mental Health Services Administration (SAMHSA)

48. TN-TIES Goals • Increase access and improve services among youth in foster care who have experienced trauma • Help Tennessee’s child welfare system become more trauma informed

49. Resource Parent Curriculum • Caring for Children Who Have Experienced Trauma: A Workshop for Resource Parents (www.nctsn.org) • 16-hour workshop that teaches caregivers about trauma and the impact it has on the youth in their care

50. Child Welfare Trauma Training Toolkit • 14-hour curriculum that teaches child welfare workers about trauma and the impact it has on youth in the child welfare system (www.nctsn.org) • Teaches the 7 essential elements of a trauma-informed child welfare system