Creating Policies to Support Trauma-informed Perspectives and Practices

1. Creating Policies to Support Trauma-informed Perspectives and Practices Janice L. Cooper, PhD Interim Director 3rd Annual Symposium, Bridging the Gap Fort Worth, Texas | November 3, 2009

2. Who We Are • NCCP is the nation’s leading research and policy center dedicated to the economic security, health, and well-being of America’s low-income children and families. • Part of Columbia University’s Mailman School of Public Health, NCCP promotes family-oriented solutions at the state and national levels. • Our ultimate goal: Improved outcomes for the next generation.

3. Outline • Background • Trauma and Its Effects • Special Populations • Current Services and Policy Challenges • Best Practices • Specific Policy Interventions • Policy Recommendations

4. Background • 1982 Jane Knitzer’s seminalstudy, Unclaimed Children: The Failure of Public Responsibility to Children and Adolescents in Need of Mental Health Services • 2005 work began for “Unclaimed Children Revisited: The Status of Children’s Mental Health in the United States 25 Years Later ” • 2007 released Trauma Report • 2008 released national report

5. Throughout her remarkable life and its many diverse experiences and achievements, Dr. Jane Knitzer embodied one consistent theme: that every child and every family is sacred, and that it is every person’s duty to reach out to the most marginalized and vulnerable among us. Her life’s work reflects these values at every stage. Most recently on the IOM Committee on Depression, Parenting Practices, and the Healthy Development of Children NCCP Director 2004-2009

6. Unclaimed Children Revisited: Interests & Aims • Identify effective state fiscal, infrastructure, training and related policies • Research-informed • Developmentally appropriate • Family/youth driven • Culturally competent • Promote research informed dialogue to move policy • Complement President’s New Freedom Commission’s initiatives by disseminating information on specific policy options

7. Understanding Trauma and its Effects • Trauma is pervasive. • Trauma refers to the severe distress, harm or suffering that results from overwhelming mental or emotional pain or physical injury.

8. Understanding Trauma and its Effects • A core feature of the impact of the trauma is the long and short term loss experienced by those exposed to traumatic events. • Critical elements of child development undermined by trauma (Cloitre, Cohen and Koenen, 2006): • healthy attachment, • social and emotional competency, • self-assurance, confidence, • independence

9. Lessons from ACES Study (Dube et al., 2001, Felitti et al., 1998) • Strong relationship between adverse childhood experiences (5+) • Suicide and Suicidal Attempts • Chronic Illness (Obesity, Heart Disease, Liver Disease) • Addictions • Mental Health Problems • Premature Death

10. What We Mean By Trauma-informed • Trauma-informed strategies ultimately seek to (Harris & Fallot, 2001): • do no further harm; • create and sustain zones of safety for children, youth and families who may have experienced trauma; • promote understanding, coping, resilience, strengths-based programming, growth, and healing

11. Children & Youth Disproportionately At-risk • Children from Military Families • Survivors of Abuse, Neglect & Sexual Violence • Children & Youth with Disabilities • Youth in Juvenile Justice • Children who Experienced Natural and Man-Made Disasters • Youth with Substance Use Disorders • Homeless & Runaway Youth • Children & Youth at Risk of Suicide • Youth of Color

12. Children from Military Families • Over 1.2 million children live in military families • Approximately 700K have at least one parent deployed (Johnson et al., 2007) • Deployment predictive of: • 2X increase risk of child maltreatment (Gibbs et al., 2007) • Increased risk of child trauma across developmental span from infancy through adolescence (Lincoln, Swift, Shorteno-Fraser, 2008) • 32% child psychological morbidity; 42% high parental stress (5-12 yo) (Flake et al., 2009)* • High parental stress put children at more than 7X increase risk for poor child psychological functioning* • Among young children (U 5yo) those 3-5 higher levels of externalizing behaviors independent of parental distress (Chartrand,et al., 2008)

13. Children and Youth from Military Families • Prevalence of Mental Health Problems among Military Personnel • Post deployment 20% of active duty and 42% of reservists needed mental health treatment (not identify prior to deployment) (Lamberg, 2008)* • Reservists, National Guard and younger active duty service members with combat related exposure increased risk for new onset of heavy drinking, binge drinking and alcohol-related problems (Jacobson et al., 2009) • Lack of confidentiality may deter soldiers from accessing SUD related treatment (Milliken, Auchterlonie & Hoge 2007)* • Referrals to SUD treatment dramatically lower compared to MH treatment*

14. Child/Youth Survivors of Abuse, Neglect & Sexual Violence • Maine: 33% females and 67% males: a trauma related diagnosis or were involved in child welfare due to traumatic event (Yoe, Russell, Ryder, Perez and Boustead 2005) • 50% female & 70 male rape survivors raped prior to age 18 (Tjaden, P and Thoennes 2006) • 20% Females • 50% Males • Raped by age 12

15. Children Who Experienced Abuse, Neglect or Sexual Violence

18. Disabled Children & Youth at Higher Risk • More likely to be abused (Sullivan & Knutson, 1998) • physically (1.5 times) • sexually (2.2 times) • Deaf children & youth higher risks (Sullivan & Knutson, 1998)

19. High Prevalence of Trauma Exposure in Juvenile Justice • Over 90 % in juvenile detention in a large urban county have been exposed to at least one traumatic event & nearly 60% have experienced 6 or more traumatic events. (Abram et al, 2004) • 11 % of youth in JJ were diagnosed with PTSD upon clinical assessment. (Abram et al, 2004)

20. What the Data Shows School-age Youth in Juvenile Detention Prevalence Behavioral Health Disorders of Youth in Detention by Gender (%) NB: Approx. 90% of youth in JJ are males. Source: Teplin, L., Abram, K., McClelland, G. M., Dulcan, M., & Washburn, J. J. (2006). Psychiatric Disorders of Youth in Detention. Juvenile Justice Bulletin (April 2006), 1-16.

21. What Data Shows: School-age Youth Who Experience Cumulative Trauma • Overall cumulative exposure to childhood trauma = 82.5 • Males were: • 3.3 x more likely than females to experience intentional or “assaultive” violence (e.g. being raped, mugged, held up or threatened with weapon) • 2.2 x more likely than females to experience other injury or trauma Source: Breslau, N., Wilcox, H. C., Storr, C. L., Lucia, V. C., & James, A. (2004). Trauma Exposure and Post-Traumatic Stress Disorder: A Study of Youths in Urban America. Journal of Urban Health, 81(4), 531-544.

22. Children who experienced trauma from natural and man-made disasters • Of Katrina survivors who were parents: (Abramson & Garfield, 2006) • Nearly 50% reported their children had new emotional/behavioral problems • Nearly 50% reported that they “never or only sometimes felt safe” • Of all returning vets from Afghanistan & Iraq, those of transition-age (18-25), were the most likely to develop PTSD (Seal, Miner, Sen, & Marmar, 2007)* • Overall PTSD rates among veterans of OEF/OIF 4X higher than community samples*

23. 3-4 times higher risk for PTSD (1) Multiple exposures to trauma predicted developing SUD (2) Youth with co-occurring PTSD & SUD lower levels of functioning (1) SUD associated with community violence, interpersonal violence, child maltreatment and self harm (3) SUD can serve as mechanism for self addressing trauma (3) SUD impedes effective trauma treatment (4) Youth with Substance Use Disorders at High Risk 1) Giaconia et al., 2000; 2) Giaconia et al., 1995; 3) Kilpatrick et al., 2003; 4) Jaycox, Ebener, Damesek, & Becker, 2004; Riggs, 2003.

24. Children of Homeless Families & Runaway Youth • Two-fifths of the homeless population in the United States is made up of families (Bassuk et al, 2005). Their homelessness puts them at increased risk for other trauma, including physical and sexual violence, emotional abuse and intense anxiety and uncertainty. • Almost two-thirds of homeless and runaway youth living on the street have witnessed violence and between 15-51 percent have been physically or sexually assaulted (Kipke et al, 1997).

27. Children at Risk of Suicide • Three groups with a greater risk: • American Indian/Alaska Native children and youth • due to the historical trauma and current deprivation and trauma • 64 % of all the completed suicide are committed by this group nationally, 17.6/100,000 versus 10.4/100,000 (Middlebrook et al, 2005)

28. Children at Risk of Suicide • Adolescent Latinas • A higher risk for suicide than Latino boys (15 % versus 7.8%) and non-Latino boys and girls (Keaton et al, 2006). • Among girls, Latinas attempted suicide 50-60% more than African-American and white female adolescents (The NHSDA report, 2003).

29. Children at Risk of Suicide • Gay, Lesbian, Bisexual, Transgendered and Questioning Youth (GLBTQ) • Between 1.7 and 2 times more likely than their non-gay and lesbian peers to have suicidal thought (Russell & Joyner, 2001) • More than 2.5 times more likely to attempt suicide than their non-gay peers (Russell & Joyner, 2001)

30. Secondary/Vicarious Trauma among Providers • Impacts their ability as caregivers (Bober et al., 2005) • Leads to higher rates of turnover (Van Hook, 2008) • Provider with self care strategies included these in tx, led to lower levels secondary trauma & reduced turnover (Gordon, 2005)

31. Strategies to Reduce Vicarious Trauma (Osofsky, Putnam & Lederman, 2008) • Smaller Caseloads • Self-care • Improve supervision of front-line workers • Access to mh services • Impart information on secondary trauma

32. Long-term Effects of Trauma • Negative Impact on Brain Development • Academic and Social Problems • Chronic Illness, Morbidity and Mortality • Intergenerational Impact

33. Current Service and Policy Challenges

34. Current Policy and Service Responses Characterized by: • Failure to routinely screen and treat for trauma • Lack of traction to use proven effective treatment strategies • Use treatment practices and environments that re-traumatize • Seclusion & Restraint • Boot Camp • Peer or Staff Abuse • Insufficient Attention to Vicarious/Secondary Trauma

35. Failure to Routinely Screen and Treat • Information on child trauma rarely received according to some studies (Taylor et al., 2005; Hansen, Hasselbrock & Tworkowski, 2002) • 84% of agencies reported in one study no/or extremely limited information on child/youth trauma history • Much of emerging knowledge on trauma fails to make it into daily practice (Taylor et al., 2005) • 33% of agencies report did not train staff to assess trauma • Less than 50% reported training their staff on EBP for children and youth with exposure to trauma

36. State Policies and Practices that Re-traumatize

37. GAO (2007) report on Abuse in State-sponsored institutions: RTFs, boot-camps, wilderness camps • 33 states with over 1600 staff involved in incidences of abuse of children and youth in 2005 • 10 investigated deaths within RTFs (one case in Texas) revealed common threads • Untrained and inexperienced staff • Lack of adequate nourishment in pursuit of “tough love” philosophy/strategies • Reckless/negligent operating procedures

38. SAMHSA Policy on Seclusion and Restraint

39. Immigration Reform Restrictive Housing Policies Disaster Response Plans Other Public Policies Can Serve to Expose Children/Youth to Trauma or Re-traumatize Photo: P. Pereira, The Standard Times

40. Immigration Policies and Trauma • 12 million undocumented workers in the US • Estimates 5 million children have at least one parent undocumented • 60% of these children are US-born citizens • Over 1.6 million immigration related arrests • Impact on children: Urban Institute/La Raza study • 506 children; impact on attending school, accessing resources, getting different caring arrangements (Capps, et al. 2007) • Children whose parents deported, arrested or detain in MN, CO, TX, NE,IA (NCCP analysis, 2006)

41. Source: http://www.ice.gov/pi/news/factsheets/worksite.htm

42. Unaddressed Challenges • Funding Restrictions that Impeded Care and Sustainable Treatment • Limited Support for Prevention & Early Intervention • Workforce problems: Inadequacy in Supply and Quality

43. Services Standardized Screening and Assessments Evidence-Based Interventions Culturally-Based Strategies Family and Youth Engagement and Support Infrastructure Training Policies to Eliminate/ Reduce Seclusion & Restraint Financial Strategies Culturally Competent Policies State Disaster-Related Plans for MH services Identifying Best Practices: Key Elements

44. Best Practices: Selected Screening & Assessment Tools Children’s Sexual Behavior Inventory Clinician Administered PTSD Scale DISC (PTSD Module) Lifetime Incidence Traumatic Events Los Angeles Symptoms Checklist Trauma Symptom Checklist (Young Children/Children) When Bad Things Happen • Acute Stress Checklist • Child Dissociative Checklist • Child Post-traumatic Stress Reaction Index • Child PTSD Symptom Scale • Child Stress Disorder Checklist • Child’s Reaction to Trauma Event Scale • Children’s Impact of Traumatic Event Scale • Children’s PTSD Inventory • Children’s PTSD Interview

45. Selected Evidence-based Interventions • Parent Child Interaction Therapy aka Honoring Children, Making Relations (Bigfoot) • Trauma-Focused CBT aka Honoring Children, Mending the Circle (Bigfoot) • Cognitive Behavioral Interventions for Trauma in Schools • Dialectical Behavior Therapy • Trauma Recovery and Empowerment for Adolescents • Seeking Safety for Adolescents

46. Case Studies (NY, ND, ME)

47. North County Children’s Clinic (NCCC): New York • Watertown, NY • 10th Mtn Division avg deployment OEF/OEF 5x • Target Population- Families (Children) of Military Personnel • 27,000 residents (16,000 active duty military – 60% deployed) • 4 school-based health centers provide over 2000 mental health visits per year to children and families

48. Strengths Positive School Relations Clinically sound programming Collaboration with the Military HMO Challenges Military reimbursement for psy. health care inadequate Sustainable program funding Magnitude of needs exceed capacity Gaps in the continuum of care TriCare two-tier system; disallows some PCTs for e.g. family conflict and child maltx; no coverage intensive commty tx North Country Children’s Clinic, New York

49. Quote from Family Member We receive our medical care at the -- Ambulatory Health Clinic. We took our son there in June and expressed our concerns for his mental health. The Doctor wrote a referral for a child psychologist in our town. That doctor had a 3 month waiting list to get on the waiting list for an appointment. By now school had started and we were having nights where he stayed up all night crying, wanting his father to come home. If I did get him to sleep, he woke up crying. It became a struggle even to get him to go to school, he saw no use in going to school if that meant growing up without his father. He had also started losing interest in church, and cub scouts, two things that he usually loves. He did not want to leave the house at all…… With the help of the school-based clinic I was able to start helping my son cope with the deployment……

50. Medicine Moon Initiative-North Dakota • State-Tribal Initiative with 6 tribes • Built upon System of Care Sacred Child Project • Strong training component draws on cultural strengths and lessons learned from historical trauma “Ours is a way of teaching parents that children are sacred” Courtesy: Deb Painte, MMI