Impact of Trauma on Children Served Within Systems of Care and Intervention Approaches

2. Trauma and Systems of Care Trauma has become more of a focus for mental health systems: Increased awareness of trauma & trauma-informed approaches to service delivery. Contributions of recent research and evaluation findings. What we have learned so far: Trauma is pervasive in mental health service populations. Clear link between untreated childhood trauma and host of serious physical and mental health disorders over the life span. Need for systemic approaches for addressing trauma. Trauma has become more of a focus for mental health due to: Diverse national efforts: NASMHPD, SAMHSA’s grants such as National Child Traumatic Stress Network, Women & Violence Study, Suicide Prevention, efforts following 9/11 and now Katrina. Also the Childhood Adverse Condition Study through the CDC. Recent research & evaluation findings: researchers & evaluators have been discovering a subgroup of kids both in programs and through systems of care that we don’t have a very good handle on – that aren’t doing very well. In looking for answers found that one area for further exploration is the whole issue of trauma. What we have learned so far: pervasive – KC Metro Trauma Exposure Study Systemic approach vs. specific treatment – not just a specific service, or select group of kids, or a particular set of clinical interventions – but that trauma needed to be thought of as an organizing strategy – a platform for system development along with recovery and cultural competence. Presentation brings together findings from corresponding SAMHSA efforts through the National Child Traumatic Stress Network, the Women and Violence Study, evaluation being done within a system of care statewide in Maine and at the agency level to hopefully initiate a dialogue about how to include trauma as an “organizing strategy” in system of care development. Trauma has become more of a focus for mental health due to: Diverse national efforts: NASMHPD, SAMHSA’s grants such as National Child Traumatic Stress Network, Women & Violence Study, Suicide Prevention, efforts following 9/11 and now Katrina. Also the Childhood Adverse Condition Study through the CDC. Recent research & evaluation findings: researchers & evaluators have been discovering a subgroup of kids both in programs and through systems of care that we don’t have a very good handle on – that aren’t doing very well. In looking for answers found that one area for further exploration is the whole issue of trauma. What we have learned so far: pervasive – KC Metro Trauma Exposure Study Systemic approach vs. specific treatment – not just a specific service, or select group of kids, or a particular set of clinical interventions – but that trauma needed to be thought of as an organizing strategy – a platform for system development along with recovery and cultural competence. Presentation brings together findings from corresponding SAMHSA efforts through the National Child Traumatic Stress Network, the Women and Violence Study, evaluation being done within a system of care statewide in Maine and at the agency level to hopefully initiate a dialogue about how to include trauma as an “organizing strategy” in system of care development.

3. Trauma“A Definition”

4. What the Research Tells us: Estimated 3 million children and adolescents in the United States are exposed to serious traumatic events each year. Nearly one out of three adolescents have been physically or sexually assaulted by the age of sixteen (Boney-McCoy & Finkelhor, 1995). Violent crime victimization among youth found to be twice as high as the rate for adults (Hashima & Finkelhor, 1999). High-rates (between 50% and 70%) of Post-Traumatic Stress Disorder in child/adolescent and adult public service users (Macy, 2002, Kessler, 2000, Switzer, et al., 1999). PTSD rates among Medicaid enrollees found to be highest among children 5-12 years (609.5 per 1000) (Macy, 2002). Child/Adolescent trauma survivors found to have higher rates of mental health service use and to use more acute mental health treatment services, including: inpatient hospitalization, crisis services, and residential treatment services at higher cost (Frothingham, et al. 2000; Macy, 2002, Newmann, et al., 1998; NTAC, 2003).

5. What the Research Tells us (Continued): Rates of Post-Traumatic Stress Disorder among adults who were formerly placed in foster care were found to be twice as high as rates as in U.S. war veterans (Northwest Foster Care Alumni Study, Pecora, et al., 2005) Children in foster care exhibit disproportionately high rates of acute and chronic medical and mental health conditions and use more mental health services at higher cost than children not in foster care (Halfon, et al., 2002; Landers & Mei Zhou, 2004). Child and youth trauma survivors at increased risk for substance abuse, criminal activity, homelessness, and re-victimization (Boney-McCoy, et al., 1996; Krahe, 2000; Flannery et al., 2001; Anderson, et al., 2003). Childhood trauma exposure consistently associated with a wide range of serious mental health & physical health disorders in adults (Felitti, et al., 1998;Schwartz & Perry, 1994; Dube, et al., 2003, Chapman, et al. 2004). Relatively few studies have specifically evaluated the impact of trauma on public service use, treatment costs or service outcomes for children/youth with serious emotional/behavioral challenges.

6. Adverse Childhood Experience (ACE) Study Without intervention, adverse childhood events (ACEs) may result in long-germ disease, disability, chronic social problems and early death. Importantly, intergenerational transmission that perpetuates ACEs will continue without implementation of interventions to interrupt the cycle.

7. Financial Costs of Untreated Trauma

8. The Maine Study 492 children and adolescents enrolled in SOC/Targeted Case Management Services in FY 2000 and FY 2001. Sample was divided into two groups: an identified trauma group (n= 227) and a non-trauma group (n=265) All participants enrolled in SOC/Targeted Case Management Services for at least 12 months. Behavioral/functional assessments completed at baseline, 6 months, and 12 months as part of comprehensive outcome tracking system. All participants active Medicaid Service recipients with at least some mental health service use during FY 2000 or FY 2001.

9. Comparison of Mental Health Service Use Between Trauma & Non-Trauma Groups

10. Comparison of Primary Health Care Service Use Between Trauma & Non-Trauma Groups

11. Comparison of Behavioral/Functional Change Between Baseline & 12 Months for Trauma and Non-Trauma Groups

12. Comparison of Median Annual Treatment Expenditures Between Trauma & Non-Trauma Groups

13. Summary of Results: Child Descriptive and Behavioral/Functional Differences Children and youth trauma survivors: Were significantly younger; Were 1.62 times more likely to be rated at moderate to serious risk of harm (as measured by the CALOCUS); Were less than ½ (Odds=.451) as likely to experience serious co-occurring (medical, substance use, or developmental) challenges (as measured by the CALOCUS) (likely due to younger age and higher substance use in non-trauma group); Were 1.76 times more likely to experience higher-levels of environmental stress and 1.65 times more likely to have moderate to severe challenges in the area of supports; Were ½ (Odds=.563) as likely to experience serious challenges with substance use (as measured by CAFAS) Had significantly greater challenges in the areas of child/youth and parent/caregiver acceptance & engagement with service providers; Than children and youth without a trauma history

14. Summary of Results: Service Use, Expenditures and Outcomes Child and youth trauma survivors: Were more likely to use high-end mental health services, including: inpatient psychiatric hospitalization, residential/group treatment, and crisis intervention services at higher cost; Were 1.92 times more likely to use out-of-home treatment (Psych. Inpatient, Resid. Tx. Crisis Residential); Were 1.55 times more likely to use Outpatient Mental Health treatment services Were 1.75 times more likely to use Medication Management Services Used more Targeted Case Management services at significant higher expense; Used outpatient-clinical and medication management services at significantly higher cost; Were 1.61 times more likely to use and used more emergency department services at higher cost; Had 73% higher mental health service expenditures & 51% higher overall treatment expenditures; Were significantly less likely to exhibit behavioral/functional stability or improvement over study period. Than children and youth without a trauma history

15. Implications for Systems These findings suggest that when service systems do not appropriately assess, identify, and effectively address the underlying trauma-related needs of these children and families, the result may be greater use of expensive and often ineffective services that are likely to be overwhelming to the child and family, lead to re-traumatizing experiences for the child, and contribute to poor treatment outcomes. Given the pervasiveness of traumatic experiences among children/youth receiving public mental health services and the potential long-term costs to individuals, service systems, and society, these findings underscore the importance of trauma screening and identification early in the treatment process and the need for establishing and testing more trauma-informed approaches to service delivery and treatment.

16. Being “trauma informed…”

17. Why a Trauma-Informed Approach? Trauma is pervasive; The impact of trauma is very broad and touches many life domains; The impact of trauma is often deep and life-shaping; Violent trauma is often self-perpetuating Trauma is insidious and preys particularly on the more vulnerable among us Trauma affects the way people approach potentially helpful relationships; Trauma has often occurred in the service context itself

18. Focus on shared values and principles between SOC and Trauma-Informed approaches. Bullets highlighted in red are characteristics of the TI approach that distinguish it from the SOC approach.Focus on shared values and principles between SOC and Trauma-Informed approaches. Bullets highlighted in red are characteristics of the TI approach that distinguish it from the SOC approach.

19. A Trauma-Informed Approach-What Does it Mean? We are more aware of the child and family’s need to feel safe when dealing with a state agency/department, community organizations, school systems, etc. THE GOAL IS TO NOT RETRAUMATIZE THE FAMILY OR YOUTH WHO ARE IN NEED OF SERVICE.

20. Guidelines for Change Services-level changes Program Procedures & Settings Formal Services Policies Trauma Screening, Assessment, & Service Planning Administrative or Systems-level changes Administrative Support for Program-Wide Trauma-Informed Services Staff Trauma Training & Education Human Resources Practice

21. Implementing a Trauma-Informed System of Care The Goal To offer services in ways that facilitate the collaborative participation of children and their families in their own service provision and are sensitive to the unique needs of children and families who are trauma survivors. SOC Logic Model???SOC Logic Model???

22. Implementing a Trauma-Informed System of Care Paradigm shift required Resilient survivors vs. damaged goods Change in focus from: “What is wrong with this child?” vs. “What has happened to this child?” Trauma is pervasive Most if not all clients we serve will have experienced some type of trauma as part of their life experience. Trauma is often transgenerational…if not the child, then perhaps the family. 0-5 focus. Don’t blame the parent…work with them. Marisol’s baby storyTrauma is often transgenerational…if not the child, then perhaps the family. 0-5 focus. Don’t blame the parent…work with them. Marisol’s baby story

23. Implementing a Trauma-Informed System of Care Focus on resiliency & skill-building for the youth and families (CBT, ACT, MST, Wraparound) Universal trauma screening, assessment and service planning…with integration of all components with targeted EBP. A look at issues of privacy, confidentiality and safety (group rooms and waiting areas) Crisis management from a trauma-informed perspective (crisis plans, options for placement) Residential services??? – It is recognized that before a placement to a tx setting that trauma issues are reviewed and understood to avoid retraumatization. Many Maine placements build-in parental involvement and have dramatically reduced length of stay to minimize retraumatization and community disruption (check Fallot & Harris residential reference). We are currently in process of fine-tuning the trauma screening and assessment. **Many services now offer initial crisis contact with a known provider.Residential services??? – It is recognized that before a placement to a tx setting that trauma issues are reviewed and understood to avoid retraumatization. Many Maine placements build-in parental involvement and have dramatically reduced length of stay to minimize retraumatization and community disruption (check Fallot & Harris residential reference). We are currently in process of fine-tuning the trauma screening and assessment. **Many services now offer initial crisis contact with a known provider.

24. Well-Established and Probably Efficacious Treatments for Child Trauma Trauma-focused CBT Abuse-focused CBT Parent-Child Interaction Therapy Child-Parent Psychotherapy for Family Violence Cognitive-Behavioral Intervention for Trauma in Schools (CBITS) TF-CBT for Child Traumatic Grief Project 12-Ways/Safe Care for Child Neglect

25. Common Elements of EBP for Child Trauma Largely behavioral or cognitive-behavioral Address symptoms, behavior, and functioning Relatively brief More effective when a caregiver is actively involved When behavior problems are a primary issue, a number of interventions that are effective are directed at the caregiver only Dropping a child off at a clinic is of limited value

26. Implementing Evidence-based Practice in a System of Care These evidence-based treatments are not uniformly available across the country Institutional care is not well-researched Benefits unsubstantiated May even be deleterious due to contagion effects Children often have complex combinations of problems, and may benefit from intensive home- and community-based services

27. In Summary… Trauma is pervasive among children/youth receiving public mental health services. Without a systemic approach to identification & treatment, underlying issues of trauma may be missed or overlooked. Unresolved trauma may result in: More high end service use a at higher cost with less functional improvement; Serious health & mental health risk behaviors as adults. Due to pervasive nature of trauma, systems of care need to take a systemic approach to trauma. A trauma-informed system includes: Universal trauma screening, assessment & service planning – integrating all components; Focus on recovery, strengths-based, and skill building; General awareness & understanding among all stakeholders of trauma, its effects and potential triggers; Changes in policy & practice to support a trauma sensitive approach throughout system & participating agencies & to reduce incidences of retraumatization (waiting room practices); Crisis management from a trauma-informed perspective; For many, violence & resulting trauma is trans-generational so need for concurrent services; Specific evidence-based practices.

28. Missouri’s DMH Trauma Initiatives Department wide Administrative Policies/Guidelines regarding trauma The DMH Trauma Work Group comprised of representatives of all three divisions was formed in 2002 and developed a Trauma FACT Sheet, Department Position Statement, and Guiding Principles. Department Operation Regulations (DOR) were rewritten to reduce seclusion and restraint in state psychiatric hospitals; Workforce requirements regarding recommended general and specific competencies in trauma identified and are available on website; The Annual Spring Training Institute has a Trauma Track. Many experts in the trauma field have presented over the past seven years; Response to current traumatic events included in Disaster Planning & Mental Health First Aide; Office of Transformation activities include presentation to Commission, budget item for children’s trauma training and funding for trauma speaker for NAMI conference; The DMH co-sponsored a successful conference in March 2007 titled Mental Health Needs of Returning Soldiers and Their Families. Nationally recognized speakers:

29. Missouri DMH Trauma Initiatives Cont. Office of Children, Youth and Families Under a OJJDP grant to develop EBPs, two local sites have trained therapists on Trauma Focused-Cognitive Behavioral Therapy (TFCBT) and one site trained on Adolescent Dialectical Behavior (DBT); Submitted grant (pending) to develop trauma treatment Center of Excellence through UMSTL; Conducted training in 5 regions on identification & screening for trauma history; BJC designing a trauma specific treatment intervention for children; Division of ADA Seeking Safety program implemented in all Women and Children CSTAR programs. Financed as individual or group counseling billing under CSTAR/Medicaid with trauma specific billing codes; Primary Recovery Plus has added trauma services and billing codes Division of CPS CPS trauma-informed workgroup to integrate trauma into service delivery; A full time Psychologist/Consultant hired to facilitate implementation of DBT; Nineteen therapists have been credentialed in eight Administrative Agents in the Northwest Region to provide TF-CBT through pooled local CMHC training dollars; FSH has developed a trauma-informed system addressing Restraint and Seclusion practices, training staff and peer specialists on trauma, risk prediction models that include trauma; Hawthorn Children’s Hospital is implementing the national Sanctuary Model

30. About the Artist

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