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 nations leading research and policy
  center dedicated to the economic security,
  health, and well-being of Americas low-income
  children and families.
• Part of Columbia Universitys 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.

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Outline

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

4
Background

• 1982 Jane Knitzers 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 Childrens Mental Health
  in the United States 25 Years Later
• 2007 released Trauma Report
• 2008 released national report

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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 persons duty to reach out to
the most marginalized and vulnerable among
us. Her lifes 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
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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 Presidents New Freedom Commissions
  initiatives by disseminating information on
  specific policy options

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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.

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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

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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

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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
  

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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

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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)

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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

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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

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• Children Who Experienced Abuse, Neglect or
  Sexual Violence

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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)

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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)

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What the Data Shows School-age Youth in Juvenile
Detention
Any MH disorder Any SUD disorder Anxiety disorder ADHD Any Disrupt. disorder Affect. disorder
Males 65.5 50.7 21.3 16.6 41.4 18.7
Females 73.8 46.8 30.8 21.4 45.6 27.7
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.
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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

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Youth with Substance Use Disorders at High Risk

• 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)

1) Giaconia et al., 2000 2) Giaconia et al.,
1995 3) Kilpatrick et al., 2003 4) Jaycox,
Ebener, Damesek, Becker, 2004 Riggs, 2003.
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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).

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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)

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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).

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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)

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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)

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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

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Long-term Effects of Trauma

• Negative Impact on Brain Development
• Academic and Social Problems
• Chronic Illness, Morbidity and Mortality
• Intergenerational Impact

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• Current Service and Policy Challenges

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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

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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

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State Policies and Practices that Re-traumatize
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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

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SAMHSA Policy on Seclusion and Restraint
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Other Public Policies Can Serve to Expose
Children/Youth to Trauma or Re-traumatize

• Immigration Reform
• Restrictive Housing Policies
• Disaster Response Plans

Photo P. Pereira, The Standard Times
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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)

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Source http//www.ice.gov/pi/news/factsheets/work
site.htm
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Unaddressed Challenges

• Funding Restrictions that Impeded Care and
  Sustainable Treatment
• Limited Support for Prevention Early
  Intervention
• Workforce problems Inadequacy in Supply and
  Quality

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Identifying Best Practices Key Elements

• 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

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Best Practices Selected Screening Assessment
Tools

• Acute Stress Checklist
• Child Dissociative Checklist
• Child Post-traumatic Stress Reaction Index
• Child PTSD Symptom Scale
• Child Stress Disorder Checklist
• Childs Reaction to Trauma Event Scale
• Childrens Impact of Traumatic Event Scale
• Childrens PTSD Inventory
• Childrens PTSD Interview

• Childrens 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

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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

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• Case Studies (NY, ND, ME)

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North County Childrens 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

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North Country Childrens Clinic, New York

• 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

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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

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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
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Medicine Moon Initiative-ND

• Strengths
• Culturally competent
• Wraparound
• Agreement with the state to bill directly for
  Medicaid
• Focus on both current and historical trauma

• Challenges
• Lack of sufficient psychiatric or behavioral
  resources to meet the most acute needs
• Lack of funding

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Thrive Trauma-informed System of Care, Maine

• Care delivery through trauma-lens
• Age 0-12
• Service philosophy What has happened to this
  family not, What is wrong with this family

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Thrive Trauma-informed System of Care, Maine

• Strengths
• System of care focused on strength, engaging
  whole family
• Universal screening
• Promotion of effective trauma specific treatments
• Staff Training
• Use of trauma sensitive assessments
• Quality assurance

• Challenges
• On-going provider buy-in, territorial issues pose
  obstacles to collaboration
• Medicaid managed care curve-out
• Struggles with substantive inclusion of all
  relevant agencies
• Sustainable financial and programmatic efficacy

54
Literature Review Analysis of publicly
available data Main Data Sources

• Jennings, Ann. (2004). Blueprint for Action.
  Building Trauma-Informed Mental Health Service
  Systems State Accomplishments, Activities and
  Resources. September 2004. http//www.annafound
  ation.org/articles.html
• State block grant applications. 2004-2007
• SAMHSA Grant Awards - State Summaries FY
  2005/2006
• Personal Interviews with selected state officials

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Services Standardized Screening and Assessments

• Most states offer some form of screening and
  assessment.
• In nearly 60 percent of states and territories
  (data available on 46 states) universal or
  selective screenings and assessments are being
  conducted. In many cases the scope is limited.

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Services Evidence-Based Interventions

• In less than 20 percent of states which provide
  screenings and assessments, the screening and
  assessment tools are evidence-based.
• More than 50 percent of states provide
  evidence-based treatment/services however, the
  scope is mostly limited.

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Services Culturally-Based Strategies

• About 30 of states have culturally competent,
  trauma informed or focused treatment/services.

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Infrastructure Training

• Many states have developed training strategies of
  varying depth to increase the clinical and
  support capacity of those who deliver services to
  children, youth and their families who have been
  exposed to trauma.
• Nearly 40 percent of states (data available for
  38 states) report training on trauma-informed/spec
  ific evidence-based practices.
• A small proportion of this training focuses on
  cultural groups, gender or families.

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Infrastructure Training (contd)

• While not widespread some best practices in
  training in states include
• Strategies those aimed at developing trauma
  specialists as in Oklahoma
• System-wide or discipline-wide training like in
  Connecticut, Maine, Nevada, New York, Oklahoma,
  Illinois and Washington
• Trauma-related training that meet the conditions
  for state clinician certification as in Wyoming
• Embedding a trauma focus in statewide
  evidence-based training dissemination center in
  New York

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Infrastructure Policies to Eliminate/Reduce
Seclusion Restraint

• At least twenty states have implemented laws,
  regulations or policies designed to reduce and
  ultimately eliminate the use of seclusion and
  restraint. Five of these states have implemented
  strategies with far-reaching impact.

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Infrastructure Financial Strategies

• A number of state legislatures have also
  appropriated funding for specific trauma-related
  initiatives.
• Other state leaders have expanded the Medicaid
  benefit set to reimburse evidence-based trauma
  treatments, to facilitate trauma-specific
  treatments through billing and to fund specific
  clinicians.
• Generally absent are any state specific
  strategies to use the focus on information
  technology to create a more trauma-informed
  system.

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Infrastructure Culturally Competent Policies

• 8 states reported have culturally competent,
  trauma-focused policies.
• Alaska
• Connecticut
• Illinois
• New York
• Oklahoma
• South Carolina
• Vermont
• Washington

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Highlights of State Responses Illinois Oklahoma

• Illinois
• Legislation requiring trauma informed services
• State plan for child welfare includes public
  health framework
• Workforce development
• Use of Effective Treatment Strategies

• Oklahoma
• Trauma strategies heavily workforce development
  centered
• Promotes cross systems collaboration
• Full-time state level trauma coordinator
• Evaluates and provides TA to contractors based on
  Jennings checklist of administrative practices
  and services

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• Key Elements of Success
• Leadership Support
• Funding
• State
• Child Trauma Counseling
• Federal
• Co-occurring Initiative
• Cross Training Initiative
• Transformation Initiative
• National Child Traumatic Stress Initiative
• Full time coordinator
• Collaboration

• Lessons Learned
• Standards for Trauma Informed Care
• Standards/Core Competencies for Trauma Informed
  Care
• Communication is essential
• Develop a common language for trauma.
• Transformation takes time.

Courtesy Julie Young, OK
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• What did NCCP Survey Questions
• on Trauma Add?

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Systematic Screening or Intervention for Trauma
or Suicide Risk (Children and/or their Parents)

• 40 states report systematic screening or
  treatment for trauma or suicide risk
• 13 states did not respond or systematic
  screen/treat
• Common state efforts
• 12 reported screening for trauma/suicide risk (4
  reported using Columbia Teen Screen)
• 10 states reported providing training on
  validated tools such as on TF-CBT Applied
  Suicide Intervention Skills Training (ASIST)
  Question, Persuade Refer (QPR) and,
  crisis/suicide prevention and intervention
• 7 states report using funds like Garrett Smith
  funds for prevention

67
Plan to Deliver Mental Health Services and
Supports in Times of Disaster or Emergency

• 34 states reported that they had a specific plan
• 17 states reported that they did not have a plan
• 2 states did not respond
• Designated Individual in CMH charged with service
  coordination in the case of disaster/emergency
• 24 states reported they had a designated
  individual
• 8 states reported that they did not (in case of 3
  for MH not specifically child mh)
• 17 missing/NA

68
Types of Responses from States on MH Services for
Children in State Emergency Plan

• Each regional coordinator has a designated
  emergency satellite phone
• Regional (10) disaster management teams
• A system of trained and coordinated crisis
  counseling staff and networks
• A network ready to respond of volunteers and
  professionals
• All hazards leadership team
• A MOU with community behavioral health centers to
  coordinate, organize and mobilize during any
  crisis

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• Policy Recommendations

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All federal, tribal, state and local policies
should reflect a trauma-informed perspective

• Important factors
• Developmentally appropriate
• Culturally Linguistically Competent
• Encompass public health framework
• Engage children, youth and their families in
  healing.
• Fiscally-responsive
• Collaborative
• Accountable
• Support infrastructural development
• Competency-based training
• Address vicarious trauma

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Policies should support/reinforce

• Delivery systems that identify and implement
  strategies to prevent trauma, increase capacity
  for early intervention and intervention and
  provide comprehensive treatment
• Strategies designed to prevent and eliminate
  practices that cause trauma or re-traumatize
• Core components of best practices in
  trauma-informed care prevention, developmentally
  appropriate, empirically supported strategies,
  cultural and linguistic competence and family and
  youth engagement

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Trauma-informed related policies must
include/ensure

• Funding that is supportive of care and that
  adequately reimburses for effective strategies
• Funding is contingent upon elimination harmful
  practices that re-traumatize
• Investment in strategies to ensure workforce
  competency in effective strategies
• Provision of incentives for care delivered in
  community-based settings like schools and child
  care settings in addition to health care settings

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For More Information, Contact Dr. Janice Cooper
cooper_at_nccp.org Or Visit NCCP web
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