Community Based Interventions In Two Parts: Systems Of Care And Approaches To Recovery From Psychological Trauma

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Community Based Interventions In Two Parts
Systems Of Care AndApproaches To Recovery From
Psychological Trauma

• Lenore B. Behar, PhD, Director
• Child Family Program Strategies
• Durham, North Carolina

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Presentation forMississippi Institute on School
Health, Wellness and Safety The Super
Conference

• September 27-29, 2006
• Philadelphia, Mississippi

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For Bibliography Slides

• Go to www.lenorebehar.com
• See Presentations
• Community Based Interventions In Two Parts
  Systems Of Care And Approaches To Recovery From
  Psychological Trauma
• Mississippi Super Conference,September 2006

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Definitions

• Children
• The term children includes all people eligible
  for System of Care services, as defined by the
  State.

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Two Paths for Children Exposed to Trauma

• System of Care as a Mode of Service Delivery for
  Children with Serious Emotional Problems
• Trauma Focused Interventions,
• usually Individual or Family Therapies

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Converging Paths for Children Exposed to Trauma

• Since 1985, System of Care
• has been federal policy for children with
  serious emotional disturbances, and their
  families
• Since 1993, System of Care has been state policy
  in Mississippi

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The Focus of System of Carein Mississippi

• To provide community based care and decrease the
  use of inappropriate out-of-home placements by
  using pooled resources from mental health,
  education, child welfare, and Medicaid for
  children with SED

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How Mississippi SOC Evolved

• legislatively mandated servicesone of the first
  in the country
• mechanisms to review service quality
• policy guidance from the State
• state and community level interagency teams for
  children who are difficult to servemulti-agency
  assessment and planning teams (MAP)
• teams include agencies and parents

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Support from the Family Organization

• Mississippi Families as Allies for Children's
  Mental Health (MSFAA) established in 1990
• one of the first family-run, family focused
  organizations in the country
• provided ongoing support to System of Care
  development

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System of Care Principles

• Child centered, individualized
• Family focused
• Community based
• Comprehensive
• Culturally competent
• Accountable/evidence based
• Coordinated across agencies
• Requires care management

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Why Do We Need SOC?

• Need collective expertise
• Need unified approach to child and family
• Need to use all the resources available to child
  and family

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It Is Rocket Science!!
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What is the Population for the System of Care?

• The definition is clear
• Children with serious/severe emotional
  disturbances and their families
• Children and families who need the services of
  multiple agencies, or who need multiple services

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What is SED?

• An emotional/behavioral disorder diagnosed by a
  qualified professional that
• Requires services of several agencies
• Significantly impairs functioning
• Is anticipated to continue for a significant
  amount of time

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Role of Agencies

• Identify children needing services
• Identify services needed by the child and family
• Coordinate services within agency
• Coordinate services across agencies
• Use a case manager, if needed

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How to Access SOC/MAP

• Refer through your agency representative to the
  MAP Team
• Refer directly to the MAP Team leader
• Refer through community mental health center

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Demonstration Sites

• 1999-2006, Children of Mississippi and their
  Parents Accessing Strength Based Services
  (COMPASS) in Hinds County
• 2006-2012, the Pinebelt System of Care in
  Forrest, Lamar and Marion Counties

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Acceptance of System of Care

• Surgeon Generals Report, 2000
• Report of the Presidents New Freedom Commission,
  2003
• Over 100 million annual funding by Congress
  through the Center for Mental Health Services,
  SAMHSA
• Lawsuit settlements in several states
• State statutes and policies

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Relevance to Children Exposed to Trauma

• 20 years of study of system of care issues has
  clarified the value of context of services
• Studies of clinical effectiveness of services for
  children exposed to trauma have evolved
  separately
• These two paths are merging for improved services
  to children and families

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Definitions

• Trauma
• Physical Abuse and Neglect
• Sexual Abuse
• Traumatic Grief
• Domestic Violence
• Community and School Violence
• National Child Traumatic Stress Network, 2006

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Definitions

• Trauma
• Complex Trauma (multiple trauma)
• Medical Trauma
• Refugee and War Zone Trauma
• Natural Disasters
• Terrorism

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Two Groups of Children

• Group 1 Children exposed to trauma who exhibit
  symptoms requiring treatment show the potential
  for PTSD (about 20)
• Group 2 Children exposed to trauma who will
  recover without treatment (about 80)

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Description of the Groups

• Both may show the same symptoms initially
• Group 1 Symptoms increase children do not
  recover with initial intervention
• Group 2 Shows resilience, recovery

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System of Care for Group 1

• They meet the definition of serious or severe
  disturbance
• The disorder interferes with daily functioning
  (sleep, school, interactions, thinking)
• It is projected to be long term, without
  treatment
• Long-term effects without treatment can be
  damaging

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SOC Principles Should Apply

• Child centered, individualized
• Strengths based
• Family focused
• Community based
• Comprehensive formal and informal
• Culturally competent
• Accountable/evidence based
• Coordinated across agencies
• Requires care management

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Evidence Based Services for Group 1

• Include
• Cognitive Behavioral Therapy
• Eye Movement Desensitization and Reprocessing
  (EMDR)
• Trauma Focused Individual, Family and Group
  Treatment

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Online Course in Trauma Focused CBT

• www.musc.edu/tfcbt

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Importance of Trauma Practices in Systems of Care

• Children exposed to trauma
• Had higher service costs
• Used more high-end services, including
  psychiatric hospitalization, residential
  treatment,and crisis intervention services at
  higher cost
• Yoe, Burns et al, 2004

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Importance of Trauma Practices in Systems of Care

• Used more Case Management services at higher
  cost and
• Used more outpatient-clinical and medication
  management services at higher cost

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Importance of Trauma Practices in Systems of Care

• Groups were the same in service use and costs in
• Substance Abuse Tx
• Home-Based Family Services
• Day Treatment
• Community Support Services
• Behavioral Health Pharmacy
• In-Home Services

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Group 2, Why Intervene?

• To alleviate traumatic stress reactions
• To provide comfort
• To (possibly) prevent longer-term, more serious
  reactions
• To identify those who need more intensive
  interventions

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SOC Principles for Group 2

• Not child centered, not individualized
• Strengths based
• Family involved
• Community based
• Comprehensive, only informal services
• Culturally competent
• Accountable/evidence based
• Coordinated across agencies
• Does not require care management

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Community Based

• Interventions delivered in the childs
  community
• With peers
• In school or other group setting
• Involves childs helpers-parents, teachers,
  shelter aides
• Uses indigenous assistants

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Strengths Based

• Focuses on stabilization
• Corrects misperceptions
• Emphasizes maintaining psychological
  control--coping
• Emphasizes support systems
• Focuses on health and self-care

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Family Focused

• Parents involved in planning
• Parents involved in learning how to cope
• Parents involved in ongoing support of children

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Impact of Trauma on Schools

• Events of past 16 years
• Desert Stormthe first war fought on television
• Oklahoma City bombingnews coverage
• School shootings
• September 11, 2001
• Hurricane Katrina
• Marlene Wong, 2006

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Crisis Emergency Planfor Schools Mental
Health Component

• www.ed.gov/emergencyplan

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Mitigation and Prevention

• Identify possible disasters
• Identify potential hazards/ barriers to a good
  response
• transportation routes
• factories/other highly populated areas

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Preparation

• Develop an emergency response plan consider
  emotional responses
• Establish relationships with mental health
  professionals
• Develop protocols for response
• Train staff in psychological first aid
• Establish back-up systems
• Practice, practice, practice

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Response

• Assess level of exposure
• Identify those most at risk
• Provide support/first aid
• Provide timely information/media messages
• Identify those who need longer-term intervention
  and arrange it

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Recovery

• Address long-term needs through interventions
  using coping strategies
• Address long-term needs through referral to
  community or in-school specialists
• Plan for anniversaries

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Actions for Schools

• Recognize children are vulnerable to many kinds
  of trauma through direct or indirect exposure
• Central point for community50 of people
  involved with school

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Ensure Internal Coordination

• Establish who is in charge
• Establish roles for each entity
• school safety personnel
• resource officers
• school counselors/psych./sw
• school health
• teachers

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Group 2 Evidence Based Services/Promising
Practices

• Psychological First-Aid
• Post Trauma Stress Management
• Classroom-Based Interventions
• or Group Interventions
• National Center for PTSD, 2005, Macy, Behar, et
  al 2005, Macy, 2006

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Trauma Response Teams

• Examples of Effective Programs
• Center for Trauma Psychology
• Community
• Classroom
• Community Policing Project (Yale)
• Community Stress Prevention Centre (Israel)

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Center for Trauma Psychology-Community

• Intensively trained volunteers
• Follow a clear protocol
• Establish contacts in communities
• Provide Psychological First Aid/Post Traumatic
  Stress Management
• Informal evidence of effectiveness

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Center for Trauma Psychology--Classroom

• Uses classroom based coping groups
• Trains teachers
• Involves parents
• Used also by Save the Children
• Most evidence of effectiveness

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Community Policing Project

• Highly trained staff
• Train police to handle child cases
• Ride along with police
• Provide team interventionspsychologists police
  together
• Informal evidence of effectiveness

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Community Stress Prevention Centre (Israel)

• Trains child caregivers, parents, teachers, first
  responders
• Provides back-up
• Experienced in international relief
• Informal evidence of effectivenesstheory based

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Resources at www.nctsnet.org

• For
• Educators
• General Public
• Juvenile Justice Professionals
• Media
• Mental Health/Medical Professionals
• Parents and Caregivers
• Policy Makers