A Trauma-Informed Answer   “Why Trauma Matters” A Trauma-Informed Answer Presented by: Arabella Perez, LCSW Director THRIVE Initiative

What is Trauma and Why Does it Matter? The personal experience of interpersonal violence including sexual abuse, physical abuse, severe neglect, loss, and/or the witnessing of violence, terrorism and/or disasters. NASMHPD, 2004 We all care clinically but why should you care as a leader about systems change? Evidence – Adverse Childhood Experiences and local research Preventable health and human event with enormous societal cost Some potential talking points : Why as leaders should you care? Societal Price we pay….. Examples of Work in Rumford, describe ACES Why Trauma Informed? Trauma is pervasive Trauma’s impact is broad and diverse Trauma’s impact is deep and life-shaping Trauma, especially interpersonal violence, is often self-perpetuating Trauma is insidious and differentially affects the more vulnerable Trauma affects how people approach services The service system has often been retraumatizing Characteristics of trauma-informed services Universal Precaution Incorporate knowledge about trauma—prevalence, impact, and recovery—in all aspects of service delivery Hospitable and engaging for survivors Minimize revictimization Facilitate recovery and empowerment

What is Trauma and Why Does it Matter? Trauma is pervasive Trauma’s impact is broad and diverse Trauma’s impact is deep and life-shaping Trauma is often self-perpetuating and differentially affects the more vulnerable Trauma affects how people approach services The service system has often been traumatizing and/or re-traumatizing Means understanding the role that violence & victimization play in the lives of large numbers of children and families Providing services & supports in a manner that is welcoming, respectful and appropriate to trauma survivors A trauma informed organization makes every effort to avoid re- traumatizing individuals

Adverse Childhood Experiences Study The ACE Pyramid represents the conceptual framework for the Study. During the time period of the 1980s and early 1990s information about risk factors for disease had been widely researched and merged into public education and prevention programs. However, it was also clear that risk factors, such as smoking, alcohol abuse, and sexual behaviors for many common diseases were not randomly distributed in the population. In fact, it was known that risk factors for many chronic diseases tended to cluster, that is, persons who had one risk factor tended to have one or more others. Because of this knowledge, the ACE Study was designed to assess what we considered to be “scientific gaps” about the origins of risk factors. These gaps are depicted as the two arrows linking Adverse Childhood Experiences to risk factors that lead to the health and social consequences higher up the pyramid. Specifically, the study was designed to provide data that would help answer the question: “If risk factors for disease, disability, and early mortality are not randomly distributed, what influences precede the adoption or development of them?” By providing information to answer this question, we hoped to provide scientific information that would be useful for the development of new and more effective prevention programs. The ACE Study takes a whole life perspective, as indicated on the orange arrow leading from conception to death. By working within this framework, the ACE Study began to progressively uncover how childhood stressors (ACE) are strongly related to development and prevalence of risk factors for disease and health and social well-being throughout the lifespan.

National Data Gordon Hodas, Responding to Childhood Trauma: the Promise and Practice of Trauma Informed Care, February 2006, Pennsylvania Office of Mental Health and Substance Abuse. Some excerpts: 81% patients in psychiatric hospital experienced physical and or sexual abuse, 67% as children Massachusetts adolescent inpatient record review showed 93% reported trauma 93.2 % males and 84% female of juvenile detainees reported a traumatic experience Males likely to witness violence, females likely to be victimized by violence Childhood abuse and neglect increases likelihood of arrest as a juvenile by 53% Up to 81% of men and women in psychiatric hospitals have experienced physical and/or sexual abuse. 67% experienced this abuse as children. 3.5-10 million witness the abuse of their mother and up to half are abused themselves In Massachusetts a medical review of inpatient psychiatric hospitals indicated that 84% of the population had a history of trauma (and those are the ones that report it). In another study of adolescent inpatient it was 93% Infants are commonly subjected to hitting: 25% of infants 1-6 months are hit and 50% of infants 6-12 months are hit In one study of juvenile detainees, 93.2% males and 84% females reported a traumatic experience Of the above males were more likely to witness vioelnce and females more likely to be victimized by violence Of the juvenile detainees 60% of the females reported being raped or in danger of rape Childhood abuse and neglect increases likelihood of arrest as a juvenile by 53%

Maine Data 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 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 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 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.

Maine Data 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; 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 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.

Maine Data N=101 Caregiver’s Trauma Experiences On average, caregivers reported 7 traumatic experiences in their lifetime. Eighty-six percent reported having experienced at least 1 traumatic event before the age of 18, while 57% percent reported having experienced 3 or more. Some of the most frequently cited childhood traumatic experiences include: sexual abuse, emotional abuse, being separated from caregiver, witnessing domestic violence and experiencing a bad accident (see chart at left).   Before 18 = 3 Ever (lifetime) = 7 Average scores on the Caregiver Strain Questionnaire indicates that caregivers who have experienced 3+ trauma events and who also have a child/youth who has experienced 3+ trauma events report higher stress levels than caregivers who have not experienced 3+ events. This is in keeping with one study that found that more than half of traumatized mothers identified their young child as their primary stressor (Schechter, “A Mother-Infant Case Study”).

Maine Data N=88 Average = 3.30 Range = 0 to 9 3 or more experiences = 54.4% Did you know...? Children and youth who experience trauma are less likely to receive a formal PTSD diagnosis than adults. This is because children and youth react to trauma differently. Instead, research has found that children who have experienced trauma are often diagnosed with separation anxiety disorder, oppositional defiance disorder, phobic disorders, and ADHD (Ford et al, 2000; Husain, Allwood, Bell, 2008; Daud & Rydelius, 2009).

Maine Data What kinds of trauma-related symptoms do children and youth experience? Youth Trauma Symptoms The chart first chart shows youth trauma symptoms by the number of youth trauma experiences. Youth with trauma histories were more likely to experience symptoms of anxiety (78% compared to 51%), anger (63% compared to 44%) and post-traumatic stress (63% compared to 18%). Youth Strengths at Intake Caregivers report that youth have many strengths, particularly affective strengths (meaning the ability to form relationships). The chart to the right illustrates the average scores, where the higher scores indicate more strength. Interestingly, the children and youth who have experienced multiple trauma appear to have as many strengths as their non-traumatized counterparts, suggesting that resiliency abounds among all young people in our sample. (Behavioral and Emotional Rating Scale)   N=91

Maine Data How do trauma-related symptoms change after being involved with Thrive, a trauma-informed system of care? N=46

Trauma-Informed Principles Instead of asking “what is wrong with you?” a trauma-informed approach asks “what has happened to you?” Arabella: Roger Fallot and Maxine Harris Book 2 minutes to review this information Using Trauma Theory to Design Service Systems

The Trauma-Informed Principles Safety Trustworthiness Choice Collaboration Empowerment Language Access and Cultural Competency 15 minute exercise Arabella Characteristics of trauma-informed services Universal Precaution Incorporate knowledge about trauma—prevalence, impact, and recovery—in all aspects of service delivery Hospitable and engaging for survivors Minimize revictimization Facilitate recovery and empowerment

The Trauma-Informed Domains Physical and Emotional Safety Youth & Family Empowerment, Choice and Collaboration Trauma Competence Trustworthiness Commitment to Trauma-Informed Philosophy Language Access and Cultural Competency Characteristics of trauma-informed services Universal Precaution Incorporate knowledge about trauma—prevalence, impact, and recovery—in all aspects of service delivery Hospitable and engaging for survivors Minimize revictimization Facilitate recovery and empowerment

Traditional vs. Trauma Informed vs. Trauma Specific How are these different? Traditional: Business as Usual Trauma Informed: First Floor Trauma Specific: Second Floor

Traditional versus Trauma-Informed Understanding of Trauma Understanding of the child/youth survivor Understanding of services Understanding of the service relationship

National Recommendations Strengthening Policies to Support Children, Youth, and Families Who Experience Trauma, July 2007 National Center for Children in Poverty Columbia University Policies should support: Delivery systems that identify and implement strategies to prevent, identify and intervene Prevent and eliminate treatment practices that cause trauma/retraumatization Reinforce best practices that embodies system of care principles Resiliency, family youth strengths and engagement strategies Ensure that funding is supportive of trauma-informed care

Essential Elements in a Trauma Informed System Trauma Training for ALL Staff Engagement of Family, Youth, Adults Trauma Screening Trauma Assessments Trauma Specific Treatments Policies Community Education and Stigma Reduction Continuous Quality Improvement

The Contract Language System of Care Principles: The goal of DHHS is that Providers of Children’s Behavioral Health Services are integrated in a Trauma Informed System of Care. Providers will promote the Federal Substance Abuse and Mental Health Services Administration’s (SAMHSA) System of Care Principles of 1) Family Driven, 2) Youth Guided, and 3) Culturally and Linguistically Competent care. These three System of Care Principles are described at http://systemsofcare.samhsa.gov/. An additional principle for a Maine’s Children’s Behavioral Health System of Care is that it is Trauma Informed. By January 1, 2010, the Provider shall administer a system of care self Assessment Tool approved by the Department that addresses the principles referenced in paragraphs 18 and 19 herein. By January 1, 2011, Provider, in collaboration with Children’s Behavioral Health Services, will include in its Quality Improvement Plan developed under Rider “A” areas of need identified by the Assessment Tool and plans to meet those needs www.maine.gov/dhhs/purchased-services/contract-2010/rider-e/RIDER-E-CS.pdf Review the contract language and hand out the CQI flowchart

For more information please contact aperez@tcmhs.org Conclusion, Resources and Contact Information www.thriveinitiative.org www.nctsn.org (national child traumatic stress) www.chadwickcenter.org www.acestudy.org www.nccp.org (national center for children in poverty) http://mentalhealth.samhsa.gov/nctic/ For more information please contact aperez@tcmhs.org