Developing a Trauma-Informed Child Welfare System WHAT WOULD IT TAKE? Bryan Samuels, Commissioner Administration on Children, Youth and Families

Most States Have the Capacity to Get Smaller Data Source: Adoption and Foster Care Reporting and Analysis System ( ). Children’s Bureau, Administration on Children, Youth, and Families (USDHHS, ACF) 2 May 3, 2012Neuroscience & Child Maltreatment

Smaller Is Not Always Better REUNIFICATION “Children who went home and stayed home had a four fold increase in internalizing behavior problems from baseline to 18- month follow-up. Though the percentage of children with behavior problems at 36-month follow-up decreased, still twice as many children met or exceeded clinical levels as compared to baseline”(1). KINSHIP CARE “Kinship placements were not predictive of mental health outcomes regardless of the amount of time in kinship care. …[M]ultiple causes of mental health problems often occur previous to placement in care and may not be mediated by the child’s foster care experience enough to show significant differences” (2). ADOPTION In assessments of children at 2, 4, and 8 years following adoption, “Adopted foster youth were more behaviourally impaired than their non-FC counterparts, although a striking number of non- FC youth displayed behaviour problems as well” (3) 3 1.Bellamy, J. (2008). Behavioral problems following reunification of children in long-term foster care. Children and Youth Services Review. 30: Fechter-Leggett, MO & O’Brien, K. (2010). The effects of kinship care on adult mental heath outcomes of alumni of foster care. Children and Youth Services Review. 32(2): Simmel, C.; et al. (2007). Adopted youths psychosocial functioning: A longitudinal perspective. Child and Family Social Work. 12(4):336. BPI: Behavior Problems Index May 3, 2012Neuroscience & Child Maltreatment

Typical Programs for Youth Yield Poor Outcomes Koball, Heather, et al. (2011). Synthesis of Research and Resources to Support At-Risk Youth, OPRE Report # OPRE , Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. 4 May 3, 2012Neuroscience & Child Maltreatment

“Simply removing a child from a dangerous environment will not by itself undo the serious consequences or reverse the negative impacts of early fear learning. There is no doubt that children in harm’s way should be removed from a dangerous situation. However, simply moving a child out of immediate danger does not in itself reverse or eliminate the way that he or she has learned to be fearful. The child’s memory retains those learned links, and such thoughts and memories are sufficient to elicit ongoing fear and make a child anxious.” May 7, 2012FFTA 5 National Scientific Council on the Developing Child (2010). Persistent Fear and Anxiety Can Affect Young Children’s Learning and Development: Working Paper No. 9. Retrieved fromwww.developingchild.harvard.edu

Challenges Associated with Trauma Cook, et. al., 2005 BIOLOGY Sensorimotor developmental problems Analgesia Problems with coordination, balance, body tone Somatization Increased medical problems across a wide span (e.g., pelvic pain, asthma, skin problems, autoimmune disorders, pseudoseizures) BIOLOGY Sensorimotor developmental problems Analgesia Problems with coordination, balance, body tone Somatization Increased medical problems across a wide span (e.g., pelvic pain, asthma, skin problems, autoimmune disorders, pseudoseizures) AFFECT REGULATION Difficulty w/ emotional self-regulation Difficulty labeling & expressing feelings Problems knowing and describing internal states Difficulty communicating wishes, needs AFFECT REGULATION Difficulty w/ emotional self-regulation Difficulty labeling & expressing feelings Problems knowing and describing internal states Difficulty communicating wishes, needs DISSOCIATION Distinct alterations in states of consciousness Amnesia Depersonalization and derealization Two or more distinct states of consciousness Impaired memory for state-based events DISSOCIATION Distinct alterations in states of consciousness Amnesia Depersonalization and derealization Two or more distinct states of consciousness Impaired memory for state-based events BEHAVIORAL CONTROL Poor modulation of impulses Self-destructive behavior Aggression toward others Pathological self-soothing behaviors Sleep disturbances Eating disorders Substance abuse Excessive compliance Oppositional behavior Reenactment of trauma in behavior or play ( e.g., sexual, aggressive) BEHAVIORAL CONTROL Poor modulation of impulses Self-destructive behavior Aggression toward others Pathological self-soothing behaviors Sleep disturbances Eating disorders Substance abuse Excessive compliance Oppositional behavior Reenactment of trauma in behavior or play ( e.g., sexual, aggressive) ATTACHMENT Problems with boundaries Distrust and suspiciousness Social isolation Interpersonal difficulties Difficulty attuning to other people’s emotional states Difficulty with perspective taking ATTACHMENT Problems with boundaries Distrust and suspiciousness Social isolation Interpersonal difficulties Difficulty attuning to other people’s emotional states Difficulty with perspective taking COGNITION Difficulties in attention regulation and executive functioning Lack of sustained curiosity Problems with processing novel information Problems focusing on and completing tasks Problems with object constancy Difficulty planning and anticipating Problems understanding responsibility Learning difficulties Problems with orientation in time and space COGNITION Difficulties in attention regulation and executive functioning Lack of sustained curiosity Problems with processing novel information Problems focusing on and completing tasks Problems with object constancy Difficulty planning and anticipating Problems understanding responsibility Learning difficulties Problems with orientation in time and space SELF CONCEPT Lack of continuous, predictable sense of self Poor sense of separateness Disturbances of body image Low self-esteem Shame and guilt SELF CONCEPT Lack of continuous, predictable sense of self Poor sense of separateness Disturbances of body image Low self-esteem Shame and guilt May 7, FFTA

Abusive or Neglectful Parenting Insecure Attachments, Emotional Dysregulation, Negative Internal Working Models Maladaptive Coping Strategies Poor Social Functioning, Disturbed Peer Relationships Psychological Distress Adult/Peer Relationship Dysfunction Path of Maltreatment’s Impact on Relationships throughout Life 7 May 3, 2012Neuroscience & Child Maltreatment

m/2012/im1204.pdf May 7, FFTA

Taking a Different Approach “Acute care” forms of child and adolescent mental health services are poorly matched to the service needs of a disadvantaged child population presenting with complex attachment- and trauma-related psychopathology, and unstable living arrangements. Promoting well-being for children who have experienced maltreatment requires evidence-based screening and interventions that address their unique behavioral and mental health needs, as well as: – Help them understand their experiences – Support the development of new coping strategies – Address developmental stages and delays – Strengthen environmental buffers For children who have experienced complex interpersonal trauma, attention must be paid to their capacity to establish and maintain healthy relationships Resilience is not seen as good fortune arising from chance encounters with a supportive friend, peer or partner, but rather as an ongoing process of developing the competencies necessary to form, maintain and benefit from supportive interpersonal relationships. Leslie, LK; Kelleher, KJ; Burns, BJ; Landsverk, J & Rolls, JA. (2003). Foster care and Medicaid managed care. Child Welfare. 82(3): May 3, 2012Neuroscience & Child Maltreatment

Framework for Well-being 10 Environmental Supports Personal Characteristics Developmental Stage (e.g., early childhood, latency) Cognitive Functioning Physical Health and Development Emotional/ Behavioral Functioning Social Functioning The framework identifies four basic domains of well being: (a) cognitive functioning, (b) physical health and development, (c) behavioral/emotional functioning, and (d) social functioning. Within each domain, the characteristics of healthy functioning relate directly to how children and youth navigate their daily lives: how they engage in relationships, cope with challenges, and handle responsibilities. May 3, 2012Neuroscience & Child Maltreatment

Elements of Social & Emotional Well- being 11 Self-awareness —Identification and recognition of one’s own emotions, recognition of strengths in self and others, sense of self-efficacy, and self-confidence. Social awareness —Empathy, respect for others, and perspective taking. Self-management —Impulse control, stress management, persistence, goal setting, and motivation. Responsible decision making —Evaluation and reflection, and personal and ethical responsibility. Relationship skills —Cooperation, help seeking and providing, and communication. May 3, 2012Neuroscience & Child Maltreatment

Measure Outcomes, Not Services “It is common for child welfare systems to gauge their success based on whether or not services are being delivered. One way to focus attention on well-being is to measure how young people are doing behaviorally, socially, and emotionally and track whether or not they are improving in these areas as they receive services” (ACYF-CB-IM-12-04). 12 Stop Measuring Services How many children received…? How many hours of training were delivered? What percent of children got…? Start Measuring Outcomes Are trauma symptoms reduced? Did services increase relationship skills? Do children have healthier coping strategies? May 3, 2012Neuroscience & Child Maltreatment

Trauma Screening, Functional Assessment & Progress Monitoring “Functional assessment—assessment of multiple aspects of a child’s social-emotional functioning (Bracken, Keith, & Walker, 1998)—involves sets of measures that account for the major domains of well-being.” “Child welfare systems often use assessment as a point-in- time diagnostic activity to determine if a child has a particular set of symptoms or requires a specific intervention. Functional assessment, however, can be used to measure improvement in skill and competencies that contribute to well-being and allows for on-going monitoring of children’s progress towards functional outcomes.” “Rather than using a “one size fits all” assessment for children and youth in foster care, systems serving children receiving child welfare services should have an array of assessment tools available. This allows systems to appropriately evaluate functioning across the domains of social-emotional well-being for children across age groups (O’Brien, 2011) and accounting for the trauma- and mental health-related challenges faced by children and youth who have experienced abuse or neglect.” May 7, 2012FFTA 13 Valid and reliable mental and behavioral health and developmental screening and assessment tools should be used to understand the impact of maltreatment on vulnerable children and youth. TRAUMA SCREENING Child and Adolescent Needs and Strengths (CANS) Trauma Version Childhood Trauma Questionnaire (CTQ) Pediatric Emotional Distress Scale (PEDS) TRAUMA SCREENING Child and Adolescent Needs and Strengths (CANS) Trauma Version Childhood Trauma Questionnaire (CTQ) Pediatric Emotional Distress Scale (PEDS) FUNCTIONAL ASSESSMENT Strengths and Difficulties Questionnaire (SDQ) Child Behavior Checklist (CBCL), the Social Skills Rating Scale (SSRS) Emotional Quotient Inventory Youth Version (EQ-i:YV) FUNCTIONAL ASSESSMENT Strengths and Difficulties Questionnaire (SDQ) Child Behavior Checklist (CBCL), the Social Skills Rating Scale (SSRS) Emotional Quotient Inventory Youth Version (EQ-i:YV)

Shifting Resources to Support What Works Psychological First Aid Evidence-Based Trauma Interventions Trauma ScreeningGeneric CounselingLife Skills Training RESEARCH-BASED APPROACHES INEFFECTIVE APPROACHES 14 De-scaling what doesn’t work Investing in what does May 3, 2012Neuroscience & Child Maltreatment

EBPs for Social & Emotional Well-being 15 May 3, 2012Neuroscience & Child Maltreatment

EBPs for Social & Emotional Well-being 16 May 3, 2012Neuroscience & Child Maltreatment

Making Meaningful and Measurable Improvements in Outcomes 17 Anticipating the challenges that children will bring with them when they enter the child welfare system Rethinking the structure of services delivered throughout the system De-scaling practices that are not achieving desired results while concurrently scaling up evidence-based interventions May 3, 2012Neuroscience & Child Maltreatment

Final Thoughts: Where We Are Going The child welfare performance proposal incentivizes the development of a child welfare workforce marked by: Focus on child & family level outcomes Progress monitor for improved child/youth functioning Proactive approach to social and emotional needs Developmentally specific approach Promotion of healthy relationships 18 IMPLICATIONS FOR CASE- LEVEL WORK WITH YOUTH Caseworkers are more aware of trauma, mental health needs, and evidence- based practices to get youth the right services at the right time. Caseworkers better understand the trauma-related relational challenges that youth bring with them when they enter care and screen for social-emotional problems. Transition planning and promotion of social/emotional skills for adulthood begin well in advance of exit from care. Service plans include activities to promote relational competencies and efforts to find/engage siblings, relatives, etc. May 3, 2012Neuroscience & Child Maltreatment

Final Thoughts: Where We Are Going The goal of the proposal is to propel the child welfare system towards greater: Organization around positive outcomes Emphasis on continuous quality improvement to include review of child functioning indicators Allocation of existing resources from ineffective, generic practice to an array of specific, evidence-based interventions Workforce is prepared to support installation and implementation of evidence-based practices that promote social-emotional well-being 19 IMPLICATIONS FOR SYSTEM’S WORK WITH YOUTH Data describing trauma and social and emotional well-being of youth are collected and analyzed regularly Research and data are used to drive decision-making, policies, program design, and contracting services. Evidence-based services that promote healing and recovery from truama and build key skills and capacities in youth are available. May 3, 2012Neuroscience & Child Maltreatment

Vehicles for Promoting Social and Emotional Well-Being Flexible Funding Waivers Discretionary Funding: – Trauma and Mental Health Screening, Assessment, and Treatment – Educational Stability – Early Childhood-Child Welfare Linkages – Youth Services – Child Welfare-Supportive Housing Regional Partnership Grants High Priority Goal on Trauma Psychotropic Medication Oversight and Monitoring President’s Budget Proposal - $2.5 billion/10 years 20 May 3, 2012Neuroscience & Child Maltreatment