1. An Introduction to Trauma Informed Systems of Care Presented by Michelle Zabel, MSS Innovations Institute University of Maryland, Baltimore, School of Medicine, Division of Child and Adolescent Psychiatry

2. Coming together is a beginning. Keeping together is progress. Working together is success. ~Henry Ford Lazear, K. (2004).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative.

3. Fundamental Challenge to Building a System of Care No one system controls everything. Every system controls something. Pires, S. (2004). Human Service Collaborative. Washington, D.C.

4. System of care is, first and foremost, a set of values and principles that provides an organizing framework for systems reform on behalf of children, youth and families. Stroul, B. 2005. Georgetown University. Washington, D.C.

5. Pires, S. (2002) Building systems of care: A primer. Washington, D.C.: Human Service Collaborative. CASSP – Systems of Care for children with SED RWJ MHSPY – Systems of Care for children with SED CASEY MHI – Systems of Care for inner city children CMHS GRANTS – Systems of Care for children with serious emotional/behavioral disorders CSAT GRANTS – Systems of Care for adolescents with substance abuse problems ACF GRANTS – Systems of Care for children involved in the child welfare system CMS GRANTS – Home and Community Based Systems of Care for youth in residential treatment PRESIDENT’S NEW FREEDOM MENTAL HEALTH COMMISSION – Home and Community Based Systems of Care National System of Care Activity

6. P OLICY L EVEL (e.g., governance, financing; regulations; rates) M ANAGEMENT L EVEL (e.g., data; quality improvement; system organization) F RONTLINE P RACTICE L EVEL (e.g., assessment; care planning; care management; services/supports provision) C OMMUNITY L EVEL (e.g., partnership with families, youth, natural helpers; community buy-in) Pires, S. (2006). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative. Systems Change Focuses On …

7. Cross-Cutting Characteristics Cultural and linguistic competence, Meaningful partnership with families, Meaningful partnership with youth, A cross-agency perspective, that is, State, local and Tribal partnership and shared commitment. Pires, S. (2002).Building systems of care: A primer. Washington D.C.: Human Service Collaborative.

8. Characteristics of Systems of Care as Systems Reform Initiatives FROM Fragmented service delivery Categorical programs/funding Limited services Reactive, crisis-oriented Focus on “deep end,” restrictive Children/youth out-of-home Centralized authority Creation of “dependency” TO Coordinated service delivery Blended resources Comprehensive service array Focus on prevention/early intervention Least restrictive settings Children/youth within families Community-based ownership Creation of “self-help” Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

9. Collaboration across agencies Partnership with families and youth Cultural & linguistic competence Blended, braided, or coordinated financing Shared governance across systems with families and youth Shared outcomes across systems System of Care: Operational Characteristics (1) Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

10. Organized pathway to services and supports Child and family teams Staff, providers, families, youth trained and mentored in a common practice model Single plan of care One accountable care manager Cross-agency care coordination Individualized service/supports “wrapped around” child/youth/family Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative. System of Care: Operational Characteristics (2)

11. Home- & community-based alternatives Broad, flexible array of services and supports Integration of clinical treatment services and natural supports; linkage to community resources Integration of evidence-based and promising treatment approaches Data-driven focus on continuous quality improvement Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative. System of Care: Operational Characteristics (3)

12. Emerging Models and Technologies in Systems of Care Standardized Screening across systems Youth Peer to Peer Support Family Peer to Peer Support and Navigation Mobile Crisis Response and Stabilization Evidence Based Practices Care Management Entities

13. The Childhood Years: A Period of Growth and Development As noted by the US Surgeon General in his 1999 report: [C]hildhood and adolescence are marked by dramatic changes in physical, cognitive, and social-emotional skills and capacities. Mental health in childhood and adolescence is defined by the achievement of expected developmental, cognitive, social, and emotional milestones and by secure attachments, satisfying social relationships, and effective coping skills (USDHHS, 1999, p. 123). From Child Traumatic Stress: What Every Policymaker Should Know

14. National Child Traumatic Stress Network Founded provided through Health and Human Services to establish The Donald J. Cohen National Child Traumatic Stress Initiative Purpose is: to improve access to care, treatment, and services for children and adolescents exposed to traumatic events to encourage and promote collaboration between service providers in the field

15. www.nctsn.org

16. The following information was obtained from the National Child Traumatic Stress Network Website: www.nctsn.org

17. Prevalence of Childhood Trauma  A study of examining the prevalence of violence, crime, and victimization in a nationally representative sample of children and youth aged 2 to 17 found widespread exposure to violence.  More than half the children sampled had experienced a physical assault during the study year;  More than one in eight had been subjected to some form of child maltreatment (e.g., child abuse or neglect);  More than one in twelve had experienced a sexual victimization; and more than one in three had been a witness to violence (Finkelhor et al., 2005). From Child Traumatic Stress: What Every Policymaker Should Know

18. Prevalence of Childhood Trauma  A longitudinal general population study of children and adolescents found that 25% had experienced at least one potentially traumatic event in their lifetime, 6% within the past 3 months. Costello, E.J., Erkanli, A., Fairbank, J.A., & Angold, A. (2002). The prevalence of potentially traumatic events in childhood and adolescence. Journal of Traumatic Stress, 15 (2):99-112.

19.  In a continuation of the North Carolina study, more than 68% of children and adolescents had experienced a potentially traumatic event by the age of 16.  Full-blown PTSD was rare, occurring in less 0.5% of children studied.  Other impairments---including school problems, emotional difficulties, and physical problems---occurred in more than 20% of children who had been traumatized.  In those who had experienced more than one traumatic event, the rate was nearly 50%. Copeland, W.E., Keeler, G., Angold, A., Costello, E.J. (2007). Traumatic events and posttraumatic stress in childhood. Archives of General Psychiatry, 64 (5): 577-584

20.  A review of research on children exposed to specific traumas found wide ranges in rates of PTSD:  20 percent to 63 percent in survivors of child maltreatment  12 percent to 53 percent in the medically ill  5 percent to 95 percent in disaster survivors Gabbay, V., Oatis, M.D,, Silva, R.R. & Hirsch, G. (2004). Epidemiological aspects of PTSD in children and adolescents. In Raul R. Silva (Ed.), Posttraumatic stress disorder in children and adolescents: Handbook. (1-17). New York: Norton. Prevalence of PTSD

21. Process How system builders conduct themselvesStructure What gets built (i.e., how functions are organized) Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

22. Core Elements of an Effective System-Building Process A core leadership group Evolving leadership Effective collaboration Partnership with families and youth Cultural and linguistic competence Connection to neighborhood resources and natural helpers Bottom-up and top-down approach Effective communication Conflict resolution, mediation, and team-building mechanisms A positive attitude The Importance of Leadership & Constituency Building Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative.

23. Working Towards Solutions Recognize the impact of trauma and make a commitment to do something about it Seek to understand Provide trauma-specific treatment Apply identified approaches to multiple systems and setting Incorporate consideration of trauma in comprehensive service planning From Child Traumatic Stress: What Every Policymaker Should Know

24. Working Toward Solutions Effective Interventions: Development and implementation of effective prevention efforts, treatment, and service interventions, including culturally competent practices that reflect the needs of diverse child populations Tools and Training: Training and tools (including data) to help systems effectively identify and help those affected by childhood trauma Trauma-Informed Policy: Informed public policy that supports and promotes all these efforts From Child Traumatic Stress: What Every Policymaker Should Know

25. Trauma-Informed Policy at the Local Level Disaster and terrorism preparations and response teams at the state and local level Prevention/early intervention program staff at mental health centers regarding trauma-informed services Public school personnel to enhance awareness and violence prevention efforts Law enforcement agencies to develop interventions in domestic violence or child abuse cases Homeless shelter agencies to provide training and resources for helping displaced children Juvenile court judges and personnel to provide training and resources Infant and child development programs and day care center staff to offer information about dealing with trauma From Child Traumatic Stress: What Every Policymaker Should Know

26. Building Local Systems of Care: Strategically Managing Complex Change Human Service Collaborative. (1996). Building local systems of care: Strategically managing complex change. [Adapted from T. Knosler (1991), TASH Presentations]. Washington: DC.

27. 27 “The promise of effective community care can only be attained when we understand how new practices fit with the needs and strengths of local communities and their existing care systems, and we adapt clinical and administrative practices to provide care that changes in response to community context.” Israel, N., Hodges, S., Ferreira, K, & Mazza, J. (2007). Systems implementation issue brief #4 – Lessons from successful systems: Evidence Based Practices and Systems of Care: Implementation Matters

28. Additional Resources http://www.nctsn.org/ Military Child Education Coalition http://www.militarychild.org/ Mental Health First Aid www.MentalHealthFirstAid.orgwww.MentalHealthFirstAid.org or www.mhfamaryland.orgwww.mhfamaryland.org

29. Contact Information Innovations Institute University of Maryland, School of Medicine, Department of Psychiatry, Department of Child & Adolescent Psychiatry 737 West Lombard Street, 4 th floor Baltimore, MD 21201-1023 Phone: 410-706-0961 Email: innovations@psych.umaryland.edu Website: http://medschool.umaryland.edu/innovations/ Michelle Zabel, MSS, Director, Innovations Institute mzabel@psych.umaryland.edu