1. Next Steps Towards a Trauma-Informed System of Care
Presented By:
Douglas E. Patrick, JD, LCSW
Manager, Children's Behavioral Health System
Children's Behavioral Health Services
Department of Health and Human Services
Arabella Perez, LCSW
Director
THRIVE Initiative
Sarah Krichels Goan, MPP
Evaluator
Hornby Zeller Associates , Inc.
Jennifer McLaughlin
Youth
Youth M.O.V.E.
Michelle LaPointe
Family Member
G.E.A.R. Parent Network

2. Goals
Provide an introductory overview of trauma theory and system of care principles
Introduce trauma informed principles and domains
Provide an overview of the TIAA© purpose, development and implementation
Provide clarity around state expectations for continuous quality improvement planning

3. What Research Tells Us
Estimated 3 million children and adolescents in the United States are exposed to serious traumatic events each year.
Nearly one out of three adolescents have been physically or sexually assaulted by the age of sixteen. (Boney-McCoy & Finkelhor, 1995)
Violent crime victimization among youth found to be twice as high as the rate for adults. (Hashima & Finkelhor, 1999)
High-rates (between 50% and 70%) of Post-Traumatic Stress Disorder in child/adolescent and adult public service users. (Macy, 2002, Kessler, 2000, Switzer, et al., 1999)
PTSD rates among Medicaid enrollees found to be highest among children 5-12 years (609.5 per 1000). (Macy, 2002)
Child/Adolescent trauma survivors found to have higher rates of mental health service use and to use more acute mental health treatment services, including: inpatient hospitalization, crisis services, and residential treatment services at higher cost. (Frothingham, et al. 2000; Macy, 2002, Newmann, et al., 1998; NTAC, 2003)
Select a few to chat about

4. Implications for the System
When service systems do not appropriately assess, identify, and effectively address the underlying trauma-related needs of these children and families, the result is often that services are:
more expensive
ineffective and overwhelming to the child and family
re-traumatizing for the child
Resulting in poorer 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.

5. A Systemic Approach
Due to pervasive nature of trauma, systems of care need to take systemic approach to trauma
A Trauma-informed system includes:
Universal trauma screening, assessments and service planning – integrating all components;
Focus on recovery, resiliency, strengths-based, and skill building;
General awareness and understandings of all stakeholders of trauma, its effects and potential triggers;
Changes in policy and practice to support a trauma sensitive approach throughout the system and participating agencies to reduce incidences of re-traumatization; and
Crisis Management from a trauma informed perspective.

6. Why Develop a Trauma Informed System of Care Approach in Maine
Data collected and analyzed by Dr. Jay Yoe, Ph.D. of DHHS showed clearly that compared to others, children and youth trauma survivors in Maine:
Were at greater risk of significant harm;
Were likely to experience co-occurring challenges physically, developmentally and with substances;
Had significantly greater challenges in the areas of child/youth and parent/caregiver acceptance and engagement with service providers;
Were more likely to use mental health services and high-end services for greater periods of time; and
Had 73% higher mental health service expenditures and 51% higher overall treatment expenditures.
Doug

7. State perspective
Six years ago Maine was awarded a six year grant by the Federal Substance Abuse and Mental Health Services Administration to develop and implement a System of Care for Children that would be:
Trauma-Informed
Family Driven
Youth Guided
Culturally and Linguistically Competent

8. Youth & Family Perspective

9. Overview of System of Care and Trauma Theory
Understanding System of Care principles and Trauma-Informed Approach

10. Legislatively initiated in 1992
Comprehensive Community Mental Health Services for Children and Their Families Program
Legislatively initiated in 1992
Goal: Develop community-based systems of care for children with serious emotional disturbance and their families
Charged to implement the goals and recommendations of the New Freedom Commission and transform children’s mental health services.
Arabella

11. Systems of Care
A system of care is a coordinated network of community-based services and supports that are organized to meet the challenges of children and youth with serious mental health needs and their families. Families and youth work in partnership with public and private organizations so services and supports are effective, build on the strengths of individuals, and address each person’s cultural and linguistic needs. A system of care helps children, youth and families function better at home, in school, in the community and throughout life.
Arabella
Gary Blau, Child, Adolescent and Family Branch, CMHS, SAMHSA

12. System of Care Values Family Driven Youth Guided
Cultural and Linguistic Competence
Trauma-Informed

13. Definition of Family Driven Care
Family-driven means families have a primary decision making role in the care of their own children as well as the policies and procedures governing care for all children in their community, state, tribe, territory and nation. This includes:
choosing supports, services, and providers;
setting goals;
designing and implementing programs;
monitoring outcomes;
managing the funding for services, treatments and supports and;
determining the effectiveness of all efforts to promote the mental health and well being of children and youth.
Osher, Federation of Families for Children’s Mental Health and Child, Adolescent and Family Branch, CMHS, SAMHSA

14. Definition of Youth Guided
It is when young people have the opportunities to achieve positive development, assist in their successful transition to adulthood, and develop a deeper connection to their community and peers
It occurs when:
The voice and actions of youth are valued
Youth are engaged from start to finish
Youth are utilized as a resource in the development of themselves and their communities
Youth are provided with an environment where they feel safe to voice opinions and won’t be judge based on experience nor age

15. Cultural Competence behaviors attitudes policies structures practices
Requires that organizations have a clearly defined, congruent set of values and principles, and demonstrate behaviors, attitudes, policies, structures, and practices that enable them to work effectively cross-culturally.
(adapted from Cross, Bazron, Dennis and Isaacs, 1989) Slide Source© 2010 National Center for Cultural Competence

16. Title VI, Section 601, Civil Rights Act of 1964
Linguistic Competence: Legal Mandates, Regulations, Guidance, and Standards
Title VI, Section 601, Civil Rights Act of 1964
Non- Discrimination based on Race, Color, National Origin, Age, Disability, Sex
U.S. Department of Health & Human Services
U.S. Department of Education
This slide need to be changed and needs to add State of Maine Mandates- Arabella was to check with Luc
U.S. Department of Justice
Slide Source: National Center for Cultural Competence, 2010

17. Maine Human Rights Act §4552. Policy
To protect the public health, safety and welfare, it is declared to be the policy of this State to keep continually in review all practices infringing on the basic human right to a life with dignity, and the causes of these practices, so that corrective measures may, where possible, be promptly recommended and implemented, and to prevent discrimination in employment, housing or access to public accommodations on account of race, color, sex, sexual orientation, physical or mental disability, religion, ancestry or national origin; …….[2005, c. 10, §1 (AMD).]

18. 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)
Historical Trauma, Stigma Trauma and Intergenerational Trauma
We care clinically but what about as a system?
Evidence – Adverse Childhood Experiences and local research
Preventable health and human event with enormous societal cost

19. What is Trauma-Informed
Means understanding the role that violence and victimization play in the lives of large numbers of children and families
Providing services and 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
Arabella
Lecture: A trauma Informed approach focuses on the core relationship. The relationship must be open and genuine collaboration between provider and consumer at all phases of the service delivery system. Allowing for consumers to choose where, how and when services are provided.

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

21. Trauma Informed Principles/Philosophy
Safety
Trustworthiness
Choice
Collaboration
Empowerment
Language Access and Cultural Competence

22. Safety
Because trauma inherently involves a physical or emotional threat to one’s sense of self, families and youth are often especially attuned to signals of possible danger.
It is essential then, that service organizations prioritize safety as a guiding principle in order to become more hospitable for trauma survivors and to avoid inadvertently re-traumatizing people who come for services.
This holds true for staff as well.

23. Trustworthiness
Survivors of trauma report a violation of boundaries resulting in a justified inability to trust others; especially those in power and authority.
A trustworthy organization is one that demonstrates appropriate boundaries, task clarity, clear and consistent policies and reasonable expectations for providers, families, and youth.
The trauma-informed organization recognizes how trust has been violated and seeks to earn trust.

24. Choice Maximizing family and youth choice and mutuality.
Allows family and youth to choose where, how and when they will receive services. They also have an active voice in selecting a provider and determining treatment.

25. Collaboration
Policies, practices and relationships that encourage empowerment, partnership, and participation, as well as strength based and community-based approaches.
Having the ability to share power and value both perspectives:
Collaboration with family and youth allows for very specific insight. Only they know their responses, their needs and history better then anyone else does.

26. Empowerment
It is the state of feeling self-empowered to take control of one's own destiny.
To become aware that one’s experience can enhance service systems and promote change.
Program opportunities to develop skills and enhance knowledge of the consumer.

27. Language Access & Cultural Competence
Extent to which policies, procedures, staff, services and treatment are sensitive to family and youth:
cultures
traditions
beliefs
The agency’s policies and procedures acknowledge that behaviors and responses to trauma are influenced by culture.
Ensure language access through:
policy
training
reimbursement

28. Achieving System of Care Goals
There is a need for common understanding about basic principles and this webinar is a step toward achieving the goal
Providers are critical in implementing these principles
An assessment of providers was needed to determine strengths and needs –this was the Trauma Informed Agency Assessment that was to be taken by all agency staff and a percentage of family and youth served by the agency.
Data specific to agencies could be used to assist agencies in making change according to the unique strengths and needs of each agency
Agencies will implement Continuous Quality Improvement activities with the support of Children’s Behavioral Health Services, Thrive and other organizations

29. Overview of the Trauma- Informed Agency Assessment: Development, Implementation, Scoring and Validation

30. Goals of the TIAA Tool
Provide agencies a mechanism to identify areas where they are successfully trauma-informed, and pinpoint areas where they want to improve.
Guide the CQI process for making the system even more trauma-informed.
Support data-driven decision-making!
Help agencies gauge whether CQI efforts were successful.

31. Development Phases
Planning: created conceptual framework, method for data collection, involved key stakeholders
Pilot Testing: implemented pilot tests, made revisions based on results
Implementing: statewide assessment and response monitoring
Discuss steps,

32. The Domains Children, Youth and Families Physical and Emotional Safety
Youth and Family Empowerment
Trustworthiness
Commitment to Trauma-informed Philosophy
Cultural Competence
Trauma Competence

33. (total potential score/total actual score)*100
How is it Scored?
Standards for each core trauma domain have been established.
Questions correspond to a domain.
Each question uses 5-point scale.
Total potential score = number of questions that comprise the domain multiplied by 5
Total actual score = summation of given responses
Final score =
(total potential score/total actual score)*100

34. Internal Consistency & Reliability
Tool Validation
Cronbach’s Alpha
Tests on the domains fall within acceptable ranges
Exploratory Factor Analysis
Groupings make sense
Each question contributes meaningfully to domain results
Internal Consistency & Reliability

35. State Expectations For Continuous Quality Improvement :
Developing a CQI Plan
Re-administering the assessment

36. States Expectations and Continuous Quality Improvement
By January 2011, agencies will have completed a CQI Plan required by contracts regarding issues identified in the Trauma Informed Agency Assessment
Agencies have been provided with resources including training opportunities, such as this web based training, and a detailed Guide to Trauma-Informed Organizational Development
Agencies have been provided with the results from the assessment and many agencies did not obtain the number of responses needed to provide data
Additional detailed reports can be accessed by contacting Sarah Krichels Goan at Hornby Zeller Associates.

37. State Expectations Continued
Agencies that did not obtain the number of responses needed will re-administer the assessment in Part of their CQI Planning would be to identify how to obtain more responses.
There will be a re-administration of the assessment in 2012 for all staff who interact with children/youth for all agencies.
Agencies will continue to refine their CQI Plans in the future toward the goals of Maine having the first fully Trauma Informed System of Care!

38. State Expectations Continued
Continuous Quality Improvement Plan - System of Care requirements
At least one goal from two separate domains in the assessment
Required Goal: Agencies that did not fully complete the first administration of the assessment must include a goal regarding completion of the next administration of the assessment. This must include objectives and action steps specifically addressing how the agency will ensure that assessment is completed.
Goals may be developed by referring to the “Key Question” section in each domain in the “Guide to Trauma- Informed Organizational Development.”
Objectives, action steps and outcomes may be developed using the “Best Practice Standards” in each Domain.

39. Resources
Technical Assistance Partnership for Child and Family Mental Health
National Child Traumatic Stress Network
The National Center for Trauma-Informed Care
National Institute for Trauma and Loss in Children
Children’s Mental Health Initiative

40. Resources Child Welfare League of America www.cwla.org
National Center for Mental Health & Juvenile Justice
Traumatic Stress Institute-Klinberg Family Centers
Training Center of the Jewish Board of Family and Children’s Services
Joyfields Institute

41. Contact Information
Douglas E. Patrick, JD, LCSW
Arabella Perez, LCSW
Sarah Krichels Goan, MPP