1. John R. Kasich, Governor Tracy J. Plouck, Director John L. Martin, Director 1 Developmental Disabilities Mental Health and Addiction Services

2. What is trauma? Individual trauma results from an event, series of events, or a set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well- being (SAMHSA) 2

3. What is trauma? The individual’s experience of these events or circumstances helps to determine whether it is a traumatic event. The long-lasting adverse effects on an individual are the result of the individual’s experience of the event or circumstance. 3

4. Prevalence of trauma Exposure to trauma is widespread Trauma can occur at any age Trauma can affect individuals from all walks of life 4

5. Prevalence of trauma Exposure to trauma is especially common among individuals with mental illness, substance use disorders and developmental disabilities 5

6. Trauma Affects… Over one out of three females with mental health disorder; and About one out of five males with mental health disorder in Ohio Source: Client Self-Reported Experiences of Trauma, SFY13, Ohio Behavioral Health Module

7. Trauma Affects… Over one out of four females with a substance use disorder; and About one out of ten males with a substance use disorder in Ohio Source: Client Self-Reported Experiences of Trauma, SFY13, Ohio Behavioral Health Module

8. Prevalence of trauma NIDA suggests that up to two thirds of individuals with substance use disorders have experienced trauma Rape victims are three times as likely to use marijuana, six time mores likely to have used cocaine and ten times as likely to have used other drugs, including heroin and amphetamines 8

9. Trauma affects… Over one out of three females with co-occurring mental health and substance use disorders; and Over one out of ten males with co-occurring mental health and substance use disorders in Ohio Source: Client Self-Reported Experiences of Trauma, SFY13, Ohio Behavioral Health Module

10. Trauma affects Ohioans with Developmental Disabilities… Neglect 1116 366 Physical Abuse 310 Verbal Abuse 83 Sexual Abuse CRN Validation Cube. Ohio Department of Developmental Disabilities 2013.

11. Ohioans with Developmental Disabilities…  Increased risk for abuse as compared to the general population (Gil, 1970; Mahoney & Camilo, 1998; Ryan, 1994)  Over four times as likely to be victims of crime (Sobsey, 1996)  Two – ten times more likely to be sexually abused than those without disabilities (Westat Ind., 1993)  Often experience rejection and loneliness (Pitonyak)

12. Trauma affects Ohio’s children… 29600 Neglect Physical Abuse 2750012600 Foster care 12100 Multiple Allegations 10600 Sexual Abuse 1800 Emotional Abuse PCSAO Fact Book: 11 th Edition, 2013-2014, Public Children Services Association of Ohio

13. In 2013, 15,000 Ohio children of a substance-abusing guardian entered the county child-welfare system At least half of these children remained in the county’s custody for more than 300 days compared with the average 70-day stay Child abuse and neglect reports in which heroin was listed as a factor increased from 4.9% of total reports in 2010 to 8.9% 2013 Substance use and impact on child welfare Ohio Department of Job and Family Services, Office of Families and Children

14. Trauma affects Ohioans with domestic violence… Statistic correlation with substance use with victims. Domestic Violence Calls (68,000) Victims (56,000) Arrests (41,000) Barbara Warner Committee on Workplace Domestic Violence -2013 Report, Ohio Department of Health Ohio Domestic Violence Statistics, 2012, Ohio Domestic Violence Network HealthDay, Copyright © 2013

15. Trauma Affects Ohioans with Domestic Violence… Of families who experience intimate partner violence: Four out of five adult children commit violence against partners Three out of four adult children become victims of domestic violence Barbara Warner Committee on Workplace Domestic Violence -2013 Report, Ohio Department of Health Ohio Domestic Violence Statistics, 2012, Ohio Domestic Violence Network HealthDay, Copyright © 2013

16. Trauma Affects Ohioans Who Are Victims of Human Trafficking… Ohio ranks fifth among all US states in human trafficking 1000 Ohio children are estimated to become victims of human trafficking each year Substances can be used to coerce potential victims Substances may be used by victims to cope with desperate situations NOT FOR SALE http://humantrafficking.ohio.gov

17. Cost of trauma Trauma is a major driver of medical illness, including cardiac disease and cancer Trauma is a major factor contributing to substance usage resulting in physical/psychological problems exacerbated by chemicals. Addressing trauma can positively impact the physical, behavioral, social and economic health of Ohio and Ohioans 17

18. Adverse Childhood Experiences Study Collaboration between Kaiser Permanente and CDC 17,000 patients undergoing physical exam provided detailed information about childhood experiences of abuse, neglect and family dysfunction (1995-1997) 18

19. ACE Categories Abuse Emotional Physical Sexual Neglect Emotional Physical Household Dysfunction Mother Treated Violently Household Substance Abuse Household Mental Illness Parental Separation or Divorce Incarcerated Household Member 19

20. ACE Categories 20 (Aces Connection, 2014)

21. ACE Score and Health Risk As the ACE score increases, risk for these health problems increases in a strong and graded fashion: Alcoholism and alcohol abuse Chronic obstructive pulmonary disease (COPD) Depression Hallucinations Fetal death Decline in Health-related quality of life Illicit drug use Ischemic heart disease (IHD) Liver disease Risk for intimate partner violence Multiple sexual partners Sexually transmitted diseases (STDs) Smoking Suicide attempts Unintended pregnancies Early initiation of smoking Early initiation of sexual activity Adolescent pregnancy HIV 21

22. ACE Score and Health Risk As the ACE score increases, risk for these health problems increases in a strong and graded fashion: Alcoholism and alcohol abuse Chronic obstructive pulmonary disease (COPD) Depression Hallucinations Fetal death Decline in Health-related quality of life Illicit drug use Ischemic heart disease (IHD) Liver disease Risk for intimate partner violence Multiple sexual partners Sexually transmitted diseases (STDs) Smoking Suicide attempts Unintended pregnancies Early initiation of smoking Early initiation of sexual activity Adolescent pregnancy HIV 22

23. ACE Pyramid 23

24. What is Trauma Informed? A program, organization or system that is trauma- informed: Realizes the widespread prevalence and impact of trauma Understands potential paths for healing Recognizes the signs and symptoms of trauma which includes the usage of substances and how trauma affects all people in the organization, including: Patients Staff Others involved with the system Responds by fully integrating knowledge about trauma into practices, policies, procedures, and environment. 24

25. Key Principles of Trauma-Informed Care Safety Trustworthiness and transparency Collaboration and mutuality Empowerment Voice and choice Peer support and mutual self-help Resilience and strength-based Inclusiveness and shared purpose Cultural, historical and gender issues Change process Proper referrals for Mental Health and Substance treatment as deemed necessary 25

26. Outcomes with TIC Improved quality of care and impact of care Improved safety for patients and staff Decreased utilization of seclusion and restraint Fewer no-shows Improved patient engagement Improved patient satisfaction Improved staff satisfaction Decreased “burnout” and staff turnover 26

27. Ohio’s Trauma Informed-Care (TIC) Initiative Many mental health and addiction treatment agencies, inpatient facilities, child-serving agencies and other community partners, have already provided training and consultation in trauma informed practice Many clinicians are trained in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Eye Movement Desensitization training (EMDR); Dialectical Behavioral Therapy (DBT) and other treatment modalities Trauma Informed Care is not the same as PTSD treatment 27

28. Ohio’s Trauma-Informed Care (TIC) Initiative There continues to be a need for training for staff/facilities and community system partners The ability of all communities and providers to organize trauma trainings internally is often beyond their finances, time and capabilities, yet the need of persons served has not changed The initiative will seek to provide additional resources for agencies and programs in Ohio who may need this support 28

29. Ohio’s Trauma-Informed Care (TIC) Initiative Since Summer of 2013, an interagency workgroup comprised of leaders from Ohio MHAS and Ohio Department of Developmental Disabilities (DODD) has been meeting to formulate plans to expand TIC across the state A portion of the “Strong Families, Safe Communities” funds from the Governor’s Office have been earmarked for this purpose The National Center for Trauma-Informed Care (NCTIC)/SAMHSA and Ohio Center for Innovative Practices (CIP) have also consulted formally Additional conversations and advice from Ohio Hospital Association, OACBHA, Ohio Council, PCSAO, and many others (thanks!) 29

30. Ohio’s Trauma-Informed Care (TIC) Initiative Vision: To advance Trauma-Informed Care in Ohio Mission: To expand opportunities for Ohioans to receive trauma- informed interventions by enhancing efforts for practitioners, facilities, and agencies to become competent in trauma- informed practices 30

31. Ohio’s TIC Initiative Trauma-Informed Care The TIC model assesses a service delivery system and makes modifications based on the basic understanding of how trauma affects the life of an individual seeking services TIC means that every part of an organization or program understands the impact of trauma on the individuals they serve and promotes cultural and organization change in responding to the consumers/clients served This is not a service; rather it is an approach to interpersonal interactions that takes into account the potential scars of a person’s past experience The TIC Initiative is not about endorsing particular trauma-informed practices, treatment models, screening or assessment instruments or processes and takes an across-the lifespan approach 31

32. Trauma-Informed Care (TIC) Promotes Cultural Change 32 “What’s wrong with you?” “What has happened to you?”

33. Interdepartmental Leadership Team 33 Dr. Mark Hurst, OhioMHAS, Co-Chair Kathy Coate-Ortiz, OhioMHAS Jody Lynch, OhioMHAS Angie Bergefurd, OhioMHAS Trudy Sharp, OhioMHAS Dr. Lisa Gordish, Twin Valley RPH Dr. Kraig Knudsen, OhioMHAS Latonya White, OhioMHAS Pam Berry, DODD, Co-Chair Sarah Lawson, DODD Angela Sausser-Short, Ohio MHAS Patrick Kanary, CIP, Case Western Reserve University Joyce Starr, OhioMHAS Dr. Tammy Collins, OhioMHAS Jackie Doodley, OhioMHAS Dr. Afet Kilinc, OhioMHAS Rob Robbins, DODD Kim Kehl, OhioMHAS

34. Framework for Ohio’s TIC Initiative Progress: Statewide TIC Project Coordinator Statewide Advisory Committee Meets monthly Endorsed “Fundamentals of TIC” approach Serve as “ambassadors” of TIC Partnership with National Center for Trauma-Informed Care NCTIC Train-the-trainers model System infrastructure and infiltration Updated TIC Website (in progress): http://mha.ohio.gov/Default.aspx?tabid=104 34

35. TIC Advisory Committee: Survivors of Trauma DODD Ohio Hospital Association Medicaid PCSAO OACBHA Ohio Council OACCA ODH Hamilton County Board of DD ODE Wright State University: MI/DD CCOE Depart of Aging Human Trafficking Commission CIP ODJFS ODYS Ohio Women’s Network Board of Regents Center for the Treatment and Study of Traumatic Stress Ohio Provider Resources Association (DD) 35

36. Framework for Ohio’s TIC Initiative TIC Summit - June 26, 2014 Creating Environments of Resiliency and Hope Thematic fundamental training for clinical and administrative leaders AM session: Didactic by leaders from NCTIC PM session: Regional breakouts to advance TIC locally Identify strengths, weaknesses, needs, champions Identify initial plan to proceed, with support from departments for communication, facilitation, etc. Sustainability 36

37. Framework for Ohio’s TIC Initiative Regional Collaboratives Progressively transmit TIC and increase expertise within regions Facilitate cultural change within organizations, addressing gaps and barriers and taking effective steps based on the science of implementation Topical workgroups (prevention, DD, child, older adult, etc.) Department(s) continue to support, facilitate, communicate 37

38. Framework for Ohio’s TIC Initiative Sustainability: Based on the passion of those involved in the initiative This can be launched and maintained with fairly little infusion of resources Encourage use and repurposing of existing resources Technical support: NCTIC and deliverables of CCOEs Encourage regions and states to develop internal expertise and learning communities to transmit, maintain and advance our ability to respond to those with trauma needs 38

39. TIC: Why is this important? 39

40. TIC: Why is this important? “What Happened to You?” 40

41. 41 Ohio Department of Developmental Disabilities National Center for Trauma-Informed Care OhioMHAS Office of Research Public Children’s Services Association of Ohio Ohio Human Trafficking Commission Ohio Department of Health Ohio Domestic Violence Network SAMHSA Ohio MHAS Trauma Website: http://mha.ohio.gov/Default.aspx?tabid=104 http://mha.ohio.gov/Default.aspx?tabid=104