1. NADD Ohio State 13 th Annual IDD/MI Conference Kim Kehl Sondra Williams September 22, 2015

2. Adverse Childhood Experiences Study 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) 2

3. 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 3

4. 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) 4

5. 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. 5

6. The Science on ACEs... 6 New lens through which to understand the human story Why we suffer How we parent, raise and mentor our children How we might better prevent, treat and manage illness in our medical care systems How we can recover and heal on deeper levels

7. ACE Pyramid 7

8. Effects of Trauma on Neurocognitive Development 8

9. Potential Traumatic Events Slide 9 Abuse EmotionalSexualPhysicalDomestic violenceWitnessing violenceBullyingCyberbullingInstitutional Loss DeathAbandonmentNeglectSeparationNatural disasterAccidentsTerrorismWar Chronic Stressors PovertyRacismInvasive medical procedureCommunity traumaHistorical trauma Family member with substance use disorder

10. Experience of Trauma Experience of trauma affected by: HowWhenWhere How Often Slide 10

11. Experience Continued Slide 11 Context, expectations, and meaning Threat to life, bodily integrity, or sanity Interventions Humiliation, betrayal, or silencing Subconscious or unrecognized

12. Prevalence of Trauma Exposure to trauma is widespread Trauma can occur at any age Trauma can affect individuals from all walks of life 12

13. Prevalence of Trauma Exposure to trauma is especially common among individuals with Mental illness Substance use disorders Developmental disabilities 13

14. Trauma in adults – Mental Health 14 More than 84% of adult mental health clients will have trauma histories (Meuser et al, 2004) 50% of female and 25% of male clients experienced sexual assault in adulthood (Read et al, 2008) Clients with histories of childhood abuse will have earlier first admissions, more frequent and longer hospital stays, more time in seclusion and restraints, greater likelihood of self-injury or suicide attempts, more medication use and more severe symptoms (Read et al, 2008)

15. Trauma in adults – Substance Abuse 15 Up to 65% of all clients in substance abuse treatment report childhood abuse (SAMHSA, 2013) Up to 75% of women in substance abuse treatment have trauma histories (SAMHSA, 2009) Over 92% of homeless mothers have trauma histories, They have twice the rate of drug and alcohol dependence as those without (SAMHSA, 2011) Almost 1/3 of all veterans seeking treatment for a substance use disorder have PTSD (National Center for PTSD)

16. Trauma in adults – Kids 16 71% of children are exposed to violence each year (Finkelhor, et. al, 2013) 3 million children are maltreated or neglected each year (Child Welfare info, 2013) 3.5-10 million witness violence against their mother each year (Child Witness to Violence Project, 2013) 1 in 4 girls and 1 in 6 boys were sexually abused before adulthood (NCTSN Fact Sheet, 2009) 94% of children in juvenile justice settings have experience trauma (Rosenberg et al, 2014)

17. Trauma in person with developmental disabilities 17 About 70 % of developmentally disabled people report being physically, and sexually assaulted, neglected or abused (Columbus Dispatch, 2015) About 90 % of the reported multiple occurrences (Columbus Dispatch, 2015) Fewer than 40% of people reported this abuse to authorities (Columbus Dispatch, 2015) Those that did saw an arrest rate of less than 10% (Columbus Dispatch, 2015)

18. Trauma in person with developmental disabilities 18 One out of every three children and adults with developmental disabilities will experience abuse in their lifetime (Envision 2014) More that 90% of the time, that abuse will be inflicted by the very person they rely on to protect and support them (Envision 2014) With limited verbal skills, they may not have been able to tell anyone. And just because the actual traumatic event is over, it continues to play out in one's response to future situations (Envision 2014) Choose to judge behavior less and seek to understand what might be underneath and behind it; we must always be particularly cautious of seeing behavior as attention-seeking or manipulative (Envision 2014)

19. Trauma in person with developmental disabilities 19 Abuse and neglect have profound influences on brain development. The more prolonged the abuse or neglect, the more likely it is that permanent brain damage will occur. Not only are people with developmental disabilities more likely to be exposed to trauma, but exposure to trauma makes developmental delays more likely. Joan Gillece, Ph.D.,NASMHPD

20. Trauma in person with developmental disabilities 20 Cognitive and processing delays that interfere with understanding of what is happening in abusive situations, and Feelings of isolation and withdrawal due to their differences, which may make them more vulnerable to manipulation because of their increased responsiveness to attention and affection. Joan Gillece, Ph.D., NASMHPD

21. 21 Increase in number of people with DD who: Have a co-occurring mental health issue Have criminal justice histories Are incarcerated Cycle across systems and/or across providers Are at risk for harm to self or others System Indicators of Failure to Recognize and Address Trauma

22. Trauma in older adults 22 Based on a community sample of older adults, about 70% of older men reported lifetime exposure to trauma; older women reported a lower rate, around 41% In a large sample of older adults, greater lifetime trauma exposure was related to poorer self-rated health, more chronic health problems, and more functional difficulties Among a community sample of older women (average age = 70), 72% had experienced at least one type of interpersonal trauma during their lives (e.g., childhood physical or sexual abuse; rape) and higher rates of interpersonal trauma were related to increased psychopathology

23. Trauma Affects Ohioans with Domestic Violence... 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

24. Ohio ranks fifth among all US states in human trafficking 1000 Ohio children are estimated to become victims of human trafficking each year NOT FOR SALE http://humantrafficking.ohio.gov Trauma Affects Ohioans Who Are Victims of Human Trafficking...

25. 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 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 25

26. ACE Categories 26 (Aces Connection, 2014)

27. ACE score and current smoking 27 A child with 6 or more categories of adverse childhood experiences is 250% more likely to become an adult smoker. Smoking may not be caused by existence of local gas station availability or genetic predisposition

28. Childhood experiences and adult alcoholism 28 A 500% increase in adult alcoholism is directly related to adverse childhood experiences. 2/3rds of all alcoholism can be attributed to adverse childhood experiences This certainly suggests that alcoholism, contrary to popular belief, may not be simply a disease – but rather be a means by which the individual has learned to ease the pain of the trauma – or to balance his/her nervous system – e.g. sooth anxiety. Important ALWAYS to address and treat trauma along with alcoholism. Alcoholic

29. ACE score and IV drug use 29 A male child with an ACE score of 6 has a 4,600% increase in the likelihood that he will become an IV drug user later in life 78% of drug injection by women can be attributed to ACEs

30. Childhood experiences underlie suicide risk 30 The likelihood of adult suicide attempts increased 30-fold, or 3,000%, with an ACE score of 7 or more.

31. How does ACES affect our society?

32. Cost of Trauma Trauma is a major driver of medical illness, including cardiac disease and cancer Addressing trauma can positively impact the physical, behavioral, social and economic health of Ohio and Ohioans 32

33. What can be done about ACEs? These wide-ranging health and social consequences underscore the importance of preventing ACEs before they happen Safe, stable and nurturing relationships can have a positive impact on a broad range of health problems and on the development of skills that will help children reach their full potential Strategies that help address the needs that children and families have include: 33 Home visiting to pregnant women and families with newborns Parenting Training Programs Intimate partner violence prevention Social support for parents Parent support programs for teens And teen pregnancy prevention programs Sufficient income support for lower income families Early childhood programs and environments Mental illness and substance abuse treatment

34. 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 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. 34

35. Key Principles of Trauma-Informed Care Safety Trustworthiness and transparency Collaboration and mutuality Empowerment Voice and choice Peer support and mutual self-help Cultural, historical and gender issues Resiliency and strength-based 35

36. Trauma-Informed Care (TIC) Promotes Cultural Change 36 “What’s wrong with you?” “What has happened to you?”

37. 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 37

38. 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 38

39. 39 Ohio’s Trauma-Informed Care (TIC) Initiative Infiltration of TIC in Regional Psychiatric Hospitals (RPHs) Goal: RPH infrastructure will support cultural and environmental changes that support effective care and excellent outcomes. RPHS will be recovery-oriented; trauma-informed; culturally and linguistically competent; and address health and wellness. Progress to date: June 2013: Initial training of MHAS Central Office and Regional Psychiatric Hospital (RPH) leadership in TIC On-site training of clinical and support staff at all RPHs 2013-2014 Continued consultation from the National Center for Trauma-Informed Care (NCTIC) on next steps in Hospital Services Launch of TIC research study in collaboration with OSU College of Social to explore implementation of TIC at two psychiatric hospitals and focusing on two implementation variables: readiness for change and implementation climate Clinical Safety Initiative Trauma Informed CareSafe Physical Interventions Assault preventionSeclusion and Restraint Prevention Goal is for staff and patients to be and feel safe to be effective in meeting the needs of the patients we are committed to serving Intervention training scheduled for all hospitals through August

40. 40 Ohio’s Trauma-Informed Care (TIC) Initiative Infiltration of TIC in Department of Developmental Disabilities (DODD) Developmental Centers (DCs) Goal: DCs become trauma aware, knowledgeable and responsive to the impact and consequences of traumatic experiences for residents, families and their communities. Progress to date: Initial training of all Developmental Centers completed in FY 2015 Plans for subsequent visits and consultation from NCTIC Consultation provided on the impact of secondary/ vicarious trauma on staff at Montgomery and Youngstown Developmental Centers scheduled to close June 30, 2017

41. 41 Infiltration of TIC in Ohio communities Goal: Expand opportunities for Ohioans to receive trauma-informed interventions by enhancing efforts for practitioners, facilities and agencies to become competent in trauma informed practices. Progress to date: Train-the-trainer model – 170 trainers available throughout the state Content focused on system infrastructure and infiltration o Understanding trauma o Trauma-informed approaches o Principles of trauma-informed approaches o Guidance and implementation o Healing and recovery http://mha.ohio.gov/traumacare http://dodd.ohio.gov/Initiatives-and-Partnerships/Pages/default.aspx Click on TIC Regional Collaboratives Click on Trauma-Informed Approach Trainers Ohio’s Trauma-Informed Care (TIC) Initiative

42. 42 Ohio’s Trauma-Informed Care (TIC) Initiative TIC Communication Plan/MHAS/DODD organizational and administrative commitment to TIC Goal: Develop an educational and communication campaign on trauma and its association to health that encourages the adoption of trauma-informed practices among facilities, agencies and practitioners to support both their customers and their workforce in achieving better health. Commit to agencies and organizations becoming trauma-informed. Progress to date: MHAS website developed as a “clearinghouse” for information related to TIC distributing up- to-date information about TIC to the field, including materials for clinicians and health professionals, those who may have experienced trauma and other interested individuals http://mha.ohio.gov/traumacare 2,000 TIC Principles of Care posters developed in collaboration with NCTIC and SAMHSA Center for Evidenced-Based Practice, Case Western Reserve University educational materials including: Remind Me cards & “Transforming Culture, Policy and Practice of Organizations” posters

43. 43 Ohio’s Trauma-Informed Care (TIC) Initiative Second Annual Trauma-Informed Summit Goal: Identify promising practices and share feedback and continuous learning and form the basis for more advanced work in developing trauma-informed environments and practices. Progress to date: Creating Environments of Resiliency and Hope in Ohio June 17, 2015 333 participants from behavioral health, juvenile justice, schools, private psychiatric hospitals, health jurisdictions, county boards, local FCF representatives, higher education and six individuals from Larimer County Department of Human Services, Colorado Twelve break-out sessions showcasing exemplary Ohio programs

44. 44 Ohio’s Trauma-Informed Care (TIC) Initiative Alternatives to Seclusion and Restraint (S/R) Initiative Goal: Initiate a statewide quality/performance improvement and trauma-informed strategy in responding to, reducing and eliminating the use of seclusion and restraint incidents in children’s residential facilities. Progress to date: June 18, 2015 - Alternatives to Seclusion and Restraint Forum 123 participants: ODJFS children’s residential and/or OhioMHAS children’s residential centers, licensed inpatient facility or a facility providing services to young persons with developmental disabilities World café model used to identify: What accomplishments do agencies have to build upon to create coercion and violence free settings? What can be accomplished together that agencies cannot accomplish alone in order to move alternatives to seclusion and restraint to the next level? What policy challenges exist that prevent the overall reduction in the use of seclusion and restraint or other aversive practices in children’s residential programs?

45. 45 Ohio’s Trauma-Informed Care (TIC) Initiative Partnership Work Goal: Support the implementation of trauma-informed care systems and trauma-specific services across Ohio’s social services systems. Progress to date: Formation of a Statewide TIC Advisory Committee by coordinating existing experts on a state and regional basis, establish means of communication and collaboration from these experts, create learning communities and establish expertise in regions of the state Partner with the Ohio Department of Health on their Early Childhood Comprehensive Systems (ECCS) Grant – MHAS, Bureau of Children and Families Partner with Attorney General’s Office VOCA (Crime Victim’s Fund) programming

46. 46 Ohio’s Trauma-Informed Care (TIC) Initiative Regional Trauma-Informed Collaboratives Goal: Expand opportunities for Ohioans to receive trauma-informed interventions by enhancing efforts for practitioners, facilities and agencies to become competent in trauma informed practices, and facilitate cultural change within organizations, addressing gaps and barriers and taking effective steps based on the science of implementation. Progress to date: Six Regional TIC Collaboratives formed Staffed by MHAS and DODD personnel – (DODD Regional Liaisons) Transitioning to local leaders http://mha.ohio.gov/traumacare Click on TIC Regional Collaboratives

47. 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 47 Ohio’s Trauma-Informed Care (TIC) Initiative

48. Trauma-Informed Care Regional Collaboratives

49. TIC: Why is this important? TIC: Why is this important? 49

50. TIC: Why is this important? “What Happened to You?” 50

52. 52 Dr. Mark Hurst, M.D., FAPA Medical Director, OhioMHAS 30 East Broad Street, 36 th Floor, Columbus, OH 43215 (614) 466-6890 Mark.Hurst@mha.ohio.gov Tina Evans Regional Liaison Team Lead, Division of Policy & Strategic Direction Ohio Department of DD 30 E. Broad St. 12 th Floor Columbus, Ohio 43215 614.752.9028 tina.evans@dodd.ohio.gov Kim Kehl TIC Project Coordinator, Office of the Medical Director OhioMHAS 30 East Broad Street, 36 th Floor, Columbus., OH 43215 (614) 644-8442 Kim.kehl@mha.ohio.gov