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Study Sample Selection Criteria

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Impact of Trauma on Children Served Within Systems of Care and Intervention Approaches Robyn Boustead MIMH Photo courtesy of The Anna Foundation. – PowerPoint PPT presentation

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Title: Study Sample Selection Criteria


1
Impact of Trauma on Children Served Within
Systems of Care and Intervention Approaches
Robyn Boustead MIMH
Photo courtesy of The Anna Foundation. Artist
Anna Caroline Jennings (1960-1992). (See about
artist at back of presentation).
Adapted from a presentation given at the
Training Institutes 2006 Developing Local Systems
of Care for Children and Adolescents with
Emotional Disturbances and their
FamiliesFamily-Driven, Youth-Guided Services to
Improve Outcomes
2
Trauma and Systems of Care
  • Trauma has become more of a focus for mental
    health systems
  • Increased awareness of trauma trauma-informed
    approaches to service delivery.
  • Contributions of recent research and evaluation
    findings.
  • What we have learned so far
  • Trauma is pervasive in mental health service
    populations.
  • Clear link between untreated childhood trauma and
    host of serious physical and mental health
    disorders over the life span.
  • Need for systemic approaches for addressing
    trauma.

3
TraumaA Definition
The American Psychiatric Associations Diagnostic
Statistical Manual (DSM-IV) defines a
traumatic event as one in which a person
experiences, witnesses, or is confronted with
actual or threatened death or serious injury, or
threat to the physical integrity of oneself or
others. A persons response to trauma often
includes intense fear, helplessness or horror.
Trauma can result from experiences that are
private (e.g. sexual assault, domestic
violence, child abuse/neglect, witnessing
interpersonal violence) or more public (e.g.
war, terrorism, natural disasters).
4
What the 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).

5
What the Research Tells us (Continued)
  • Rates of Post-Traumatic Stress Disorder among
    adults who were formerly placed in foster care
    were found to be twice as high as rates as in
    U.S. war veterans (Northwest Foster Care Alumni
    Study, Pecora, et al., 2005)
  • Children in foster care exhibit
    disproportionately high rates of acute and
    chronic medical and mental health conditions and
    use more mental health services at higher cost
    than children not in foster care (Halfon, et al.,
    2002 Landers Mei Zhou, 2004).
  • Child and youth trauma survivors at increased
    risk for substance abuse, criminal activity,
    homelessness, and re-victimization (Boney-McCoy,
    et al., 1996 Krahe, 2000 Flannery et al., 2001
    Anderson, et al., 2003).
  • Childhood trauma exposure consistently associated
    with a wide range of serious mental health
    physical health disorders in adults (Felitti, et
    al., 1998Schwartz Perry, 1994 Dube, et al.,
    2003, Chapman, et al. 2004).
  • Relatively few studies have specifically
    evaluated the impact of trauma on public service
    use, treatment costs or service outcomes for
    children/youth with serious emotional/behavioral
    challenges.

6
Adverse Childhood Experience (ACE) Study
  • Without intervention, adverse childhood events
    (ACEs) may result in long-germ disease,
    disability, chronic social problems and early
    death. Importantly, intergenerational
    transmission that perpetuates ACEs will continue
    without implementation of interventions to
    interrupt the cycle.

Adverse Childhood Experiences
Impact of Trauma Adoption of Health Risk
Behaviors
Long-Term Consequences Of Unaddressed Trauma
Disease Disability
  • Abuse of Child
  • Psychological abuse
  • Physical abuse
  • Sexual abuse
  • Trauma in Childs
  • Household Environment
  • Substance Abuse
  • Parental separation /or
  • Divorce
  • Mentally ill or suicidal
  • Household member
  • Violence to mother
  • Imprisoned household
  • member
  • Neglect of Child
  • Abandonment
  • Childs basic physical /or
  • Emotional needs unmet

Neurobiologic Effects of Trauma
  • Ischemic heart disease
  • Cancer
  • Chronic lung disease
  • Chronic emphysema
  • Asthma
  • Liver disease
  • Skeletal fractures
  • Poor self rated health
  • HIV/AIDS
  • Disrupted neuro-development
  • Difficulty controlling anger
  • Hallucinations
  • Depression
  • Panic reactions
  • Anxiety
  • Multiple (6) somatic problems
  • Impaired memory
  • Flashbacks

Social Problems
Health Risk Behaviors
  • Homelessness
  • Prostitution
  • Delinquency, violence criminal
  • Behavior
  • Inability to sustain employment-
  • Re-victimization rape domestic
  • Violence
  • Inability to parent
  • Inter-generational transmission
  • Of abuse
  • Long-term use of health social
  • services
  • Smoking /or Drug abuse
  • Severe obesity
  • Physical inactivity
  • Self Injury /or Suicide attempts
  • Alcoholism
  • 50 sex partners
  • Sexually transmitted disease
  • Repetition of original trauma
  • Eating Disorders
  • Dissociation
  • Perpetrate domestic violence

Adapted from presentation Jennings (2006). The
Story of a Childs Path to Mental Illness.
7
Financial Costs of Untreated Trauma
The financial burden to society of undiagnosed
and untreated trauma is staggering. The
estimated cost to society of child abuse and
neglect is 94 billion per year, or 258 million
per day (Prevent Child Abuse America 2001). For
child abuse survivors, long-term psychiatric and
medical health care costs are estimated at 100
billion per year (The Ross Institute).
8
The Maine Study
  • 492 children and adolescents enrolled in
    SOC/Targeted Case Management Services in FY 2000
    and FY 2001.
  • Sample was divided into two groups an identified
    trauma group (n 227) and a non-trauma group
    (n265)
  • All participants enrolled in SOC/Targeted Case
    Management Services for at least 12 months.
  • Behavioral/functional assessments completed at
    baseline, 6 months, and 12 months as part of
    comprehensive outcome tracking system.
  • All participants active Medicaid Service
    recipients with at least some mental health
    service use during FY 2000 or FY 2001.

Courtesy of James T Yoe, Ph.D Maine Department of
Human Services
9
Comparison of Mental Health Service Use Between
Trauma Non-Trauma Groups







Groups differ significantly at P lt .05
Courtesy of James T Yoe, Ph.D Maine Department of
Human Services
10
Comparison of Primary Health Care Service Use
Between Trauma Non-Trauma Groups

Groups differ significantly at P lt .05
Courtesy of James T Yoe, Ph.D Maine Department of
Human Services
11
Comparison of Behavioral/Functional Change
Between Baseline 12 Months for Trauma and
Non-Trauma Groups


Groups differ significantly, plt.05
Courtesy of James T Yoe, Ph.D Maine Department of
Human Services
12
Comparison of Median Annual Treatment
Expenditures Between Trauma Non-Trauma Groups



Groups differ significantly at P lt .05
Courtesy of James T Yoe, Ph.D Maine Department of
Human Services
13
Summary of Results Child Descriptive and
Behavioral/Functional Differences
  • Children and youth trauma survivors
  • Were significantly younger
  • Were 1.62 times more likely to be rated at
    moderate to serious risk of harm (as measured by
    the CALOCUS)
  • Were less than ½ (Odds.451) as likely to
    experience serious co-occurring (medical,
    substance use, or developmental) challenges (as
    measured by the CALOCUS) (likely due to younger
    age and higher substance use in non-trauma
    group)
  • Were 1.76 times more likely to experience
    higher-levels of environmental stress and 1.65
    times more likely to have moderate to severe
    challenges in the area of supports
  • Were ½ (Odds.563) as likely to experience
    serious challenges with substance use (as
    measured by CAFAS)
  • Had significantly greater challenges in the areas
    of child/youth and parent/caregiver acceptance
    engagement with service providers
  • Than children and youth without a trauma history

14
Summary of Results Service Use, Expenditures
and Outcomes
  • Child and youth trauma survivors
  • Were more likely to use high-end mental health
    services, including inpatient psychiatric
    hospitalization, residential/group treatment, and
    crisis intervention services at higher cost
  • Were 1.92 times more likely to use out-of-home
    treatment (Psych. Inpatient, Resid. Tx. Crisis
    Residential)
  • Were 1.55 times more likely to use Outpatient
    Mental Health treatment services
  • Were 1.75 times more likely to use Medication
    Management Services
  • Used more Targeted Case Management services at
    significant higher expense
  • Used outpatient-clinical and medication
    management services at significantly higher cost
  • Were 1.61 times more likely to use and used more
    emergency department services at higher cost
  • Had 73 higher mental health service expenditures
    51 higher overall treatment expenditures
  • Were significantly less likely to exhibit
    behavioral/functional stability or improvement
    over study period.
  • Than children and youth without a trauma history

15
Implications for Systems
  • These findings suggest that when service systems
    do not appropriately assess, identify, and
    effectively address the underlying trauma-related
    needs of these children and families, the result
    may be greater use of expensive and often
    ineffective services that are likely to be
    overwhelming to the child and family, lead to
    re-traumatizing experiences for the child, and
    contribute to poor 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.

16
Being trauma informed
To be trauma informed means to know the history
of the past and current abuse in the life of the
child/family with whom one is working. This
allows for more holistic and integrated
treatment. Second, and more important, is to
understand the role that violence and
victimization plays in the lives of most
consumers of mental health servicesand to use
that to design services which address the
vulnerabilities of survivors and facilitate their
participation in treatment (Fallot Harris,
2001). Services must be welcoming and
appropriate to produce successful outcomes.
17
Why a Trauma-Informed Approach?
  • Trauma is pervasive
  • The impact of trauma is very broad and touches
    many life domains
  • The impact of trauma is often deep and
    life-shaping
  • Violent trauma is often self-perpetuating
  • Trauma is insidious and preys particularly on the
    more vulnerable among us
  • Trauma affects the way people approach
    potentially helpful relationships
  • Trauma has often occurred in the service context
    itself

Fallot Harris, 2006
18
How is a Trauma-Informed System of Care Different?
Trauma-Informed Approach
Traditional Approach
  • Trauma as defining organizing
  • experience
  • Focus on understanding whole
  • individual context
  • Focus on trust safety
  • Trauma awareness/sensitivity
  • instilled at all levels of system
  • Strengths-based,resilience
  • recovery-oriented
  • Family-driven youth-guided
  • Individualized service delivery
  • Use of non-traditional natural
  • supports
  • Prevention-oriented
  • Culturally-Competent
  • Trauma viewed as
  • single, discrete event
  • Focus on understanding
  • childs problem (PersonProblem)
  • Child family passive
  • recipients of services
  • Reactive/crisis-oriented
  • service delivery
  • Focus on traditional
  • service delivery
  • approaches

19
A Trauma-Informed Approach-What Does it Mean?
  • We are more aware of the child and familys need
    to feel safe when dealing with a state
    agency/department, community organizations,
    school systems, etc.
  • THE GOAL IS TO NOT RETRAUMATIZE THE FAMILY OR
    YOUTH WHO ARE IN NEED OF SERVICE.

20
Guidelines for Change
Self Assessment Exercise
  • Services-level changes
  • Program Procedures Settings
  • Formal Services Policies
  • Trauma Screening, Assessment, Service Planning
  • Administrative or Systems-level changes
  • Administrative Support for Program-Wide
    Trauma-Informed Services
  • Staff Trauma Training Education
  • Human Resources Practice

21
Implementing a Trauma-Informed System of Care
  • The Goal
  • To offer services in ways that facilitate the
  • collaborative participation of children and their
    families in their own service provision and are
    sensitive to the unique needs of children and
    families who are trauma survivors.

22
Implementing a Trauma-Informed System of Care
  • Paradigm shift required
  • Resilient survivors vs. damaged goods
  • Change in focus from What is wrong with this
    child? vs. What has happened to this child?
  • Trauma is pervasive
  • Most if not all clients we serve will have
    experienced some type of trauma as part of their
    life experience.

23
Implementing a Trauma-Informed System of Care
  • Focus on resiliency skill-building for the
    youth and families (CBT, ACT, MST, Wraparound)
  • Universal trauma screening, assessment and
    service planningwith integration of all
    components with targeted EBP.
  • A look at issues of privacy, confidentiality and
    safety (group rooms and waiting areas)
  • Crisis management from a trauma-informed
    perspective (crisis plans, options for placement)

24
Well-Established and Probably Efficacious
Treatments for Child Trauma
  • Trauma-focused CBT
  • Abuse-focused CBT
  • Parent-Child Interaction Therapy
  • Child-Parent Psychotherapy for Family Violence
  • Cognitive-Behavioral Intervention for Trauma in
    Schools (CBITS)
  • TF-CBT for Child Traumatic Grief
  • Project 12-Ways/Safe Care for Child Neglect

Leyla Faw Stambaugh, Ph.D, 2006 Duke University
Medical Center
25
Common Elements of EBP for Child Trauma
  • Largely behavioral or cognitive-behavioral
  • Address symptoms, behavior, and functioning
  • Relatively brief
  • More effective when a caregiver is actively
    involved
  • When behavior problems are a primary issue, a
    number of interventions that are effective are
    directed at the caregiver only
  • Dropping a child off at a clinic is of limited
    value

Stambaugh, 2006
26
Implementing Evidence-based Practice in a System
of Care
  • These evidence-based treatments are not uniformly
    available across the country
  • Institutional care is not well-researched
  • Benefits unsubstantiated
  • May even be deleterious due to contagion effects
  • Children often have complex combinations of
    problems, and may benefit from intensive home-
    and community-based services

Stambaugh, 2006
27
In Summary
  • Trauma is pervasive among children/youth
    receiving public mental health services.
  • Without a systemic approach to identification
    treatment, underlying issues of trauma may be
    missed or overlooked.
  • Unresolved trauma may result in
  • More high end service use a at higher cost with
    less functional improvement
  • Serious health mental health risk behaviors as
    adults.
  • Due to pervasive nature of trauma, systems of
    care need to take a systemic approach to trauma.
  • A trauma-informed system includes
  • Universal trauma screening, assessment service
    planning integrating all components
  • Focus on recovery, strengths-based, and skill
    building
  • General awareness understanding among all
    stakeholders of trauma, its effects and potential
    triggers
  • Changes in policy practice to support a trauma
    sensitive approach throughout system
    participating agencies to reduce incidences of
    retraumatization (waiting room practices)
  • Crisis management from a trauma-informed
    perspective
  • For many, violence resulting trauma is
    trans-generational so need for concurrent
    services
  • Specific evidence-based practices.

28
Missouris DMH Trauma Initiatives
  • Department wide Administrative Policies/Guidelines
    regarding trauma
  • The DMH Trauma Work Group comprised of
    representatives of all three divisions was formed
    in 2002 and developed a Trauma FACT Sheet,
    Department Position Statement, and Guiding
    Principles.
  • Department Operation Regulations (DOR) were
    rewritten to reduce seclusion and restraint in
    state psychiatric hospitals
  • Workforce requirements regarding recommended
    general and specific competencies in trauma
    identified and are available on website
  • The Annual Spring Training Institute has a Trauma
    Track. Many experts in the trauma field have
    presented over the past seven years
  • Response to current traumatic events included in
    Disaster Planning Mental Health First Aide
  • Office of Transformation activities include
    presentation to Commission, budget item for
    childrens trauma training and funding for trauma
    speaker for NAMI conference
  • The DMH co-sponsored a successful conference in
    March 2007 titled Mental Health Needs of
    Returning Soldiers and Their Families.
    Nationally recognized speakers

29
Missouri DMH Trauma Initiatives Cont.
  • Office of Children, Youth and Families
  • Under a OJJDP grant to develop EBPs, two local
    sites have trained therapists on Trauma
    Focused-Cognitive Behavioral Therapy (TFCBT) and
    one site trained on Adolescent Dialectical
    Behavior (DBT)
  • Submitted grant (pending) to develop trauma
    treatment Center of Excellence through UMSTL
  • Conducted training in 5 regions on identification
    screening for trauma history
  • BJC designing a trauma specific treatment
    intervention for children
  • Division of ADA
  • Seeking Safety program implemented in all Women
    and Children CSTAR programs. Financed as
    individual or group counseling billing under
    CSTAR/Medicaid with trauma specific billing
    codes
  • Primary Recovery Plus has added trauma services
    and billing codes
  • Division of CPS
  • CPS trauma-informed workgroup to integrate
    trauma into service delivery
  • A full time Psychologist/Consultant hired to
    facilitate implementation of DBT
  • Nineteen therapists have been credentialed in
    eight Administrative Agents in the Northwest
    Region to provide TF-CBT through pooled local
    CMHC training dollars
  • FSH has developed a trauma-informed system
    addressing Restraint and Seclusion practices,
    training staff and peer specialists on trauma,
    risk prediction models that include trauma
  • Hawthorn Childrens Hospital is implementing the
    national Sanctuary Model

30
About the Artist
About the Artist Anna Caroline Jennings (1960
1992)   The artist, Anna Caroline Jennings, was
sexually abused when she was less than three
years old. This was the first of several abuses
that occurred over her lifetime, and put a
confused, frightened child into a mental health
system that neither recognized nor treated Annas
real problem. She was institutionalized for more
than 12 years from age 15 to 32. Although she
attempted to communicate the awful things that
had happened to her, there was no one to listen,
understand or help her. She took her life on
October 24, 1992, on a back ward of a state
mental hospital.   Anna expressed her abuse at
the hands of perpetrators and within the mental
health system vividly and poignantly through her
sketches, oil paintings, water colors and
writings. Although she had no formal art
training, her work is stark, sophisticated and
haunting. Her work was exhibited first at the
1994 Dare To Vision conference in Washington, DC,
since then in many hospitals and at numerous
conferences across the country, and recently at
the Dare To Act conference in Baltimore, MD. Her
work and story are displayed on the website
www.AnnaFoundation.org.
31
Resources
National Child Traumatic Stress Network has
information about trauma, fact sheets,
resources, screening/assessment tools and
treatments that work. www.nctsn.com The Anna
Foundation has information on trauma, its
effects and resources for addressing trauma
including research, screening and assessment
tools, effective treatments. www.AnnaFoundation.
org
  • http//tfcbt.musc.edu/ provides a (free!)
    web-based course on TF-CBT (Saunders Smith)
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