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Creating Policies to Support Trauma-informed Perspectives and Practices


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Title: Creating Policies to Support Trauma-informed Perspectives and Practices

Creating Policies to Support Trauma-informed
Perspectives and Practices
  • Janice L. Cooper, PhD
  • Interim Director

3rd Annual Symposium, Bridging the Gap Fort
Worth, Texas November 3, 2009
Who We Are
  • NCCP is the nations leading research and policy
    center dedicated to the economic security,
    health, and well-being of Americas low-income
    children and families.
  • Part of Columbia Universitys Mailman School of
    Public Health, NCCP promotes family-oriented
    solutions at the state and national levels.
  • Our ultimate goal Improved outcomes for the
    next generation.

  • Background
  • Trauma and Its Effects
  • Special Populations
  • Current Services and Policy Challenges
  • Best Practices
  • Specific Policy Interventions
  • Policy Recommendations

  • 1982 Jane Knitzers seminalstudy, Unclaimed
    Children The Failure of Public Responsibility to
    Children and Adolescents in Need of Mental Health
  • 2005 work began for Unclaimed Children
    Revisited The Status of Childrens Mental Health
    in the United States 25 Years Later
  • 2007 released Trauma Report
  • 2008 released national report

Throughout her remarkable life and its many
diverse experiences and achievements, Dr. Jane
Knitzer embodied one consistent theme that
every child and every family is sacred, and
that it is every persons duty to reach out to
the most marginalized and vulnerable among
us. Her lifes work reflects these values at
every stage. Most recently on the IOM Committee
on Depression, Parenting Practices, and the
Healthy Development of Children
NCCP Director 2004-2009
Unclaimed Children Revisited Interests Aims
  • Identify effective state fiscal, infrastructure,
    training and related policies
  • Research-informed
  • Developmentally appropriate
  • Family/youth driven
  • Culturally competent
  • Promote research informed dialogue to move policy
  • Complement Presidents New Freedom Commissions
    initiatives by disseminating information on
    specific policy options

Understanding Trauma and its Effects
  • Trauma is pervasive.
  • Trauma refers to the severe distress, harm or
    suffering that results from overwhelming mental
    or emotional pain or physical injury.

Understanding Trauma and its Effects
  • A core feature of the impact of the trauma is the
    long and short term loss experienced by those
    exposed to traumatic events.
  • Critical elements of child development undermined
    by trauma (Cloitre, Cohen and Koenen, 2006)
  • healthy attachment,
  • social and emotional competency,
  • self-assurance, confidence,
  • independence

Lessons from ACES Study (Dube et al., 2001,
Felitti et al., 1998)
  • Strong relationship between adverse childhood
    experiences (5)
  • Suicide and Suicidal Attempts
  • Chronic Illness (Obesity, Heart Disease, Liver
  • Addictions
  • Mental Health Problems
  • Premature Death

What We Mean By Trauma-informed
  • Trauma-informed strategies ultimately seek to
    (Harris Fallot, 2001)
  • do no further harm
  • create and sustain zones of safety for children,
    youth and families who may have experienced
  • promote understanding, coping, resilience,
    strengths-based programming, growth, and healing

Children Youth Disproportionately At-risk
  • Children from Military Families
  • Survivors of Abuse, Neglect Sexual Violence
  • Children Youth with Disabilities
  • Youth in Juvenile Justice
  • Children who Experienced Natural and Man-Made
  • Youth with Substance Use Disorders
  • Homeless Runaway Youth
  • Children Youth at Risk of Suicide
  • Youth of Color

Children from Military Families
  • Over 1.2 million children live in military
  • Approximately 700K have at least one parent
    deployed (Johnson et al., 2007)
  • Deployment predictive of
  • 2X increase risk of child maltreatment (Gibbs et
    al., 2007)
  • Increased risk of child trauma across
    developmental span from infancy through
    adolescence (Lincoln, Swift, Shorteno-Fraser,
  • 32 child psychological morbidity 42 high
    parental stress (5-12 yo) (Flake et al., 2009)
  • High parental stress put children at more than 7X
    increase risk for poor child psychological
  • Among young children (U 5yo) those 3-5 higher
    levels of externalizing behaviors independent of
    parental distress (Chartrand,et al., 2008)

Children and Youth from Military Families
  • Prevalence of Mental Health Problems among
    Military Personnel
  • Post deployment 20 of active duty and 42 of
    reservists needed mental health treatment (not
    identify prior to deployment) (Lamberg, 2008)
  • Reservists, National Guard and younger active
    duty service members with combat related exposure
    increased risk for new onset of heavy drinking,
    binge drinking and alcohol-related problems
    (Jacobson et al., 2009)
  • Lack of confidentiality may deter soldiers from
    accessing SUD related treatment (Milliken,
    Auchterlonie Hoge 2007)
  • Referrals to SUD treatment dramatically lower
    compared to MH treatment

Child/Youth Survivors of Abuse, Neglect Sexual
  • Maine 33 females and 67 males a trauma
    related diagnosis or were involved in child
    welfare due to traumatic event (Yoe, Russell,
    Ryder, Perez and Boustead 2005)
  • 50 female 70 male rape survivors raped prior
    to age 18 (Tjaden, P and Thoennes 2006)
  • 20 Females
  • 50 Males
  • Raped by age 12

  • Children Who Experienced Abuse, Neglect or
    Sexual Violence

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Disabled Children Youth at Higher Risk
  • More likely to be abused (Sullivan Knutson,
  • physically (1.5 times)
  • sexually (2.2 times)
  • Deaf children youth higher risks (Sullivan
    Knutson, 1998)

High Prevalence of Trauma Exposure in Juvenile
  • Over 90 in juvenile detention in a large urban
    county have been exposed to at least one
    traumatic event nearly 60 have experienced 6
    or more traumatic events. (Abram et al, 2004)
  • 11 of youth in JJ were diagnosed with PTSD upon
    clinical assessment. (Abram et al, 2004)

What the Data Shows School-age Youth in Juvenile
Any MH disorder Any SUD disorder Anxiety disorder ADHD Any Disrupt. disorder Affect. disorder
Males 65.5 50.7 21.3 16.6 41.4 18.7
Females 73.8 46.8 30.8 21.4 45.6 27.7
Prevalence Behavioral Health Disorders of Youth
in Detention by Gender () NB Approx. 90 of
youth in JJ are males. Source Teplin, L., Abram,
K., McClelland, G. M., Dulcan, M., Washburn, J.
J. (2006). Psychiatric Disorders of Youth in
Detention. Juvenile Justice Bulletin (April
2006), 1-16.
What Data Shows School-age Youth Who Experience
Cumulative Trauma
  • Overall cumulative exposure to childhood trauma
  • Males were
  • 3.3 x more likely than females to experience
    intentional or assaultive violence (e.g. being
    raped, mugged, held up or threatened with weapon)
  • 2.2 x more likely than females to experience
    other injury or trauma

Source Breslau, N., Wilcox, H. C., Storr, C. L.,
Lucia, V. C., James, A. (2004). Trauma Exposure
and Post-Traumatic Stress Disorder A Study of
Youths in Urban America. Journal of Urban Health,
81(4), 531-544.
Children who experienced trauma from natural and
man-made disasters
  • Of Katrina survivors who were parents (Abramson
    Garfield, 2006)
  • Nearly 50 reported their children had new
    emotional/behavioral problems
  • Nearly 50 reported that they never or only
    sometimes felt safe
  • Of all returning vets from Afghanistan Iraq,
    those of transition-age (18-25), were the most
    likely to develop PTSD (Seal, Miner, Sen,
    Marmar, 2007)
  • Overall PTSD rates among veterans of OEF/OIF 4X
    higher than community samples

Youth with Substance Use Disorders at High Risk
  • 3-4 times higher risk for PTSD (1)
  • Multiple exposures to trauma predicted developing
    SUD (2)
  • Youth with co-occurring PTSD SUD lower levels
    of functioning (1)
  • SUD associated with community violence,
    interpersonal violence, child maltreatment and
    self harm (3)
  • SUD can serve as mechanism for self addressing
    trauma (3)
  • SUD impedes effective trauma treatment (4)

1) Giaconia et al., 2000 2) Giaconia et al.,
1995 3) Kilpatrick et al., 2003 4) Jaycox,
Ebener, Damesek, Becker, 2004 Riggs, 2003.
Children of Homeless Families Runaway Youth
  • Two-fifths of the homeless population in the
    United States is made up of families (Bassuk et
    al, 2005). Their homelessness puts them at
    increased risk for other trauma, including
    physical and sexual violence, emotional abuse and
    intense anxiety and uncertainty.
  • Almost two-thirds of homeless and runaway youth
    living on the street have witnessed violence and
    between 15-51 percent have been physically or
    sexually assaulted (Kipke et al, 1997).

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Children at Risk of Suicide
  • Three groups with a greater risk
  • American Indian/Alaska Native children and youth
  • due to the historical trauma and current
    deprivation and trauma
  • 64 of all the completed suicide are committed
    by this group nationally, 17.6/100,000 versus
    10.4/100,000 (Middlebrook et al, 2005)

Children at Risk of Suicide
  • Adolescent Latinas
  • A higher risk for suicide than Latino boys (15
    versus 7.8) and non-Latino boys and girls
    (Keaton et al, 2006).
  • Among girls, Latinas attempted suicide 50-60
    more than African-American and white female
    adolescents (The NHSDA report, 2003).

Children at Risk of Suicide
  • Gay, Lesbian, Bisexual, Transgendered and
    Questioning Youth (GLBTQ)
  • Between 1.7 and 2 times more likely than their
    non-gay and lesbian peers to have suicidal
    thought (Russell Joyner, 2001)
  • More than 2.5 times more likely to attempt
    suicide than their non-gay peers (Russell
    Joyner, 2001)

Secondary/Vicarious Trauma among Providers
  • Impacts their ability as caregivers (Bober et
    al., 2005)
  • Leads to higher rates of turnover (Van Hook,
  • Provider with self care strategies included these
    in tx, led to lower levels secondary trauma
    reduced turnover (Gordon, 2005)

Strategies to Reduce Vicarious Trauma
(Osofsky, Putnam Lederman, 2008)
  • Smaller Caseloads
  • Self-care
  • Improve supervision of front-line workers
  • Access to mh services
  • Impart information on secondary trauma

Long-term Effects of Trauma
  • Negative Impact on Brain Development
  • Academic and Social Problems
  • Chronic Illness, Morbidity and Mortality
  • Intergenerational Impact

  • Current Service and Policy Challenges

Current Policy and Service Responses
Characterized by
  • Failure to routinely screen and treat for trauma
  • Lack of traction to use proven effective
    treatment strategies
  • Use treatment practices and environments that
  • Seclusion Restraint
  • Boot Camp
  • Peer or Staff Abuse
  • Insufficient Attention to Vicarious/Secondary

Failure to Routinely Screen and Treat
  • Information on child trauma rarely received
    according to some studies (Taylor et al., 2005
    Hansen, Hasselbrock Tworkowski, 2002)
  • 84 of agencies reported in one study no/or
    extremely limited information on child/youth
    trauma history
  • Much of emerging knowledge on trauma fails to
    make it into daily practice (Taylor et al., 2005)
  • 33 of agencies report did not train staff to
    assess trauma
  • Less than 50 reported training their staff on
    EBP for children and youth with exposure to

State Policies and Practices that Re-traumatize
GAO (2007) report on Abuse in State-sponsored
institutions RTFs, boot-camps, wilderness camps
  • 33 states with over 1600 staff involved in
    incidences of abuse of children and youth in 2005
  • 10 investigated deaths within RTFs (one case in
    Texas) revealed common threads
  • Untrained and inexperienced staff
  • Lack of adequate nourishment in pursuit of tough
    love philosophy/strategies
  • Reckless/negligent operating procedures

SAMHSA Policy on Seclusion and Restraint
Other Public Policies Can Serve to Expose
Children/Youth to Trauma or Re-traumatize
  • Immigration Reform
  • Restrictive Housing Policies
  • Disaster Response Plans

Photo P. Pereira, The Standard Times
Immigration Policies and Trauma
  • 12 million undocumented workers in the US
  • Estimates 5 million children have at least one
    parent undocumented
  • 60 of these children are US-born citizens
  • Over 1.6 million immigration related arrests
  • Impact on children Urban Institute/La Raza study
  • 506 children impact on attending school,
    accessing resources, getting different caring
    arrangements (Capps, et al. 2007)
  • Children whose parents deported, arrested or
    detain in MN, CO, TX, NE,IA (NCCP analysis, 2006)

Source http//
Unaddressed Challenges
  • Funding Restrictions that Impeded Care and
    Sustainable Treatment
  • Limited Support for Prevention Early
  • Workforce problems Inadequacy in Supply and

Identifying Best Practices Key Elements
  • Services
  • Standardized Screening and Assessments
  • Evidence-Based Interventions
  • Culturally-Based Strategies
  • Family and Youth Engagement and Support
  • Infrastructure
  • Training
  • Policies to Eliminate/ Reduce Seclusion
  • Financial Strategies
  • Culturally Competent Policies
  • State Disaster-Related Plans for MH services

Best Practices Selected Screening Assessment
  • Acute Stress Checklist
  • Child Dissociative Checklist
  • Child Post-traumatic Stress Reaction Index
  • Child PTSD Symptom Scale
  • Child Stress Disorder Checklist
  • Childs Reaction to Trauma Event Scale
  • Childrens Impact of Traumatic Event Scale
  • Childrens PTSD Inventory
  • Childrens PTSD Interview
  • Childrens Sexual Behavior Inventory
  • Clinician Administered PTSD Scale
  • DISC (PTSD Module)
  • Lifetime Incidence Traumatic Events
  • Los Angeles Symptoms Checklist
  • Trauma Symptom Checklist (Young
  • When Bad Things Happen

Selected Evidence-based Interventions
  • Parent Child Interaction Therapy aka Honoring
    Children, Making Relations (Bigfoot)
  • Trauma-Focused CBT aka Honoring Children, Mending
    the Circle (Bigfoot)
  • Cognitive Behavioral Interventions for Trauma in
  • Dialectical Behavior Therapy
  • Trauma Recovery and Empowerment for Adolescents
  • Seeking Safety for Adolescents

  • Case Studies (NY, ND, ME)

North County Childrens Clinic (NCCC) New York
  • Watertown, NY
  • 10th Mtn Division avg deployment OEF/OEF 5x
  • Target Population- Families (Children) of
    Military Personnel
  • 27,000 residents (16,000 active duty military
    60 deployed)
  • 4 school-based health centers provide over 2000
    mental health visits per year to children and

North Country Childrens Clinic, New York
  • Strengths
  • Positive School Relations
  • Clinically sound programming
  • Collaboration with the Military HMO
  • Challenges
  • Military reimbursement for psy. health care
  • Sustainable program funding
  • Magnitude of needs exceed capacity
  • Gaps in the continuum of care
  • TriCare two-tier system disallows some PCTs for
    e.g. family conflict and child maltx no coverage
    intensive commty tx

Quote from Family Member
  • We receive our medical care at the -- Ambulatory
    Health Clinic. We took our son there in June and
    expressed our concerns for his mental health. The
    Doctor wrote a referral for a child psychologist
    in our town. That doctor had a 3 month waiting
    list to get on the waiting list for an
    appointment. By now school had started and we
    were having nights where he stayed up all night
    crying, wanting his father to come home. If I did
    get him to sleep, he woke up crying. It became a
    struggle even to get him to go to school, he saw
    no use in going to school if that meant growing
    up without his father. He had also started losing
    interest in church, and cub scouts, two things
    that he usually loves. He did not want to leave
    the house at all
  • With the help of the school-based clinic I was
    able to start helping my son cope with the

Medicine Moon Initiative-North Dakota
  • State-Tribal Initiative with 6 tribes
  • Built upon System of Care Sacred Child Project
  • Strong training component draws on cultural
    strengths and lessons learned from historical

Ours is a way of teaching parents that children
are sacred
Courtesy Deb Painte, MMI
Medicine Moon Initiative-ND
  • Strengths
  • Culturally competent
  • Wraparound
  • Agreement with the state to bill directly for
  • Focus on both current and historical trauma
  • Challenges
  • Lack of sufficient psychiatric or behavioral
    resources to meet the most acute needs
  • Lack of funding

Thrive Trauma-informed System of Care, Maine
  • Care delivery through trauma-lens
  • Age 0-12
  • Service philosophy What has happened to this
    family not, What is wrong with this family

Thrive Trauma-informed System of Care, Maine
  • Strengths
  • System of care focused on strength, engaging
    whole family
  • Universal screening
  • Promotion of effective trauma specific treatments
  • Staff Training
  • Use of trauma sensitive assessments
  • Quality assurance
  • Challenges
  • On-going provider buy-in, territorial issues pose
    obstacles to collaboration
  • Medicaid managed care curve-out
  • Struggles with substantive inclusion of all
    relevant agencies
  • Sustainable financial and programmatic efficacy

Literature Review Analysis of publicly
available data Main Data Sources
  • Jennings, Ann. (2004). Blueprint for Action.
    Building Trauma-Informed Mental Health Service
    Systems State Accomplishments, Activities and
    Resources. September 2004. http//www.annafound
  • State block grant applications. 2004-2007
  • SAMHSA Grant Awards - State Summaries FY
  • Personal Interviews with selected state officials

Services Standardized Screening and Assessments
  • Most states offer some form of screening and
  • In nearly 60 percent of states and territories
    (data available on 46 states) universal or
    selective screenings and assessments are being
    conducted. In many cases the scope is limited.

Services Evidence-Based Interventions
  • In less than 20 percent of states which provide
    screenings and assessments, the screening and
    assessment tools are evidence-based.
  • More than 50 percent of states provide
    evidence-based treatment/services however, the
    scope is mostly limited.

Services Culturally-Based Strategies
  • About 30 of states have culturally competent,
    trauma informed or focused treatment/services.

Infrastructure Training
  • Many states have developed training strategies of
    varying depth to increase the clinical and
    support capacity of those who deliver services to
    children, youth and their families who have been
    exposed to trauma.
  • Nearly 40 percent of states (data available for
    38 states) report training on trauma-informed/spec
    ific evidence-based practices.
  • A small proportion of this training focuses on
    cultural groups, gender or families.

Infrastructure Training (contd)
  • While not widespread some best practices in
    training in states include
  • Strategies those aimed at developing trauma
    specialists as in Oklahoma
  • System-wide or discipline-wide training like in
    Connecticut, Maine, Nevada, New York, Oklahoma,
    Illinois and Washington
  • Trauma-related training that meet the conditions
    for state clinician certification as in Wyoming
  • Embedding a trauma focus in statewide
    evidence-based training dissemination center in
    New York

Infrastructure Policies to Eliminate/Reduce
Seclusion Restraint
  • At least twenty states have implemented laws,
    regulations or policies designed to reduce and
    ultimately eliminate the use of seclusion and
    restraint. Five of these states have implemented
    strategies with far-reaching impact.

Infrastructure Financial Strategies
  • A number of state legislatures have also
    appropriated funding for specific trauma-related
  • Other state leaders have expanded the Medicaid
    benefit set to reimburse evidence-based trauma
    treatments, to facilitate trauma-specific
    treatments through billing and to fund specific
  • Generally absent are any state specific
    strategies to use the focus on information
    technology to create a more trauma-informed

Infrastructure Culturally Competent Policies
  • 8 states reported have culturally competent,
    trauma-focused policies.
  • Alaska
  • Connecticut
  • Illinois
  • New York
  • Oklahoma
  • South Carolina
  • Vermont
  • Washington

Highlights of State Responses Illinois Oklahoma
  • Illinois
  • Legislation requiring trauma informed services
  • State plan for child welfare includes public
    health framework
  • Workforce development
  • Use of Effective Treatment Strategies
  • Oklahoma
  • Trauma strategies heavily workforce development
  • Promotes cross systems collaboration
  • Full-time state level trauma coordinator
  • Evaluates and provides TA to contractors based on
    Jennings checklist of administrative practices
    and services

  • Key Elements of Success
  • Leadership Support
  • Funding
  • State
  • Child Trauma Counseling
  • Federal
  • Co-occurring Initiative
  • Cross Training Initiative
  • Transformation Initiative
  • National Child Traumatic Stress Initiative
  • Full time coordinator
  • Collaboration
  • Lessons Learned
  • Standards for Trauma Informed Care
  • Standards/Core Competencies for Trauma Informed
  • Communication is essential
  • Develop a common language for trauma.
  • Transformation takes time.

Courtesy Julie Young, OK
  • What did NCCP Survey Questions
  • on Trauma Add?

Systematic Screening or Intervention for Trauma
or Suicide Risk (Children and/or their Parents)
  • 40 states report systematic screening or
    treatment for trauma or suicide risk
  • 13 states did not respond or systematic
  • Common state efforts
  • 12 reported screening for trauma/suicide risk (4
    reported using Columbia Teen Screen)
  • 10 states reported providing training on
    validated tools such as on TF-CBT Applied
    Suicide Intervention Skills Training (ASIST)
    Question, Persuade Refer (QPR) and,
    crisis/suicide prevention and intervention
  • 7 states report using funds like Garrett Smith
    funds for prevention

Plan to Deliver Mental Health Services and
Supports in Times of Disaster or Emergency
  • 34 states reported that they had a specific plan
  • 17 states reported that they did not have a plan
  • 2 states did not respond
  • Designated Individual in CMH charged with service
    coordination in the case of disaster/emergency
  • 24 states reported they had a designated
  • 8 states reported that they did not (in case of 3
    for MH not specifically child mh)
  • 17 missing/NA

Types of Responses from States on MH Services for
Children in State Emergency Plan
  • Each regional coordinator has a designated
    emergency satellite phone
  • Regional (10) disaster management teams
  • A system of trained and coordinated crisis
    counseling staff and networks
  • A network ready to respond of volunteers and
  • All hazards leadership team
  • A MOU with community behavioral health centers to
    coordinate, organize and mobilize during any

  • Policy Recommendations

All federal, tribal, state and local policies
should reflect a trauma-informed perspective
  • Important factors
  • Developmentally appropriate
  • Culturally Linguistically Competent
  • Encompass public health framework
  • Engage children, youth and their families in
  • Fiscally-responsive
  • Collaborative
  • Accountable
  • Support infrastructural development
  • Competency-based training
  • Address vicarious trauma

Policies should support/reinforce
  • Delivery systems that identify and implement
    strategies to prevent trauma, increase capacity
    for early intervention and intervention and
    provide comprehensive treatment
  • Strategies designed to prevent and eliminate
    practices that cause trauma or re-traumatize
  • Core components of best practices in
    trauma-informed care prevention, developmentally
    appropriate, empirically supported strategies,
    cultural and linguistic competence and family and
    youth engagement

Trauma-informed related policies must
  • Funding that is supportive of care and that
    adequately reimburses for effective strategies
  • Funding is contingent upon elimination harmful
    practices that re-traumatize
  • Investment in strategies to ensure workforce
    competency in effective strategies
  • Provision of incentives for care delivered in
    community-based settings like schools and child
    care settings in addition to health care settings

For More Information, Contact Dr. Janice Cooper Or Visit NCCP web
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