Children with Special Health Care Needs, Child Maltreatment/Trauma

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Children with Special Health Care Needs, Child
Maltreatment/Trauma Foster Care A Statewide
Interagency Approach to Care and Capacity Building
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University of Tennessee Center of Excellence for
Children in State Custody

• Boling Center for Developmental Disabilities

Janet Todd, Ph.D. Melissa Hoffmann,
Ph.D. Kristin Hoffman, Ph.D.
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LEARNING OBJECTIVES

• 1. Describe functioning of COE and its relevance
  in a UCEDD
• 2. Describe collaborations with stakeholders to
  improve outcomes for children
• 3. Discuss importance of understanding impact of
  trauma on child development

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Tri-Partite Structure for Case Management for
Children in Custody and at Risk of Custody
Centers of Excellence for Children in State
Custody
Vanderbilt COE

• DCS Health Units Regional units composed of
  psychologist, nurse, and case manager who
  identify and manage health and mental health care
  for children in custody and at risk.
• COEs Provide specialty consultative,
  diagnostic, and clinical services, improvement of
  the system of care referrals from Health Units
  and Implementation Team.
• Crisis Management Team

ETSU COE
UT-Cherokee COE
Southeast COE
UT Boling Center COE
Map of COEs across Tennessee
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Development of COEs

• Collaboration of multiple stakeholders
• - University partners
• - Commissioners of Child Serving State
  Departments
• - Child Advocacy Organizations
• - TennCare (TNs managed Medicaid)

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Staff of UT COE

• Psychologists
• Psychiatrists
• Pediatrician
• Social Workers
• Speech Pathologist
• Training Coordinator

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CONTINUING COLLABORATIONS

• - Child Welfare
• - Community health and behavioral health
  providers
• - Schools
• TennCare
• State Departments
• Commission on Children and Youth

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COEs and Children with Disabilities

• Children in or at risk of entering the child
  welfare or juvenile justice systems are much more
  likely to be victims of abuse or neglect and to
  have physical, developmental, or psychiatric
  disabilities.

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Characteristics of ReferralsOct. 2012 Oct. 2014

• N 165
• Ages ranged from 1 to 17 years
• 0 to 5 years 19
• 6 to 11 years 38
• 12 to 17 years 43
• 61 Male, 39 Female
• 50 African American, 50 Caucasian

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Referrals continued

• 60 Resource (Foster) Home
• 22 Biological or Adoptive Home
• 11 Residential Treatment
• 7 Other (kinship/relative care, psychiatric
  hospital, etc.)
• Among those in out-of-home care, youth
  experienced an average of 2.8 placement
  changes/moves (range 1-12)

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Referrals - continued

• Average of 3.4 prior DSM disorders (ranged from
  0-8)
• Most Common Prior Diagnoses
• Behavior Disorder (19 of youth)
• ADHD (18)
• Mood Disorder (17)

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Intellectual Disabilities among Referrals

• 10 of referrals (among children 6 and older) had
  a previous diagnosis of Intellectual Disability
• Following assessment, COE diagnosed 28 youth with
  Intellectual Disabilities (21 of referrals)

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Youth Diagnosed with Intellectual Disability by
COE

• Only 13 (46) had prior diagnoses of Intellectual
  Disability
• Among ages 12-18, 8 out of 16 (50) had not been
  previously identified
• Among ages 6-11, 8 out of 12 (67) had no prior
  diagnosis

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Pre and Post Diagnoses among Referrals
Diagnoses with Prior Diagnoses Diagnosed by COE
Emotional Disorder 70 81
Behavior Disorder 110 126
Intellectual Disability 13 28
Mixed Delay 5 13
Speech/Language 8 23
Medical Diagnoses 14 30
ASD 4 6
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Reporting Requirements

• 2010 Reauthorization of the Child Abuse
  Prevention and Treatment Act (CAPTA)
• Requires states to include child disability in
  their abuse and neglect incidence and prevalence
  reporting

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Reporting Requirements

• Under 2010 Reauthorization of CAPTA
• A child is considered to have a disability based
  on the definition used in IDEA

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Victims with a reported disability, 2012

• Data from CHILD MALTREATMENT 2012
• Tennessee Total Reported Disabilities 160 out
  of 10,069
• 155 Behavior Problem
• 5 Physically Disabled
• No other categories reported

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Disabilities Child Maltreatment

• Disproportionate rates of maltreatment among
  children with disabilities
• Children with disabilities are 1.7 to 4 times
  more likely to experience abuse or neglect
• 11 to 22 of children who experience
  maltreatment have a disability

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Why at Higher Risk?

• Increased dependence/demands on caregivers
• Lack of personal safety abuse prevention
  programs
• Communication difficulties
• Susceptibility to manipulation

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Effects of trauma may be increased as well

• Reduced protective factors
• Belief that people with developmental
  disabilities cannot benefit from traditional
  verbally oriented therapies
• A lack of trained professionals who are
  comfortable working with people who have
  developmental disabilities and trauma

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Maltreatment and the Developing Brain
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• Not only are people with developmental
  disabilities more likely to be exposed to trauma,
  but exposure to trauma makes developmental delays
  more likely.

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• Abuse and neglect have profound influences on
  brain development. The more prolonged the abuse
  or neglect, the more likely it is that permanent
  brain changes will occur.

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PET Scans Showing IncreasingBrain Metabolic
Activity Birth to One Year of Age
Images Harry Chugani Science Vol 288, June 23,
2000
Slide modified from Frank Putnam, M.D. PCIT
Trauma presentation
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(No Transcript)
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• By age 7, 93 of brain growth (volume) has
  occurred
• However, children between the ages of 0 and 7
  experience the highest rates of abuse and neglect

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• Experience in Adulthood.
• Alters the Organized Brain
• Experience in Childhood.
• Organizes the Developing Brain

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Neural Imprinting

• The brain develops and modifies itself in
  response to experience. Neurons and neuronal
  connections (i.e., synapses) change in an
  activity-dependent fashion.
• The more an experience is repeated, the stronger
  the connections become

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What Fires Together Wires Together

• The more an event occurs, the more a neural path
  is fired and traveled, and the more permanent the
  message or new learning becomes
• So, when you repeatedly activate specific brain
  activity you are wiring or rewiring the brain.

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Normal vs. Neglected Brain
As cited by Felitti Anda, 2003 source CDC
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Fight, Flight, or Freeze

• During traumatic experiences childrens brains
  are in a state of activation (survival mode).
• The neurohormones released are good for short
  stress periods but can become harmful when in
  the system for long periods of time.

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• Young children who are neglected or maltreated
  have abnormal patterns of cortisol production
  that can last even after the child has been moved
  to a safe and loving home.

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• Chronic activation of this adaptive fear response
  can result in the persistence of a fear state
• Hypervigilance
• Increased muscle tone
• Focus on threat-related cues
• Anxiety
• Behavioral Impulsivity

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• Under stress, traumatized childrens analytic
  capacities disintegrate, and their emotional
  reactions take over, resulting in uncontrolled
  emotions and behavior

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Normal Stress Response

• All affective energy mobilized in the limbic
  system (red).
• Higher Cortical areas less active (blue).

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The Good News

• The brain is very plastic and capable of changing
  in response to experiences, especially repetitive
  experiences.
• Early identification and intervention with abused
  and neglected children has the capacity to modify
  development

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Defining the Problem in Tennessee in 2008

• 8,000 children and youth in custody
• Underserved and complex population
• No screening/assessment for trauma
• Few assessments recognized trauma etiology of
  externalizing behavior problems in outpatient
  mental health or residential treatment centers

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Defining the Problem in Tennessee

• Dearth of therapists trained to work with
  families
• Lack of evidence-based practice

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OPPORTUNITY KNOCKS
Governors Office of Child Care Coordination
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A Building Momentum for Change Nationally

• Kaufman Best Practices Report (2004)
• National Child Traumatic Stress Network (est. by
  Congress 2000)
• Mission To raise the standard of care increase
  access to services for traumatized children and
  their families

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Kaufman Report

• Best Practices
• Criteria for clinical utility
• Criteria for evidence supporting the efficacy of
  the treatment
• Criteria for transportability
• Science of Dissemination

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Large Gap Between Scientific Knowledge/Front-line
Practice

• Institute of Medicine has found that it requires
  17 years for scientific knowledge generated in
  randomized clinical trials to be routinely
  incorporated into everyday medical practice
  across the nation.

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Traditional Training Approach

• Single Training Event
• Passive Learning
• Individual Change
• Minimal Follow-up
• Minimal Accountability
• Minimal Consultation

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Learning Collaborative Model of Dissemination

• 9 to 18 months time frame
• Develop a learning community
• Include key administrators
• Pre-Work Phase
• Three 2-day Learning Sessions
• Action Periods between sessions

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Learning Collaborative Model of Dissemination

• Ongoing phone consultation coaching
• Model of Improvement
• Small Tests of Change
• Plan, Do, Study, Act
• Monthly metrics

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Dissemination of Trauma-Informed EBPs in Tennessee

• 6 Learning Collaboratives (2008 to present) and
  27 Booster Trainings
• 5 TF-CBT (55 agencies, more than 900 clinicians)
• 1 ARC (10 agencies, more than 100 clinicians)

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TN-TIES

• Tennessee Network for Trauma-Informed and
  Evidence-Based Systems (TN-TIES)
• 4-year grant from the National Child Traumatic
  Stress Initiative and the Substance Abuse and
  Mental Health Services Administration (SAMHSA)

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TN-TIES Goals

• Increase access and improve services among youth
  in foster care who have experienced trauma
• Help Tennessees child welfare system become more
  trauma informed

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Resource Parent Curriculum

• Caring for Children Who Have Experienced Trauma
  A Workshop for Resource Parents (www.nctsn.org)
• 16-hour workshop that teaches caregivers about
  trauma and the impact it has on the youth in
  their care

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Child Welfare Trauma Training Toolkit

• 14-hour curriculum that teaches child welfare
  workers about trauma and the impact it has on
  youth in the child welfare system (www.nctsn.org)
• Teaches the 7 essential elements of a
  trauma-informed child welfare system

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TN Infant Early Childhood Mental Health
Initiative

• Lack of trained workforce capacity to screen,
  assess, provide services for infants and young
  children in child welfare system (1/3 of children
  entering the system)
• TIECMHI (est. 2010) multi-agency/stakeholder
  grassroots collaboration lead by COEs

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Tennessee Breakthrough Series Collaborative

• Trauma-Informed Screening and Assessment of
  Infants and Young Children Breakthrough Series
  Collaborative (August 2014 June 2015)

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Tennessee BSC Goals

• Screening of DCS-involved infants young
  children (under age 5) for trauma exposure and
  trauma-related needs
• Parent included in process
• Results used in case planning
• Children families receive needed assessment
  treatment

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Intervention

• Early Identification Intervention
• Communication
• Supportive Services Assistance
• Educational Placement
• Medical Home
• Prevention of Victimization
• Prioritize Stability

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Evidence-Based Treatment (EBT) for Child Trauma

• nctsn.org
• Trauma-Focused Cognitive Behavioral Therapy
  (TF-CBT)
• Attachment, Self-Regulation, and Competency (ARC)
• Child-Parent Psychotherapy (CPP)

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Disabilities EBTs for Child Trauma

• Tailor to developmental level
• Prioritize safety security
• Emphasize attachment sensitive parenting
  practices