Title: Children with Special Health Care Needs, Child Maltreatment/Trauma
1Children with Special Health Care Needs, Child
Maltreatment/Trauma Foster Care A Statewide
Interagency Approach to Care and Capacity Building
2University 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.
3LEARNING 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
4Tri-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
5Development of COEs
- Collaboration of multiple stakeholders
- - University partners
- - Commissioners of Child Serving State
Departments - - Child Advocacy Organizations
- - TennCare (TNs managed Medicaid)
6Staff of UT COE
- Psychologists
- Psychiatrists
- Pediatrician
- Social Workers
- Speech Pathologist
- Training Coordinator
7CONTINUING COLLABORATIONS
- - Child Welfare
- - Community health and behavioral health
providers - - Schools
- TennCare
- State Departments
- Commission on Children and Youth
8COEs 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.
9Characteristics 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
10Referrals 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)
11Referrals - 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)
12Intellectual 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)
13Youth 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
14Pre 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
15Reporting 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
16Reporting Requirements
- Under 2010 Reauthorization of CAPTA
- A child is considered to have a disability based
on the definition used in IDEA
17Victims 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
18Disabilities 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
19Why at Higher Risk?
- Increased dependence/demands on caregivers
- Lack of personal safety abuse prevention
programs - Communication difficulties
- Susceptibility to manipulation
20Effects 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
21Maltreatment and the Developing Brain
22- Not only are people with developmental
disabilities more likely to be exposed to trauma,
but exposure to trauma makes developmental delays
more likely.
23- 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.
24PET 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
25(No Transcript)
26- 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
27- Experience in Adulthood.
- Alters the Organized Brain
- Experience in Childhood.
- Organizes the Developing Brain
28Neural 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
29What 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.
30Normal vs. Neglected Brain
As cited by Felitti Anda, 2003 source CDC
31Fight, 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.
32- 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.
33- 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
34- Under stress, traumatized childrens analytic
capacities disintegrate, and their emotional
reactions take over, resulting in uncontrolled
emotions and behavior
35Normal Stress Response
- All affective energy mobilized in the limbic
system (red). - Higher Cortical areas less active (blue).
36The 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
37Defining 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
38Defining the Problem in Tennessee
- Dearth of therapists trained to work with
families - Lack of evidence-based practice
39OPPORTUNITY KNOCKS
Governors Office of Child Care Coordination
40A 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
41Kaufman Report
- Best Practices
- Criteria for clinical utility
- Criteria for evidence supporting the efficacy of
the treatment - Criteria for transportability
- Science of Dissemination
42Large 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.
43Traditional Training Approach
- Single Training Event
- Passive Learning
- Individual Change
- Minimal Follow-up
- Minimal Accountability
- Minimal Consultation
44Learning 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
45Learning Collaborative Model of Dissemination
- Ongoing phone consultation coaching
- Model of Improvement
- Small Tests of Change
- Plan, Do, Study, Act
- Monthly metrics
46Dissemination 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)
47TN-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)
48TN-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
49Resource 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
50Child 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
51TN 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
52Tennessee Breakthrough Series Collaborative
- Trauma-Informed Screening and Assessment of
Infants and Young Children Breakthrough Series
Collaborative (August 2014 June 2015)
53Tennessee 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
54Intervention
- Early Identification Intervention
- Communication
- Supportive Services Assistance
- Educational Placement
- Medical Home
- Prevention of Victimization
- Prioritize Stability
55Evidence-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)
56Disabilities EBTs for Child Trauma
- Tailor to developmental level
- Prioritize safety security
- Emphasize attachment sensitive parenting
practices