TIC Report - 07 26 17texaschildrenscommission.gov/media/83503/trauma-informed-care-fi… · We...

Trauma-Informed Care

FINAL REPORT

July26,2017

Trauma-Informed Care Page i

Contents

ListofTables..........................................................................................................................iii

ExecutiveSummary................................................................................................................1

Purpose..................................................................................................................................4

OrganizationoftheReport.....................................................................................................4

BriefOverviewofTrauma-InformedCareLiteratureandResearch.........................................5

Introduction...............................................................................................................................5

WhatIsTrauma-InformedCare?................................................................................................5

TheHistoryofTrauma-InformedCare.......................................................................................6

HowIs“Trauma-InformedCare”Defined?................................................................................6

Evidence-BasedTrauma-InformedPractices.............................................................................9

Trauma-FocusedTraining.......................................................................................................9

Trauma-SpecificInterventionsinMentalHealth.................................................................10

Trauma-SpecificInterventionsinJuvenileJustice................................................................11

Trauma-SpecificInterventionsinChildWelfare..................................................................12

Trauma-SpecificInterventionsinSchools............................................................................14

Trauma-Informed,Cross-SystemCollaborationModels......................................................15

ALookatStateConsortiumsandCouncils...............................................................................16

StateResolutions..................................................................................................................18

WhatDoesTrauma-InformedCareLookLikeinTexas?..........................................................20

HowManyChildreninTexasHaveBeenAffectedbyTrauma?...............................................20

MethodologyforEstimatingPrevalence..............................................................................21

Trauma-InformedCareLegislationinTexas.............................................................................25

Trauma-InformedTraininginTexas.........................................................................................27

Trauma-InformedApproachesinTexas...................................................................................28

ChildTraumaAcademy–NeurosequentialModelofTherapeutics(NMT)andNeurosequentialModelofEducation(NME).......................................................................28

FosteringResilience–ReachingTeens©–Dr.KennethGinsburg........................................30

KarynPurvisInstituteofChildDevelopment–Trust-BasedRelationalIntervention(TBRI®)–Dr.KarynPurvisandDr.DavidCross....................................................................................32

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SummaryofKeyInformantInterviews....................................................................................34

HowTexasDefinesTrauma-InformedCare(TIC).................................................................34

HowTrauma-InformedCareIsOperationalized..................................................................37

WhatAretheBenefitsofTIC?..............................................................................................40

BarrierstoImplementation..................................................................................................40

SuccessfulCommunity-BasedCross-SystemEfforts.............................................................42

LocalMentalHealthAuthorities(LMHAs)TICEfforts..........................................................47

FundingTIC...............................................................................................................................50

Findings.................................................................................................................................55

AppendixOne:NationalEvidence-BasedPracticesRepositories............................................60

AppendixTwo:Trauma-InformedCareTraining....................................................................63

AppendixThree:KeyInformants...........................................................................................69

AppendixFour:Trauma-FocusedApproachesUtilizedbyKeyInformants..............................74

AppendixFive:Trauma-focusedApproachesUtilizedbyKeyInformants...............................78

AppendixSix:TravisCountyCollaborativeforChildren:DefiningaTrauma-InformedOrganization,Program,orSystem.........................................................................................80

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List of Tables Table1:ChildrenandYouthWhoHaveExperiencedThreeorMoreAdverseChildhoodExperiences..................................................................................................................................21Table2:ChildrenandYouthAnnualExposuretoViolence..........................................................22Table3:CharacteristicsofYouthAdmittedtotheTexasDepartmentofJuvenileJusticeinFY2015.............................................................................................................................................24Table4:ChildandYouthTraumaExposureAssessedThroughCANSFY2016............................25Table5:Trauma-InformedCareLegislationinTexas...................................................................26

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Executive Summary Thephilosophicalfoundation,keyassumptions,andprinciplesthatcomprisetheSubstanceAbuseandMentalHealthServicesAdministration’s(SAMHSA)trauma-informedcareapproachalignswiththoseofotherleadingbehavioralhealthandhealthcareorganizations.However,thereisnoconsensusonasingledefinitionof“trauma-informedcare.”Thisambiguityhasresultedinvariationsinhowtrauma-informedcareisoperationalizednationallyandstatewideandrisksthisdesignationhavinglittleornomeaning.TheMeadowsMentalHealthPolicyInstitute(MMHPI)examinedprevalenceestimates,reviewedliteratureandnationalbestpractices,andtalkedwithkeyinformantsinTexastodescribehowthestate’smajorchildservingagencieshaveoperationalizedtrauma-informedcareforchildrenandyouthinvolvedwiththechildwelfaresystem.PrevalenceestimatesofAdverseChildhoodExperiences(ACE)amongchildrenandyouthinthemajorchild-servingsystemsinTexasunderscoretheneedforthesesystemstobeadeptatidentifying,understanding,andtreatingtrauma.

• Statewide,approximately730,000childrenandyouth,or1in10children/youthoverall,haveexperiencedthreeormoreACEs.

• Forchildrenandyouthage0–17,nearly90,000havebeenexposedto10ormoreepisodesofviolence.

• AmongyouthinvolvedwithinthejuvenilejusticesysteminTexas,5,900haveexperiencedfourormoreACEs.

• AmongallchildrenandyouthlivinginfostercareinthestateofTexas,approximately24,300haveexperiencedoneormoreACEs.

• AmongchildrenandyouthenrolledinserviceswiththeLMHA,7,700(or19%)childrenandyouthhaveexperiencedatraumaticlifeevent;nearlyhalfoftheseindividualsshowedevidencethatthetraumaticexperiencewasimpactingoneormorelifedomains.

Inrecognitionofthisneed,Texaslawmakersandmajorchild-servingagencieshavetakeninitialstepstowardstransformingthestate’ssystems.Legislativemandatesrequirechildwelfare,juvenilejustice,andstatehospitalstafftotrainprofessionals,staff,andcaregiversinunderstandingtheeffectsoftrauma.Childwelfareandjuvenilejusticehavedevelopedandareimplementingsystem-widetraining.Additionallegislationrequiresthatallchildrenandyouthenteringthechildwelfaresystemarescreenedfortrauma.Likewise,effortsinmentalhealthhavekeptpacewiththoseinjuvenilejusticeandchildwelfare,ensuringchildrenandyoutharescreenedandagencystaffaretrainedtorecognize,understand,andtreattrauma.Inadditiontotrainingandscreening,mostorganizationsservingchildrenandyouthprovideatleastsometrauma-focused,evidence-basedtherapeuticapproaches.

Areviewofthetrauma-informedlandscapeinTexasrevealedgrassrootsandformaleffortstoshapetrauma-informedcareatagencyandcommunitylevels.Theseefforts,tovaryingdegrees,useSAMHSA’ssixguidingprinciplesandimplementationdomainstodriveorganizationalandsystematicchange.Thetwocommunityeffortswiththelargestreachusetrauma-focused,evidence-informedapproachestopromotecommonlanguage.Keystakeholdersattributetheirsuccesstowide-spreadcross-systemtrainingontraumaandtrauma-informedcareapproaches,supportfromleadership,anidentifiedtrauma-champion,andexternalresourcesandphilanthropicsupport.Thesesameindividualsidentifiedlimitedresources,regulatorystandards,andstafftraumaasbeingmajorbarrierstodevelopingatrauma-informedsystem.Keyinformantsstressedthatprovidingtrauma-informedcarerequiresorganizationalchangeatmultiplelevelsandfundingstructuresthatsupporttheprinciplesunderlyingthisapproach.Traditionalstatefundingstructuresallowfortheprovisionofevidence-basedtraumascreening,assessment,treatment,andrecoverysupports.However,theydonotsupportthedevelopmentofappropriateandsafefacilities;theprovisionofpeersupportforprofessionals,staff,andcaregivers;thedevelopmentandimplementationoforganization-widetraumatraining;thetrainingandimplementationoftrauma-informedcommunicationstrategiesandcaregivermodels;thedevelopmentofcross-agencycollaborations;andtheevaluationoftrauma-informedprogramsandservices.Thefollowingisasummaryofthefindingsthatresultedfromthislookattrauma-informedcareforchildren,youth,andfamiliesinthechildwelfare,juvenilejustice,andmentalhealthsystems.

• Child-servingsystemsaretrainingstaffontrauma-informedcare.• Despitetheavailabilityoftrainingthataddressesunderstandingandtreatingtrauma,

thereisstillanexpressedneedtotrainchildwelfarestaffandfosterparents.• Themainchild-servingsystemsinthestateofTexashavetakensomestepstowards

becomingtrauma-informed.• Theprimarycross-systemtrauma-informedapproachesbeingimplementedinTexasare

basedonthe“AdverseChildhoodExperience”researchandaregroundedinthesametrauma-informedframework.

• ReachingTeensãandTrust-BasedRelationalIntervention(TBRIâ)provideaphilosophicalframework,sharedlanguage,andcommonsetofapproachesthatallowprovidersinacommunitytooperationalizetheconceptoftrauma-informedcare.Thesetwoapproachesareeasytounderstandandcanbeimplementedbyalargecross-sectionofprofessionals,parents,andfosterparents.

• Inadditiontoasharedapproach,successfultrauma-informedcross-systemeffortsinTexasallhaveanexternalfunderandacommunitychampion.

• Thelocalmentalhealthauthorities(LMHAs)areconstrainedtoacoresetoftrauma-focusedinterventionsthatlimitLMHAabilitytoselectaninterventionbasedonthechild’soryouth’straumahistory,needs,orbraindevelopment.

• Medicaid(StarHealth)paysfortraditionaloffice-basedtrauma-informedservicesandsupports,andSTARHealthprovidestraininginTrauma-FocusedCognitiveBehavioralTherapy(TF-CBT)andParentChildInteractionTherapy(PCIT).However,providersstillidentifiedfundingasabarriertoexpandingTrauma-FocusedEvidence-BasedTreatment(TF-EBT)capacity.

Purpose Mostchildrenandyouthinthechildwelfaresystemareimpactedbytrauma.Formany,theseexperiencesleadtobehaviorsthataremisunderstoodandmisdiagnosed,resultingindisruptionsincare,suspensionorexpulsionfromschool,orjuvenilejusticeinvolvement.Tobettersupportthesechildrenandyouth,itisnecessarytounderstandtrauma,itsmanifestations,andhowtodelivercareinawaythatbuildsrelationships,fostershope,andpromotesresilienceandsuccess.Asasteptowardthisgoal,theMeadowsMentalHealthPolicyInstitute(MMHPI)partneredwiththeSupremeCourtofTexasChildren’sCommissiontosupporttheChildWelfareTraumaConsortiuminunderstandingandaddressingtheneedsofchildreninfostercarewithmentalhealthconditions,particularlyinrelationtoexposuretotraumaandinunderstandingtrauma-informedcare(TIC).Organization of the Report Inthefirstsectionsofthisreport,weexaminethenationalTIClandscapetoprovidecontextforunderstandingTICeffortsinTexas.WereviewcommonlyciteddefinitionsofTICandhighlightsharedcorecomponents.Weprovideanoverviewofnationaltrauma-informedbestpracticesforavarietyofindividualswhointeractwithchildrenandyouthinthechildwelfaresystem.Inaddition,weprovideareviewofseveralsuccessfulstatewidesystem-levelTICinitiatives.Thelatersectionsofthisreportdescribetrauma-informedinitiativesandeffortsinthestateofTexas.First,weidentifykeytrauma-informedplayersinTexasanddiscusstheirapproaches,reach,andimplementationefforts.Ourresearchutilizedinformationgainedfrom75keyinformantinterviewstounderstandhowprovidersdefineandoperationalizeTICinTexasandtodiscussthebarrierstheyhaveencountered.Wealsofocusonthelocalmentalhealthauthorities(LMHAs)andtheirroleinservingchildrenandyouthwhohaveexperiencedtrauma.Finally,weprovideanoverviewofTexasMedicaidanddiscussfundingbarriersrelatedtothedeliveryofTIC.Inthefinalsectionofthisreport,wesummarizeourfindingsandhighlightareasfortheChildren’sCommissionPlanningWorkGrouptoconsiderwhensupportingTICeffortsinTexas.

Brief Overview of Trauma-Informed Care Literature and Research Introduction

UnderstandingandrecognizingtheprevalenceofAdverseChildhoodExperiences(ACE)shelpstorecognizeandtreattrauma.ACEsaretraumaticorstressfuleventsthattakeplaceinchildhoodandcanpotentiallyhaveenduringanddamagingeffectsonachild’shealthandwell-being.Theycanaffectchildrenandyouthofallbackgrounds,economicclasses,andgeographiclocations.1Furthermore,ACEscomeinmanyforms,includingeconomichardship,abuseandneglect,neighborhoodviolenceordomesticviolence,growingupwithaparentwhohasamentalillnessorasubstanceusedisorder,incarcerationofaparent,orparentaldivorce.Nationally,economichardshipisthemostcommonlyreportedACE.2AchildwhohasexperiencedACEsismorelikelytoexperiencelearningorbehavioralissuesandtodevelopawiderangeofhealthproblemsincludingobesity,alcoholism,anddruguse.TheoriginalstudyonACEswasconductedbyKaiserPermanenteandtheCentersforDiseaseControlandPrevention(CDC)from1995to1997.Over17,000healthmaintenanceorganization(HMO)memberscompletedsurveysontheirchildhoodexperiencesandcurrenthealthstatusandbehaviors.ThestudyfoundthatACEsarecommon,anditidentifiedanassociationbetweenthenumberofACEsanindividualsexperiencedandsocialandhealthproblemstheyreportedhavinglaterinlife.3What Is Trauma-Informed Care?

Atrauma-informedapproachacknowledgestheprevalenceandimpactoftraumaandattemptstocreateasenseofsafetyforallpersons,whetherornottheyhaveexperiencedtrauma.Becomingtrauma-informedrequiresare-examinationofpoliciesandproceduresthatmayresultinparticipantsfeelingalossofcontrol,trainingstafftobewelcomingandnon-judgmental,andmodifyingphysicalenvironments.Becomingtrauma-informedalsoinvolvesminimizingperceivedthreats,avoidingre-traumatization,andsupportingrecovery.

1AmericanAcademyofPediatrics(2014).Adversechildhoodexperiencesandthelifelongconsequencesoftrauma.https://www.aap.org/en-us/Documents/ttb_aces_consequences.pdf2Sacks,V.,Murphy,D.,&Moore,K.(2014).ResearchBrief-Adversechildhoodexperiences:Nationalandstatelevelprevalence.ChildTrends.Publication#2014-283CentersforDiseaseControlandPrevention.(2016,March).Adversechildhoodexperiences(ACEs).Retrievedfromhttps://www.cdc.gov/violenceprevention/acestudy/.

The History of Trauma-Informed Care

TheNationalAssociationofSocialWorkers(NASW)providesanoverviewoftheeventsthatformedthefoundationforandinfluencedtheframeworkofwhatisnowknownastrauma-informedcare(TIC).4Theseeventsincludethefollowing:

• Thedomesticviolenceandrapecrisismovementofthe1970sandchildadvocacycentersandmultidisciplinaryteamresponsetochildabuseinthe1980sgaveavoicetovictimsofinterpersonalviolence.

• TheformationoftheInternationalSocietyofTraumaticStressStudies(ISTSS)in1985servedasaresourceforprofessionalstreatinghighlytraumatizedpopulations.

• Theinvestigationofthehighprevalenceofphysicalandsexualabuseamongwomenservedbythepublicmentalhealthsystemhighlightedthevictimizationmanywomenexperiencedwhenseekingmentalhealthservices.

• The1998WomenandCo-OccurringDisordersandViolenceStudyencouragedproviderstodeliverservicesinamannerthatdidnotaddtrauma,unnecessarilytriggermemoriesofpasttraumaticevents,orplaceawomaninaphysicallyorpsychologicallydangeroussituation.

• TheNationalChildTraumaticStressNetwork(NCTSN)wasestablishedbyCongressin2000aspartoftheChildren’sHealthActtoidentifyandpromotetheuseofevidence-based,trauma-specificmentalhealthinterventionswithchildrenandtheirfamilies.

• TheNCTSNcreatedtheSystemIntegrationCommitteein2005inrecognitionofthefactthatsystemissuesunderminetheeffectivenessoftrauma-specificinterventions.

How Is “Trauma-Informed Care” Defined?

“Trauma”isdefinedsomewhatdifferentlyacrossdisciplines.However,themostcommonlyreferenceddefinitioncomesfromtheSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA):

Individualtraumaresultsfromanevent,seriesofevents,orsetofcircumstancesthatisexperiencedbyanindividualasphysicallyoremotionallyharmfulorlifethreateningandthathaslastingadverseeffectsontheindividual’sfunctioningandmental,physical,social,emotional,orspiritualwell-being.(p.7)5

4NationalAssociationofSocialWorkersandOxfordUniversityPress(2013).EncyclopediaofSocialWork:TraumaInformedCare.Retrievedfromhttp://socialwork.oxfordre.com/view/10.1093/acrefore/9780199975839.001.0001/acrefore-9780199975839-e-10635SubstanceAbuseandMentalHealthServicesAdministration.(2014,July).SAMHSA’sconceptoftraumaandguidanceforatrauma-informedapproach.HHSPublicationNo.(SMA)14-4884.Rockville,MD:SubstanceAbuseandMentalHealthServicesAdministration.Retrievedfromhttps://store.samhsa.gov/shin/content//SMA14-4884/SMA14-4884.pdf

Theterms“trauma-informedcare”,“trauma-informedapproach,”and“trauma-informedsystem”areoftenusedinterchangeablytodescribehowcareisdeliveredatanorganizationalorsystemlevel.TICcanbeimplementedinanyservicesettingororganizationanddiffersfromatrauma-specificinterventionortrauma-focusedtreatmentthatisdesignedspecificallytoaddresstheconsequencesoftrauma.AreviewoftheliteraturerevealsseveraldefinitionsforTICandlittleconsensusonasingleone.Thisambiguityleavesproviders,organizations,andsystemstointerprethowtooperationalizetheconcept.Ingeneral,thereisafairlylowbarforsomethingtobeconsidered“trauma-informed,”anddefinitionscenteronaphilosophicalfoundationthatTICispresentwhentheawarenessthattraumaexistsiscombinedwithanunderstandingoftrauma.Asaresult,thereisoftenlittlemeaningbehindanorganization’sdesignationas“trauma-informed.”Hopper,Bassuk,andOlivet6summarizedthebasicprinciplesofTICdefinitionsandidentifiedfourcross-cuttingthemes:

• Traumaawareness:Stafftraining,consultation,andmodificationsinorganizationalpracticesreflectanunderstandingoftraumaandthevariousbehaviorsandsymptomsthatrepresentadaptationstotrauma.

• Emphasisonsafety:Organizationaloperationsensurethatconsumersarephysicallyandemotionallysafe,potentialtriggersandre-traumatizationareavoided,andclearrolesandboundariesaredefined.

• Opportunitiestorebuildcontrol:Trauma-informedservicesemphasizetheimportanceofchoiceandbuildasenseofefficacyandpersonalcontrol.

• Strength-basedapproach:TICisstrength-basedandfuture-oriented;itutilizesskill-buildingtodevelopresiliency.

Basedonthesecombinedprinciples,Hopperetal.offerthefollowingconsensus-baseddefinitionofTIC:

Trauma-InformedCareisastrengths-basedframeworkthatisgroundedinanunderstandingofresponsivenesstotheimpactoftrauma,thatemphasizesphysical,psychological,andemotionalsafetyforbothprovidersandsurvivors,andthatcreatesopportunitiesforsurvivorstorebuildasenseofcontrolandempowerment.(p.82)7

TheNCTSNdefinesatrauma-informedchildandfamilyservicessystemasfollows:

Atrauma-informedchild-andfamily-servicesystemisoneinwhichallpartiesinvolvedrecognizeandrespondtotheimpactoftraumaticstressonthosewhohavecontact

6Hopper,E.K.,Bassuk,E.L.,&Olivet,J.,(2010).Shelterfromthestorm:Trauma-informedcareinhomelessservicesettings.TheOpenHealthServicesandPolicyJournal,3,80-100.7Hopper,E.K.,Bassuk,E.L.,&Olivet,J.,(2010).Shelterfromthestorm:Trauma-informedcareinhomelessservicesettings.TheOpenHealthServicesandPolicyJournal,3,82.

withthesystemincludingchildren,caregivers,andserviceproviders.Programsandagencieswithinsuchasysteminfuseandsustaintraumaawareness,knowledge,andskillsintotheirorganizationalcultures,practices,andpolicies.Theyactincollaborationwithallthosewhoareinvolvedwiththechild,usingthebestavailablescience,tomaximizephysicalandpsychologicalsafety,facilitatetherecoveryofthechildandfamily,andsupporttheirabilitytothrive.8

SAMHSAdefinesTICasanapproachtothedeliveryofbehavioralhealthservicesthat

includesanunderstandingoftraumaandanawarenessoftheimpactitcanhaveacrosssettings,services,andpopulations.Itinvolvesviewingtraumathroughanecologicalandculturallensandrecognizingthatcontextplaysasignificantroleinhowindividualsperceiveandprocesstraumaticevents,whetheracuteorchronic.(p.xix)9

SAMHSAutilizesthe“FourRs”todescribethefourelementsthatarenecessaryinatrauma-informedapproach:

Aprogram,organization,orsystemthatistrauma-informed…realizesthewidespreadimpactoftraumaandunderstandspotentialpathsforrecovery;recognizesthesignsandsymptomsoftraumainclients,families,staff,andothersinvolvedwiththesystem;respondsbyfullyintegratingknowledgeabouttraumaintopolicies,procedures,andpractices;andseekstoactivelyresistre-traumatization.(p.33)10

Inaddition,SAMHSAstatesthatatrauma-informedapproachadherestoakeysetofsixprinciplesratherthanasetofpoliciesandprocedures.11TheseprinciplesappeartobuildonHopper,Bassuk,andOlivet’swork:

• Safety• Trustworthinessandtransparency• Peersupport• Collaborationandmutuality• Empowerment,voice,andchoice• Cultural,historical,andgenderissues

8TheNationalChildTraumaticStressNetwork.(n.d.)Creatingtrauma-informedsystems.Retrievedfromhttp://www.nctsn.org/resources/topics/creating-trauma-informed-systems9SubstanceAbuseandMentalHealthServicesAdministration.(2014).Trauma-InformedCareinBehavioralHealthServices.TreatmentImprovementProtocol(TIP)Series57.HHSPublicationNo.(SMA)13-4801.Rockville,MD:SubstanceAbuseandMentalHealthServicesAdministration.Retrievedfromhttps://store.samhsa.gov/shin/content/SMA14-4816/SMA14-4816.pdf10Flatow,R.B.,Blake,M.,&Huang,L.N.,(2015).SAMHSA’sconceptoftraumaandguidanceforatrauma-informedapproachinyouthsettings.FocalPoint:Youth,YoungAdults,&MentalHealth.Trauma-InformedCare,29–35.Retrievedfromhttps://www.pathwaysrtc.pdx.edu/pdf/fpS1510.pdf11SubstanceAbuseandMentalHealthServicesAdministration.(n.d.)Trauma-informedapproachandtrauma-specificinterventions.Retrievedfromhttps://www.samhsa.gov/nctic/trauma-interventions

TheCenterforHealthCareStrategies(CHCS)statesthatTICmustinvolveorganizationalandclinicalpracticesthatrecognizetheimpactoftraumaonboththeproviderandthepatient.12

CHCSstressesthat,inordertobetrauma-informed,anorganizationmustinitiatewidespreadtrauma-informedorganizationalchangethatincludeschangestocultureandpolicy.Thesechangesformthefoundationforthedeliveryoftrauma-specifictreatment.Evidence-Based Trauma-Informed Practices

DespitethefactthatthereisnosingledefinitionfortraumaorTIC,therearemanyevidence-based,trauma-specificortrauma-focusedapproachesavailabletoworkwithwhenprovidingservicestochildren,youth,andtheirfamiliesinthevariouschild-servingsystems.Severaloftheseapproachesandinterventionsarelistedinthisreport.Thisisnotanexhaustivelist.Furtherinformationontheapproachesmentionedbelowandonadditionalevidence-basedpracticescanbefoundbyaccessingthewebsitesfortheNCTSN,13theNationalRegistryofEvidence-BasedProgramsandPractices(NREPP),14andtheCaliforniaEvidence-BasedClearinghouseforChildWelfare(CEBC).15SeeAppendixOneforanoverviewNREPPandCEBC.Trauma-FocusedTrainingTrauma-focusedinterventionsaremosteffectivewhentheyareimplementedwithinandthroughoutanorganizationsothatapproachesbecomeingrainedinthecultureofanorganizationandthateverypersonwhocomesincontactwithachildoryouthunderstandstheimpactoftraumaandcanrespondtotraumaticstresssymptomsinasupportivemanner.BelowisasampleofcurriculadevelopedbytheNCTSNaswellasadditionalpromisingtraumamodelsandtools.16ChildWelfareCaseworkers

• ChildWelfareTraumaTrainingToolkit(ChildWelfareCollaborativeGroup,NCTSN,andtheCaliforniaSocialWorkEducationCenter,2013)17

12Menschner,C.,&Maul,A.,(2016).Issuebrief:Keyingredientsforsuccessfultrauma-informedcareimplementation.AdvancingTrauma-InformedCare.CenterforHealthCareStrategies,Inc.Retrievedfromwww.chcs.org13NationalChildren’sTraumaticStressNetwork(NCTSN).http://www.nctsn.org/14NationalRegistryofEvidence-basedProgramsandPractices(NREPP).https://www.samhsa.gov/nrepp.15CaliforniaEvidence-BasedClearinghouseforChildWelfare(CEBC).http://www.cebc4cw.org/16Olafson,E.,HalladayGoldman,J.,Gonzalez,C.(2016).Trauma-informedcollaborationsamongjuvenilejusticeandotherchild-servingsystems:Anupdate.OJJDPJournalofJuvenileJustice.(5)1.Retrievedfromhttp://www.journalofjuvjustice.org/JOJJ0501/article01.htm17ChildWelfareCollaborativeGroup,NationalChildTraumaticStressNetwork,CaliforniaSocialWorkEducationCenter.(2013).Childwelfaretraumatrainingtoolkit:Trainer’sguide(2nded.).LosAngeles,CA&Durham,NC:NationalCenterforChildTraumaticStress.

ResidentialTreatmentStaff,ProbationOfficers,CourtPersonnel

• ThinkTrauma:AFour-ModuleTraumaMilieuTraining(Marrow,Benamati,Decker,Griffing,&Lott,2012)18

• Cops,Kids,andDomesticViolence(NCTSN,2006)19• TenThingsEveryJuvenileCourtJudgeShouldKnowAboutTraumaandDelinquency

(Buffington,Dierkhising,&Marsh,2010)20• NCTSNBenchCardfortheTrauma-InformedJudge(NCTSNJusticeConsortiumand

NationalCouncilofJuvenileandFamilyCourtJudges,2013)21FosterFamilies

• CaringforChildrenWhoHaveExperiencedTrauma:AWorkshopforResourceParents(NCTSN,2010).22Thistrainingwasco-createdbyNCTSNexpertsandexperiencedfosterparents.Itcombinestraumaknowledgeandpeersupportwithopportunitiestoapplythatknowledgetoachildinthecaregiver’shome.

Educators

• ChildTraumaToolkitforEducators(NCTSNSchoolsCommittee,2008)23Trauma-SpecificInterventionsinMentalHealth24,25,26

Thetrauma-specific,evidence-basedorevidence-informedtherapeuticapproachesmostcommonlymentionedintheliteraturefortreatingchildren,youth,andtheirfamiliesarethefollowing:

18Marrow,M.,Benamati,J.,Decker,K.,Griffin,D.,Lott,D.A.(2012).Thinkingtrauma:Atrainingforstaffinjuvenilejusticeresidentialsettings.LosAngeles,CA&Durham,NC:NationalCenterforChildTraumaticStress.19NationalChildTraumaticStressNetwork(2006).Cops,Kids&Domesticviolence:Protectingourfuture(DVD).LosAngeles,CA&Durham,NC:NationalCenterforChildTraumaticStress.20Buffington,K.,Dierkhising,C.B.,Marsh,S.C.(2010).Tenthingseveryjuvenilecourtjudgeshouldknowabouttraumaanddelinquency.Retrievedfromhttp://www.ncjfcj.org/sites/default/files/trauma%20bulletin_1.pdf21NationalChildTraumaticStressNetwork,JusticeConsortium&NationalCouncilforJuvenileandFamilyCourtJudges.(2013).NCTSNbenchcardforthetrauma-informedjudge.Retrievedfromhttp://www.nctsn.org/sites/default/files/assets/pdfs/judge_bench_cards_final.pdf22NationalChildTraumaticStressNetwork.(2010).Caringforchildrenwhohaveexperiencedtrauma:Aworkshopforresourceparents.Retrievedfromhttp://nctsn.org/nctsn_assets/pdfs/rpc/RPCParticipantHandbookFINAL.pdf23NationalChildTraumaticStressNetworkSchoolsCommittee.(2008).Childtraumatoolkitforeducators.LosAngeles,CA&Durham,NC:NationalCenterforChildTraumaticStress.Retrievedfromhttps://wmich.edu/sites/default/files/attachments/u57/2013/child-trauma-toolkit.pdf24DeArellano,M.A.,Ko,S.J.,&Sprague,C.M.(2008).Trauma-informedinterventions:Clinicalandresearchevidenceandculture-specificinformationproject.LosAngeles,CA&Durham,NC:NationalCenterforChildTraumaticStress.25NationalChildTraumaticStressNetwork.TreatmentsthatWork.Retrievedfromhttp://www.nctsn.org/resources/topics/treatments-that-work/promising-practices#q426ChildTraumaAcademy.(n.d.).NMT.Retrievedfromhttp://childtrauma.org/nmt-model/

• Attachment,Self-Regulation,andCompetency(ARC):AComprehensiveFrameworkforInterventionwithComplexlyTraumatizedYouth

• CognitiveBehavioralTherapyApproaches(CBT)- Trauma-FocusedCognitiveBehavioralTherapy(TF-CBT)- CombinedParentChildCognitiveBehavioralApproachforChildrenandFamiliesAt-

RiskforChildPhysicalAbuse(CPC-CBT)- AlternativesforFamilies-CognitiveBehavioralTherapy(AF-CBT)

• DialecticalBehavioralTherapy(DBT)- AdaptedDialecticalBehavioralTherapyforSpecialPopulations(DBT-SP)

• EyeMovementDesensitizationandReprocessing(EMDR)-ChildandAdolescent• Parent-ChildInteractionTherapy(PCIT)• ProlongedExposureTherapyforAdolescents(PE-A)• NeurosequentialModelofTherapy(NMT)• StructuredPsychotherapyforAdolescentsRespondingtoChronicStress(SPARCS)• TraumaAffectRegulationGuidelineforEducationandTherapyforAdolescents

(TARGET-A)• TraumaandGriefComponentTherapyforAdolescents(TGCT)

Trauma-SpecificInterventionsinJuvenileJusticeProbationofficersandjuvenilejusticestaffarenotmentalhealthprofessionals.Theydonotneedtoknowhowtoimplementtrauma-specifictreatmentapproaches.However,itisimportantthattheyunderstandhowtraumaimpactsbehaviors,aretrainedtodeterminetheneedsofayouth,andidentifytheservicesandsupportsrequiredtomeettheseneeds.Probationofficersandjuvenilejusticestaffmusthaveaccesstoacomprehensivecontinuumofcarethatincludesevidence-based,trauma-specifictreatmentseffectivewithyouthinthejuvenilejusticesystem.27Ford,Kerig,Desai,andFeirmanidentifiedfourevidence-basedpsychosocialinterventionsthathavebeenproventobeeffectivewiththejuvenilejusticepopulation.28

• CognitiveProcessingTherapy(CPT)• TraumaAffectRegulation:GuideforEducationandTherapy(TARGET)• TraumaandGriefComponentsTherapyforAdolescents(TGCTA)• Trauma-AdaptedMultidimensionalTreatmentFosterCare(TA-MTFC)

27NationalCenterforMentalHealthandJuvenileJusticePolicyResearchAssociates.(2015).Strengtheningourfuture:Keyelementstodevelopingatrauma-informedjuvenilejusticediversionprogramforyouthwithbehavioralhealthconditions.Retrievedfromhttps://www.ncmhjj.com/wp-content/uploads/2015/12/Strengthening-Our-Future.pdf28Ford,J.D.,Kerig,P.K.,Desai,N.,&Feierman,J.(2016).Psychosocialinterventionsfortraumatizedyouthinthejuvenilejusticesystem:Research,evidencebase,andclinical/legalchallenges.OJJDPJournalofJuvenileJustices.(5),1.

Twoadditionalmodelsthatsupportatrauma-informedcareenvironmentinjuvenilejusticediversionandsupervisionpracticesareidentifiedinStrengtheningOurFuture.29T4(TARGET1,2,3,4)isafour-stepshortcuttotheTARGETtraining.Itprovidesconcretetoolsthathelpyouthandstaffachieveoptimalpersonalcontrol.TheSanctuaryModelisawhole-organizationalmodelofserviceandcare.Itwasoriginallydesignedforanacuteinpatientpsychiatricpopulationofadultswhohadbeentraumatizedaschildren.Ithasbeenadaptedtocoveravarietyofpopulations,includingchildrenandyouth.Trauma-SpecificInterventionsinChildWelfare30,31,32,33

Manypeopletouchthelivesofchildrenandyouthwhoareinvolvedinthechildwelfaresystem.Theseincludejudges,lawyers,childprotectiveservice(CPS)workers,CourtAppointedSpecialAdvocates(CASAs),mentalhealthandprimarycareproviders,biologicalparents,relatives,andfosterparents.Theseindividualsneedtounderstandwhattraumais,recognizesignsandsymptoms,knowhowtotreatit,andcreateopportunitiesforchildrenandyouthwhohaveexperiencedtraumatofeelsafeandempowered.Thereareseveralevidence-basedinterventions,evidence-informedapproaches,tools,andsourcesofinformationtohelpindividualswhoprovideservicesandsupportstochildrenandyouthinvolvedinthechildwelfaresystemandtheirfamilies.TherapeuticInterventionsforMentalHealthProfessionals

Thefollowingapproacheswerefoundtobeeffective,specificallywithchildrenandyouthinvolvedinthechildwelfaresystem,andsupplementthetherapeuticapproachesmentionedabove.

• AttachmentandBiobehavioralCatch-Up(ABC)• ChildandFamilyTraumaticStressIntervention• RealLifeHeroes:Resiliency-FocusedTreatmentforChildrenwithTraumaticStress(RLH)• TreatmentFosterCareOregon(TFCO-A)EducationalInterventionforChildreninFoster

29StrengtheningOurFuture.(2015).Strengtheningourfuture:Keyelementstodevelopingatrauma-informedjuvenilejusticediversionprogramforyouthwithbehavioralhealthconditions.Retrievedfromhttps://www.ncmhjj.com/wp-content/uploads/2016/01/traumadoc012216-reduced-003.pdf30NationalChildTraumaticStressNetwork.(n.d.).Treatmentsthatwork.Retrievedfromhttp://www.nctsn.org/resources/topics/treatments-that-work/promising-practices#q431CaliforniaEvidence-BasedClearinghouseforChildWelfare.(n.d.).TreatmentFosterCareOregon.Retrievedfromhttp://www.cebc4cw.org/program/32CircleofSecurityInternational.ForParents.Retrievedfromhttps://www.circleofsecurityinternational.com/for-parents33FosteringResilience:Preparingchildrenandteenstothrivethroughbothgoodandchallengingtimes.(n.d.).Retrievedfromhttp://www.fosteringresilience.com/professionals/

InterventionsforFoster,Kinship,andBiologicalParents

• Trauma-InformedPSMAPP(TIPS-MAPP)• Trust-basedRelationalIntervention(TBRI®)• KEEP(KeepingFosterandKinParentsSupportedandTrained)• CircleofSecurity-Parents(COS-P)• ReachingTeens©:Strength-BasedCommunicationStrategiestoBuildResilienceand

SupportHealthyAdolescentDevelopmentInterventionforCaseworkers

Thefollowingapproachesareinadditiontotheinterventionslistedforparents.• Child-AdultRelationshipEnhancement(CARE):AdaptationofParentChildInteraction

Therapy(PCIT)• Wraparound

Trauma-InformedResourcesInformationforJudges,Attorneys,andCASAsTherearenospecifictrauma-focusedinterventionsorapproachesforjudges.However,theNCTSNrecommendsthatcourtsbecometrauma-informedatalllevels.Theintentistomakethecourtasafeenvironmentthatdoesnotincreasethetraumaexperiencedbythechild,youth,orparentsandthatdoesprovideopportunitiestolearntoolstocopewithtraumaticstressreactions.Inaddition,courtscanscreenfortrauma,referfornecessarytraumaassessments,andrefertoprovidersthatusetrauma-focusedapproaches.Courtsareencouragedtotakealeadershiproleinincreasingsystem-wideawarenessoftrauma,developingcommunitycapacitytodelivertrauma-focusedapproaches,andfosteringpartnershipsamongyouth,families,professionals,andstakeholders.Thefollowingtoolwasidentifiedaseffectiveinassistingattorneysandothercourt-appointedadvocatesinincorporatingtraumaknowledgeintotheirdailypractices.Itisnotintendedtobeascreeningtool.Itisdesignedtohelpadvocatesidentifytraumaexperiencesandsymptomsoftraumaandidentifybeneficialservices.34

• IdentifyingPolyvictimizationandTraumaAmongCourt-InvolvedChildrenandYouth:AChecklistandResourceGuideforAttorneysandOtherCourt-AppointedAdvocates.35

34Klain,E.J.,&White,A.R.,(2013).Implementingtrauma-informedpracticesinchildwelfare.Retrievedfromhttp://www.centerforchildwelfare.org/kb/TraumaInformedCare/ImplementingTraumaInformedPracticesNov13.pdf35Pilnik,L.,&Kendall,J.R.(2012).Identifyingpolyvictimizationandtraumaamongcourt-involvedchildrenandyouth:Achecklistforattorneysandothercourt-appointedadvocates.NorthBethesda,MD:SafeStartCenter,OfficeofJuvenileJusticeandDelinquencyPrevention,Programs,U.S.DepartmentofJustice.Retrievedfromhttps://www.ojjdp.gov/programs/safestart/IdentifyingPolyvictimization.pdf

KlainandWhiteidentifyfivetrauma-informedpracticerecommendationsforchildwelfaresystems,courts,advocates,andstaff:36

• Educatestakeholdersabouttheeffectsoftraumaonchildrenandfamiliesaswellaseffectivetrauma-specifictreatments.

• Ensurechildrenenteringthechildwelfaresystemarescreenedandassessedfortrauma.• Referchildrentoappropriateevidence-based,trauma-specifictreatment.• Provideinformationandtrauma-relatedservicestobirthfamiliesandcaregivers.• Encouragestakeholderstocollaboratetoformacohesive,integratedcommunity

approachtoaddressingtrauma.Trauma-SpecificInterventionsinSchools37,38,39

Socialandemotionallearning(SEL)isaprocessthroughwhichastudentacquiresandappliestheknowledgeandskillsnecessarytounderstandandmanageemotions,setandachievegoals,feelandshowempathy,anddeveloppositiverelationships.40TICandSELshareinterrelatedcharacteristicsthat,whenusedintandem,helpchildrenandyouthwhohaveexperiencedtraumasucceedinschool.BlodgettandDoradobelievethatthesocialandemotionalskillsofachildoryouthwhohasexperiencedtraumawilldevelopnaturallywhentrauma-sensitiveeducationalpracticesareutilized.Despitethisalignment,therearenostandardpracticesforintegratingtrauma-informedortrauma-sensitivecareandSELinschools.Thereareseveralevidence-basedandevidenced-informedschool-basedinterventionsidentifiedintheliterature.Theseinterventionsareeffectivewithchildrenandyouthwhohaveexperiencedabuseandneglect,exceptforPsychologicalFirstAid(PFA).PFAforschoolsisdesignedtoassistchildren,youth,andtheirfamiliesintheaftermathofdisasterorterrorism.Structured,MentalHealth-Focused,Student-Centered,andTrauma-Specific

• CognitiveBehavioralInterventionforTraumainSchools(CBITS)isaschool-basedprogramdesignedtoreducethesymptomsofpost-traumaticstressdisorder,depression,andgeneralanxietyamongchildrenexposedtomultipleformsoftrauma

• MultimodalityTraumaTreatment(MMTT),alsoknownasTrauma-FocusedCopinginSchools

36Klain,E.J.,&White,A.R.,(2013).Implementingtrauma-informedpracticesinchildwelfare.Retrievedfromhttp://www.centerforchildwelfare.org/kb/TraumaInformedCare/ImplementingTraumaInformedPracticesNov13.pdf37NationalChildTraumaticStressNetwork.TreatmentsthatWork.38ChildTraumaAcademy.NME.39Blodgett,C.,&Dorado,J.(n.d.).CLEARtrauma-informedschoolswhitepaper:Aselectreviewoftrauma-informedschoolpracticeandalignmentwitheducationalpractices.Retrievedfromhttp://ext100.wsu.edu/cafru/wp-content/uploads/sites/65/2015/02/CLEAR-Trauma-Informed-Schools-White-Paper.pdf40CASEL:EducatingHearts.InspiringMinds.(n.d.).WhatisSEL.Retrievedfromhttp://www.casel.org/what-is-sel/

Structured,Population-Focused,Trauma-informed,System-Centered

• CollaborativeLearningforEducationalAchievementandResilience(CLEAR)• HealthyEnvironmentsandResponsetoTraumainSchools(HEARTS)• NeurosequentialModelinEducation(NME)• PsychologicalFirstAid(PFA)-Schools

School-Wide,TeacherCentered,Trauma-Informed

• FuelEd:FuelingSchoolswiththePowerofRelationshipsTrauma-Informed,Cross-SystemCollaborationModelsOlafson,HalladayGoldman,andGonzalez41identifiedfourthemesthatareessentialtofosteringtrauma-informedcross-systemcollaborations.Theyare(1)effectivecross-system,multi-levelleadership;(2)formalizedstakeholderengagementthroughmemorandaofunderstanding(MOUs)andmulti-disciplinaryteams;(3)collaborativeidentificationofsharedoutcomesbykeystakeholdersandcommunitymembers;and(4)evaluationoftheimpactinordertoinformfutureplanningandsupportsustainability.Usingthesethemes,theyidentifiedseveralexamplesoftrauma-informedcross-systemcollaboration.

• GeorgetownUniversityCrossoverYouthPracticeModel42ThismodelisacollaborationbetweenCaseyFamilyProgramsandtheCenterforJuvenileJusticeReform(CJJR).Itfocusesonyouthwhoareknowntobeinboththechildwelfareandjuvenilejusticesystems.

• Trauma-SystemsTherapy(TST)43Thisisapromisingcross-systemcomprehensiveapproachforyouthwhohaveexperiencedtrauma.Ithasbeenusedwithvariouspopulationsincludingyouthinvolvedinthechildwelfareandjuvenilejusticesystems.

• PositiveStudentEngagementModelforSchoolPolicing44InitiallyknownastheMulti-IntegratedSystemsApproach,thismodelwasdevelopedinresponsetotheschool-to-prisonpipeline.Itencouragestheuseofrestorativeratherthanpunitivepractices.

41Olafson,E.,HalladayGoldman,J.,&Gonzalez,C.,(2016).Trauma-informedcollaborationsamongjuvenilejusticeandotherchild-servingsystems:Anupdate.OJJDPJournalofJuvenileJustice,(5)1.42GeorgetownUniversityCrossoverYouthPracticeModel.(n.d.).Retrievedfromhttp://cjjr.georgetown.edu/our-work/crossover-youth-practice-model/43Trauma-SystemsTherapy.(n.d.).Retrievedfromhttps://med.nyu.edu/child-adolescent-psychiatry/research/institutes-and-programs/trauma-and-resilience-research-program/trauma-systems-therapy44Multi-IntegratedSystemsApproach.(n.d.).Retrievedfromhttp://www.ncjfcj.org/sites/default/files/Zero%20Tolerance%20Policies%20in%20Schools%20%282%29.pdf

• ChildDevelopmentCommunityPolicingProgram(CDCP)45DevelopedbytheYaleChildStudyCenterincollaborationwiththeNewHavenPoliceDepartment,CDCPsupportstheworkofmentalhealthprovidersandpoliceofficersattendingtotheneedsofchildrenandyouthexposedtotraumaticevents,respondingimmediatelytocallsinvolvingchildrenoryouthwhoarewitnessesorvictimstoviolentevents,includingdomesticviolence.

• CourtandMentalHealthCollaborations46Olafsonetal.providenumerousexamplesofproactivecollaborationsbetweenthecourtsystemandmentalhealthsystemthathaveshownpromiseintheareasofpreventionandtreatment.

A Look at State Consortiums and Councils

Successfulstateshavecollaboratedacrossservicesystemstodeveloptheirworkforces,screenfortrauma,changepractices,andincreaseaccesstoevidence-basedpractices.Connecticut,Iowa,Ohio,andOregonhavedevelopedstatewideorregionalcross-systemcollaboratives,steeringcommittees,andlearningcommunities.Iowa’ssteeringcommitteehasdevelopedafive-yearvisionandcommonlegislativeagenda.ConnecticutandOregonhaveexpandedtheircollaborativeeffortstoincludetrainingprimaryhealthcareproviders,withConnecticutdevelopingatraumascreeningforphysicians.Ohio’sinitiativeprovidestrainingtoexpandopportunitiesforpractitionerstobecomecompetentintrauma-informedapproaches.Inaddition,Washington,Pennsylvania,andCaliforniahavepassedstatewideresolutionsthatsupporttrauma-informedcare.Thefollowingareexamplesofstates’collaborativeefforts.Thislistisnotexhaustive.ConnecticutTheChildHealthandDevelopmentInstituteofConnecticut,Inc.(CHDI)hasbeenworkingtoimplementatrauma-informedsystemofcareinConnecticutsince2007.CHDIhasworkedwithstateagencies,providerorganizations,andfamiliestoimproveaccessforchildrentoservicesthataddresstrauma.Theirstrategiesincludeworkforcedevelopment,traumascreening,practicechangeandaccesstoevidence-basedpractices,andcross-systemcollaboration.47WithfundingfromtheDepartmentofChildrenandFamiliesandtheFederalAdministrationforChildrenandFamilies,CHDIhasdevelopedandimplementedtrauma-informedpolicies,systems,andpracticesinthechildwelfare,juvenilejustice,andchildren’smentalhealth

45ChildDevelopmentCommunityPolicingProgram(CDCP).https://medicine.yale.edu/childstudycenter/cvtc/programs/cdcp.aspx.46Olafson,E.,HalladayGoldman,J.,&Gonzalez,C.,(2016).Trauma-informedcollaborationsamongjuvenilejusticeandotherchild-servingsystems:Anupdate.OJJDPJournalofJuvenileJustice,(5)1.47Lang,J.,Campbell,K.,&Vanderploeg,J.(2015)Advancingtrauma-informedsystemsforchildren.Farmington,CT:ChildHealthandDevelopmentInstituteofConnecticut.

systems.Theyhavealsotrainedpediatrichealthproviderstoidentifytraumaandlinkchildrenandfamiliestoservices,developedascreeningtoolforchildhoodtrauma(TheChildTraumaScreen),anddevelopedawebsitetoincreasepublicawarenessforparentsandcaregivers.AnotherstatewideTICconsortiumistheConnecticutWomen’sConsortium,whichexpandedstatewidein1998.TheconsortiumhasworkedwiththeDepartmentofMentalHealthandAddictionServicestotrainprovidersonevidence-basedpracticesandtopromotearecovery-orientedsystemthatistrauma-informedandgender-responsive.Theconsortium’spartnership,theTraumaandGenderInitiative,willbemovingtowardsaregionalcollaborativemodelin2017.IowaCentralIowaAdverseChildhoodExperiencesSteeringCommitteefocusesoncollectivecommunityeffortstopreventorlessentheimpactofACEsandisacoalitionofbusiness,education,non-profit,andphilanthropicentities.48Thestructureofthecoalitionincludesalearningcommunitywithopenmembershipthatconvenesatleasttwiceayeartoshareinformationandopportunitiesforengagement,asteeringcommittee,andactiongroups.TheIowaACEsSteeringCommitteestartedin2011afterlearningabouttheACEsstudyfindings.49Thegroup’spasteffortsincludedevelopingastandardpresentationtoover1,000peopleinthestate,addingchildneglectquestionstotheBehavioralRiskFactorSurveillanceSystem(BRFSS)questionnaire,andhostingasummittoengageeducationandjuvenilejusticesectorsonACEs.IncollaborationwithotherIowagroups,thepolicycommitteehasdevelopedafive-yearvisionalongwithacommonlegislativeagendaregardingACEs.Ohio

Ohio’sTrauma-InformedCareInitiative50isorganizedthroughsixregionalcollaboratives.TheOhioDepartmentofMentalHealthandAddictionServices(OhioMHAS)andDepartmentofDevelopmentalDisabilities(DODD)collaborateonastatewideTrauma-InformedCareInitiative.Theinitiative’sintentistopromoteasenseofsafety,security,andequalityamongclients.Theinitiativeexpandsopportunitiesforpeopletoreceivetrauma-informedinterventionsby

48IowaACEs360.(n.d.).Aboutus.Retrievedfromhttp://www.iowaaces360.org/uploads/1/0/9/2/10925571/central_iowa_aces_360_steering_committee_timeline.pdf49Felitti,V.J.,Anda,R.F.,Nordenberg,D.,Williamson,D.F.,Spitz,A.M.,Edwards,V.,Koss,M.P.,&Marks,J.S.(1998).Relationshipofchildhoodabuseandhouseholddysfunctiontomanyoftheleadingcausesofdeathinadults.AmericanJournalofPreventiveMedicine.14(4),245–258.DOI:http://dx.doi.org/10.1016/S0749-3797(98)00017-850OhioMentalHealthandAddictionServices.(n.d.).Ohio’sTraumaInformedCareInitiative.Retrievedfromhttp://mha.ohio.gov/traumacare

improvingopportunitiesforpractitioners,facilities,andagenciestobecomecompetentintrauma-informedpractices.AnannualTrauma-InformedSummitthatpromotesknowledgeabouttheimpactoftrauma,implementationoftrauma-informedpractice,sustainability,andcollaborationamongagencieshasbeenheldforfouryears.TheNationalCenterforTrauma-InformedCare(NCTIC)hasprovidedconsultationandtrainingtodifferentsectors.TheTICInitiativehasprovidedtrainingtoallRegionalPsychiatricHospitalsandtheDODDDevelopmentalCenters,createdatrain-the-trainermodelfortrauma-informedapproaches,developedaneducationalandcommunicationcampaignontrauma,initiatedareductionofseclusionandrestraintinitiative,supportedatrauma-informedinitiativeacrosssocialservicesystems,andcreatedastatewideTICAdvisoryCommittee.Oregon

TraumaInformedOregon(TIO)51reflectsthestate’scommitmenttopromotetraumapreventionandtobetteralignpoliciesandpracticewiththeprinciplesofTIC.Thestatewidecollaborationwasinitiatedin2014whentheOregonHealthAuthority’sHealthSystemsDivisioncontractedwithPortlandStateUniversityinpartnershipwithOregonHealthandScienceUniversity(OHSU)andtheOregonPediatricSocietytopromoteandsustainTICacrosschild-andfamily-servingsystems.In2015,thecollaborativewasexpandedtoincludeadultbehavioralhealth-servingsystems.TIOcoordinatesandprovidestrainingandservesasasourceofinformationandresources.Italsoworkswithstateagencies,stateandlocalproviders,communities,familyandyouthorganizations,andotherstakeholderstobringperspectivestogethersothattheymaylearnfromeachotherandtoadvocatefortrauma-informedpoliciesandpractices.StateResolutionsThefollowingstatespassedresolutionstopromoteexpansionoftrauma-informedpracticesandpolicies.California

In2014,theCaliforniaSenatepassedAssemblyConcurrentResolution155(ACR155),whichencouragesstatewidepoliciestoreducechildren’sexposuretostressandACEs.52The

51TraumaInformedOregon.(n.d.).Abouttrauma-informedOregon.Retrievedfromhttp://traumainformedoregon.org/about52TraumaInformedOregon.(n.d.).Abouttrauma-informedOregon.Retrievedfromhttp://traumainformedoregon.org/about

resolutionencouragesofficialstosupportresearch-basedsolutions,investinpreventivehealthcare,andpromotementalhealthandwellnessinterventions.Pennsylvania

InApril2013,PennsylvaniaHouseResolution191,whichdeclaressupportforapublichealthapproachtoviolenceandstatewidetrauma-informededucation,waspassed.53Theresolutionacknowledgestheimpactoftraumaandesblishesaframeworkfordialogueontheissue.ItalsosecuredapprovalbytheNationalConferenceofStateLegislaturesanactionwhichiscommunicatedtoCongressandthePresident,movingtheissuetoanationalstage.Theresolutiondidnotauthorizeorfundnewmandatesorprograms,andtheSenatedidnotissueasimilarresolution.Washington

In2011,HouseResolution1965,whichwasintendedtoidentifyandpromoteinnovativestrategiestopreventorreduceACEs,waspassed.Italsodevelopedapublic-privatepartnershiptosupporteffectivestrategieswhichformedtheWashingtonStateACEsPublic-PrivateInitiative(APPI).APPIexamineseffectivecommunity-basedapproachestoreducingACEsanddocumentingpublicsavingsresultingfromthiswork.54TheAPPIconductedatwo-and-a-half-yearevaluationthatstudiedhowfivecommunitiesinthestateimplementedcommunity-basedapproaches.

53Prewitt,E.(2014,April30).State,federallawmakerstakeactionontrauma-informedpolicies,programs.Retrievedfromhttp://acestoohigh.com/2014/04/30/state-federal-lawmakers-take-action/54Prewitt,E.(2014,April30).State,federallawmakerstakeactionontrauma-informedpolicies,programs.Retrievedfromhttp://acestoohigh.com/2014/04/30/state-federal-lawmakers-take-action/

What Does Trauma-Informed Care Look Like in Texas? TounderstandhowTICisdeliveredtochildren,youth,andfamiliesinthechildwelfare,juvenilejustice,andmentalhealthsystemsinTexas,weneededtoexplorethefollowingactions:

• EstimatehowmanychildrenandadolescentsinTexashaveexperiencedtrauma• ReviewstatewidelegislationthataddressestraumaandTIC• IdentifyandreviewTICtrainingavailabletoprofessionalsandcaregiversthroughoutthe

state• ReviewtheprimarymodelsofTICutilizedinTexas• Meetwithkeyinformantsinthestate’schild-servingsystemstofindouthowTICis

beingoperationalizedanddeliveredincommunitiesacrossthestate,whichtrauma-focusedmodelsarebeingused,andwhatorganizational-andsystem-levelsuccessesandbarrierstheyhaveexperienced

• Identifysuccessfulcross-systemTICcollaboratives• ReviewthefundingstreamsthatareavailabletofundTICandtrauma-focused

approachesHow Many Children in Texas Have Been Affected by Trauma?

Anadversechildhoodexperienceisapotentiallytraumaticeventthatcanhavealasting,negativeeffectonachildoryouth’sphysicalandemotionalwellbeing.55TheprevalenceofACEsismeasuredbywhetherachildhasbeenavictimofviolence,experiencedeconomichardship“somewhatoften”or“often,”livedwithaparentwhodivorcedorseparated,livedwithaparentwhodiedorwasincarcerated,witnessedviolenceathomeorinhisorherneighborhood,orlivedwithaparentwhohadamentalillnessorstruggledwithasubstanceabuseproblem.ChildrenandyouthwhohaveexperiencedmultipleACEsareathighestriskfornegativeoutcomes,includinghealthandbehavioralproblems.56JustunderhalfofchildrenintheUnitedStateshaveexperiencedonetraumaticlifeeventorACE.57Areviewofnationalprevalenceestimatesandstate-leveldataindicatesthatapproximately10%ofTexaschildrenhaveexperiencedthreeormoreACEsintheirlifetime.58Manyhaveexperiencedeightormoreepisodesofviolence.Inaddition,childrenandyouthwhoareinvolvedinthechildwelfareandjuvenilejusticesystemsaresignificantlymorelikelythan

55Felitti,V.J.,Anda,R.F.,Nordenberg,D.,Williamson,D.F.,Spitz,A.M.,Edwards,V.,Koss,M.P.,&Marks,J.S.(1998).Relationshipofchildhoodabuseandhouseholddysfunctiontomanyoftheleadingcausesofdeathinadults.AmericanJournalofPreventiveMedicine.14(4),245–258.DOI:http://dx.doi.org/10.1016/S0749-3797(98)00017-856Sacks,V.,Murphy,D.,&Moore.,K.(2014).Adversechildhoodexperiences:Nationalandstate-levelprevalence.ResearchBrief:ChildTrends.Publication#2014-28.57AmericanPsychologicalAssociation.(n.d.).Childrenandtrauma:Updateformentalhealthprofessionals.Retrievedfromhttp://www.apa.org/pi/families/resources/children-trauma-update.aspx58Sacks,V.,Murphy,D.,&Moore.,K.(2014).Adversechildhoodexperiences:Nationalandstate-levelprevalence.ResearchBrief:ChildTrends.Publication#2014-28.

thegeneralpopulationtohaveexperiencedanACE.Takingthesefactorsintoconsideration,child-servingsystemsinTexasneedtobeabletoidentify,understand,andtreattrauma.MethodologyforEstimatingPrevalenceMeasuringtheprevalenceofchildandyouthtraumaisdifficultandimprecise.National-andstate-leveldatamustbetriangulatedtoestimatehowmanychildrenandyouthhavebeenexposedtotrauma.ThefollowingestimatesforTexaschildrenandyouthdrawontheNationalSurveyofChildren’sExposuretoViolenceandtheNationalSurveyofChildren’sHealth.Otherdataincludethenumberofyouthwhohavebeenidentifiedwithmentalhealthneedswithinthesocialservicesandjuvenilejusticesystem.FindingsonChildandYouthTraumaExposure(TE)inTexas

• Finding1:Statewide,approximately730,000childrenandyouth,or1in10children/youthoverall,haveexperiencedthreeormoreACEs.ThemostprevalentACEsamongTexaschildrenandyouthareexposuretoeconomichardship,livingwithadivorcedparentorguardian,livingwithsomeonewhohasasubstanceuseproblem,andlivingwithsomeonewithamentalillness.

Table1:ChildrenandYouthWhoHaveExperiencedThreeorMoreAdverseChildhoodExperiences59,60

AdverseChildhoodExperiences(ACEs)TexasPrevalence

Proportion(Age0–17)

TexasPrevalenceCount

(Age0–17)Threeormoreadversechildhoodexperiences 10.0% 728,289Livedwithaparentorguardianwhogotdivorcedorseparated

20.0% 1,456,577

Livedwithaparentorguardianwhodied 2.6% 189,355Livedwithaparentorguardianwhoservedtimeinjailorprison

6.9% 502,519

Livedwithanyonewhowasmentallyillorsuicidal,orseverelydepressedformorethanacoupleofweeks;livedwithanyonewhohadaproblemwithalcoholordrugs

8.0% 582,631

Livedwithanyonewhohadaproblemwithalcoholordrugs 10% 728,289Witnessedaparent,guardian,orotheradultinthehouseholdbehavingviolentlytowardanother(e.g.,

7.9% 575,348

59Sacks,V.,Murphey,D.,&Moore,K.(2014).Adversechildhoodexperiences:Nationalandstate-levelprevalence.ChildTrends:ResearchBrief,Publication#2014-28.Retrievedfrom:https://www.childtrends.org/wp-content/uploads/2014/07/Brief-adverse-childhood-experiences_FINAL.pdf60AdditionaldatanotfoundinSacksetal.(2014)wasretrievedfromtheDataResourceCenterforChild&AdolescentHealth:http://www.childhealthdata.org/browse/survey.

AdverseChildhoodExperiences(ACEs)TexasPrevalence

Proportion(Age0–17)

TexasPrevalenceCount

(Age0–17)slapping,hitting,kicking,punching,orbeatingeachotherup)Waseverthevictimofviolenceorwitnessedanyviolenceinhisorherneighborhood

7.3% 531,651

Experiencedeconomichardship“somewhatoften”or“veryoften”(i.e.,thefamilyfoundithardtocovercostsoffoodandhousing)

29.0% 2,112,037

• Finding2:Forchildrenandyouthage0–17,nearly90,000havebeenexposedto10or

moreepisodesofviolence.AccordingtoTheNationalSurveyofChildren’sExposuretoViolence,approximately90,000Texaschildrenandyouthmayhavebeenregularlyexposedtoanyformofviolence.ThetablebelowsummarizestheestimatedprevalenceofchildandyouthexposuretoviolenceinTexasbasedonnationalprevalenceestimatesbythetypeofviolenceandthegeneralfrequencyofmultipleexposureswithina12-monthperiod.

Table2:ChildrenandYouthAnnualExposuretoViolence61

ViolentExperience National12-MonthPrevalence

(Age0–17)

TexasStateCount(Age0–17)

DirectExposuretoOneorMoreEpisodesofViolence(Low)

60.8% 4,427,995

DirectExposuretoSixorMoreEpisodesofViolence(Moderate)

10.1% 735,572

DirectExposureto10orMoreEpisodesofViolence(High)

1.2% 87,395

Direct,IndirectorWitnessedExposuretoOneorMoreEpisodesofViolence

67.5% 4,915,949

AnyPhysicalAssault 37.3% 2,716,517“AnyPhysicalAssault”includesassaultwithaweapon,assaultwithinjury,assaultwithnoweapon,attemptedassault,attemptedorcompletedkidnapping,assaultbyadult,assaultbyjuvenilesibling,assaultbynon-siblingpeer,assaultbygangorgroup,genitalassault,datingviolence,biasattack,threatenedassault,physicalintimidation,relationalaggression,internetorcellphoneharassmentAnySexualOffence 5.0% 364,144

61Finkelhor,D.,Turner,H.A.,Shattuck,A.,&Hamby,S.L.(2015).Prevalenceofchildhoodexposuretoviolence,crime,andabuse:ResultsfromtheNationalSurveyofChildren’sExposuretoViolence.JAMAPediatrics,169(8).Thesedatahaveappliednationalprevalenceratestothe0–17ageTexaspopulation.

ViolentExperience National12-MonthPrevalence

(Age0–17)

TexasStateCount(Age0–17)

“AnySexualOffence”includessexualassault,completedrape,attemptedrape,sexualassaultbyknownadult,sexualassaultbyadultstranger,sexualassaultbypeer,flashedbypeer,flashedbyadult,sexualharassment,internetsextalk,statutorysexoffense

AnyMaltreatment 15.2% 1,106,999“AnyMaltreatment”includesphysicalabuse,emotionalabuse,sexualabuse,neglect,custodialinterferenceorfamilyabductionAnyPropertyCrime 27.1% 1,973,662“AnyPropertyCrime”includesrobberybynon-sibling,vandalizedbynon-sibling,theftbynon-siblingWitnessedAnyViolence 24.5% 1,784,307“WitnessedAnyViolence”includesfamilyassault,partnerassault,physicalabuse,assaultincommunity,exposuretoshooting,exposuretowar,exposuretohouseholdtheft,indirectexposuretoschoolthreat,bomb,orattack

• Finding3:AmongyouthwithinthejuvenilejusticesysteminTexas,5,900have

experiencedfourormoreACEs.Youthinvolvedinthejuvenilejusticesystemaremorelikelytohaveexperiencedmultipletypesoftrauma,are13timeslesslikelytoreportzeroACEs,andexperience3timestheprevalenceofACEsasthegeneralpopulation.62Amongjuvenileoffenders,themostprevalentACEsarefamilyviolence,parentalseparation/divorce,andhouseholdmemberincarceration.BasedonastudybyBaglivioandEppsexaminingtheprevalenceofACEsamong64,000juvenileoffenders,25%ofjuvenileoffendersreportedfourormoreACEs.63Amongthe23,963youthonprobationinthestateofTexas,anestimated5,900youthhaveexperiencedanACEofsomekind.TheTexasJuvenileJusticeDepartment(TJJD)doesnotuseaformalscreenforcapturingtraumaexposure.However,itcurrentlyscreensformentalhealthtreatmentneeds.InFY2015,morethan11,500juvenileoffenderswereidentifiedwithamentalhealthneeduponenteringtheTJJDsystem.64

62Baglivio,M.T.,Epps,N.,Swartz,K.,Huq,M.S.,&Hardt,N.S.(2014).TheprevalenceofAdverseChildhoodExperiences(ACE)inthelivesofjuvenileoffenders.JournalofJuvenileJustice,3,1–23.63Baglivio,M.T.,Epps,N.,Swartz,K.,Huq,M.S.,&Hardt,N.S.(2014).TheprevalenceofAdverseChildhoodExperiences(ACE)inthelivesofjuvenileoffenders.JournalofJuvenileJustice,3,1–23.64TJJD.(2016).FY2015.Department-identifiedmentalhealthneedsandservicesprovidedtoyouthonprobation.DatasetprovidedtoMMHPIbyPernillaJohanssonofTJJDonMarch9,2016.

Table3:CharacteristicsofYouthAdmittedtotheTexasDepartmentofJuvenileJusticeinFY201565

OtherYouthCharacteristics(NewAdmissions)

HighMHNeed

ModerateMHNeed

LowMHNeed

NoMHNeed

ParentsUnmarried,Divorced,Separated,oratLeastOneDeceased 16(93%) 117(86%) 223(89%) 351(87%)

OnProbationatCommitment 13(76%) 94(69%) 203(81%) 283(70%)

PrioroutofHomePlacement 11(65%) 94(69%) 195(78%) 238(59%)

FamilyHistoryofCriminalInvolvement 10(59%) 82(60%) 125(50%) 218(54%)

SuspectedHistoryofAbuseorNeglect 14(82%) 80(59%) 95(38%) 117(29%)

SpecialEducationEligible 14(82%) 45(33%) 105(42%) 81(20%)

• Finding4:AmongallchildrenandyouthlivinginfostercareinthestateofTexas,

approximately24,300haveexperiencedoneormoreACEs.RelativelylittleresearchhasexaminedtheprevalenceratesofACEsamongyouthinsubstitutecare.Childwelfareresearchestimatesthat6%ofallU.S.childrenandyouthwillexperienceentryintoafostercaresystembeforeage18.66AfricanAmericansandNativeAmericansaremuchmorelikelytoenterafostercaresystem(12%and15%respectively).67Basedonthe2011–2012NationalSurveyofChildren’sHealth(NSCH),76%ofallyouthinfostercare(orpreviouslyinfostercare)experiencedoneormoreACEs,comparedto33%amongchildrenwithoutexposuretothefostercaresystem.68In2016,therewere31,943totalfostercareplacementsstatewide.Basedoncurrentresearch,asmanyas24,300childrenandyouthinfostercareinTexasmayhaveexperiencedanACE.The2011–2012NSCHisbasedonarepresentativesampleofparentsintheUnitedStates.ThereislikelytobesomeunknowndegreeofmisclassificationofACEstatusassomeguardiansandparentsoffostercaredependentsmaynotknowthecompletehistoryoftheirchildoryouth.Forthisreason,somechildwelfareexpertssuspectACEprevalenceamongchildrenwithexposuretothefostercaresystemtobegreaterthanreported.

• Finding5:AmongchildrenandyouthenrolledinserviceswiththeLMHA,7,700(or

19%)childrenandyouthwhowereassessedfortraumahaveexperiencedatraumatic

65TJJD.(2016).ResidentialmentalhealthservicesprovidedtoyouthonprobationinFY2015.DatasetprovidedtoMMHPIbyPernillaJohanssonofTJJDonMarch9,2016.66Turney,K.,&Wildeman,C.(2016).Adversechildhoodexperiencesamongchildrenplacedinandadoptedfromfostercare:Evidencefromanationallyrepresentativesurvey.ChildAbuse&Neglect,64:117–129.67Wildeman,C.,&Emanuel,N.(2014).Cumulativerisksoffostercareplacementbyage18forU.S.children,2000–2011.PublicLibraryofScience,9(3),1–7.68Turney,K.,&Wildeman,C.(2016).Adversechildhoodexperiencesamongchildrenplacedinandadoptedfromfostercare:Evidencefromanationallyrepresentativesurvey.ChildAbuse&Neglect,64:117–129.

lifeevent;nearlyhalfoftheseindividualsshowedevidencethatthetraumaticexperiencewasimpactingoneormorelifedomains.TheLMHAcompletedthetraumaitemontheCANSassessmentformorethan41,000childrenandyouthinFY2016.Approximately7,700or19%childrenandyouthassessedhadexperiencedatraumaticlifeevent,ofwhom,nearlyhalfshowedevidencethatthetraumaticexperiencewasimpactingoneormorelifedomains.AmongchildrenandyouthwhowereassessedfortraumathroughtheCANSassessment,1%(566childrenandyouth)reportedfeaturesconsistentwithoneormorePTSDsystemsinthepast30days.

Table4:ChildandYouthTraumaExposureAssessedThroughCANSFY201669

CANSAssessmentFindings NumberofYouth

PercentofTotal

CANSAssessment-Total 49,275 100%

TraumaHistorynotrecordedbytheLMHA 8,040 16%

TotalCompletedCANSTraumaSection 41,221 100%

NoHistoryofTraumainpast30days 29,674 80%

HistoryofTraumaticLifeEvent 7,698 19%

Traumaimpacts³1lifedomain 3,297 8%

Experiencing³1PTSDsymptomsinpast30days 566 1%

Trauma-Informed Care Legislation in Texas

Texaslawmakershavebeguntolayafoundationtoaddresstraumastatewide.Betweenthe82ndand84thlegislativesessions,sevenbillscontainingmandatesrelatedtoTICwerepassed(seeTable5,below).Therewerenobillspassedduringthe85thlegislativesessionthatrequiredstatewidesystematicchangestoaddresstrauma,specifictochildrenandyouth.Sixofsevenpastmandatesfocusedontrainingthechildwelfare,juvenilejustice,statehospital,andstatesupportivelivingcenterworkforceaswellasfostercarefamiliesandcaregivers.Theintensityandfrequencyoftrainingvariesbylegislativemandate.Atminimum,thoseagenciesarerequiredtoprovidenewemployees,fostercarefamilies,andcaregiverswithweb-basedorface-to-faceintroductorytrainingonTIC.Themandatesaroundjuvenilejusticetrainingrequirementsarethemoststringent.Theyrequireface-to-facetrainingthatincludesbestpracticesinbehaviormanagementandseclusionandrestraints.

69Lynch,C.(June16,2017).Email.TexasCANSAggregateData.HealthandHumanServicesCommission-OfficeofGeneralCounsel

Duringthe84thlegislativesession,lawmakerstookstepstoensurethatchildrenandyouthenteringthechildwelfaresystemarescreenedfortrauma.SenateBill(SB)125requiredtheDepartmentofFamilyandProtectiveServices(DFPS)toimplementastatewide,developmentallyappropriatecomprehensiveassessmentthatincludesascreeningfortraumaandmentalhealthneedswithin45daysofachildoryouthenteringthesystem.DFPSbeganimplementingtheChildandAdolescentNeedsandStrengths(CANS)AssessmentstatewideinSeptember2016.InpreparationforCANSimplementation,thestatewasrequiredtotrainstaffontraumaandhowtousethistooltomaketrauma-informeddecisionsforchildren,youth,andfamilies.Thefollowingtableoffersanoverviewoflegislationrelatedtotraumaandtrauma-informedcareinTexas,datingbacktothe82ndLegislativeSession.Legislationcoverstrainingrequirementsandassessmentsusedforchildrenandyouth.Table5:Trauma-InformedCareLegislationinTexas

LegislativeSession

BillNumber

Description

82nd SB219 MandatestheDFPStoincludetrainingintrauma-informedprogramsandservicesinanytrainingthedepartmentprovidestofosterparents,adoptiveparents,kinshipcaregivers,departmentcaseworkers,anddepartmentsupervisors.AlsorequiresallDFPScaseworkerstocompleteaninitial,in-persontrainingontrauma-informedcareduringtheirbasicskillsdevelopmenttrainingandcompleteanonlinerefreshercourseannually.70

83rd SB1356 Relatedtohumantraffickingandcareofjuvenileswhohaveexperiencedtrauma.Requirestrauma-informedtrainingforprobationofficers,juvenilesupervisionofficers,correctionalofficers,andcourt-supervisedcommunity-basedpersonnel.Thetrainingmustincludebestpracticesinbehaviormanagementaswellasappropriaterestrainttechniques,whichshouldonlybeusedinemergenciesasalastresort.71

83rd SB7 TheDepartmentofAgingandDisabilityServices(DADS)mustensurethatprofessionalsworkingonabehavioralinterventionteamthatissupportinganindividualwithadevelopmentaldisabilityandabehavioralhealthneedwhoisatriskforinstitutionalizationhavetrainingonTICpractices.72

70CodifiedatTexasFamilyCode§264.015.Retrievedfromhttp://www.statutes.legis.state.tx.us/Docs/FA/htm/FA.264.htm71CodifiedatHumanResourcesCodeSection221.002.Retrievedfromhttp://www.statutes.legis.state.tx.us/Docs/HR/htm/HR.221.htm72PortaltoTexasHistory.83rdTexasLegislature,RegularSession,SenateBill7,Chapter1310.Retrievedfromhttps://texashistory.unt.edu/ark:/67531/metapth438730/m1/71/

LegislativeSession

BillNumber

Description

83rd SB152 Relatedtotheprotectionandcareofpersonswhoareelderlyordisabledorwhoarechildren.Ensuresthatdirectstaffatstatehospitalshavetrainingintrauma-informedcare.73

84th HB2789 Requiresweb-basedTICtrainingfornewemployeeshiredatstatesupportedlivingcenters(SSLCs)andintermediatecarefacilities(ICFs)forpeoplewithintellectualdisabilities.RequiresDADStodeveloporadoptTICtrainingforemployeeswhoworkwithindividualswithIDDinSSLCsandICFs.

84th SB125 RequiresthatchildrenwhoareenteringintoDFPSconservatorshipreceivea“developmentallyappropriatecomprehensiveassessment”thatincludesascreeningfortraumaandmentalhealthneedswithin45daysofthechild’sentranceintoDFPScare.Thetoolmustincludeatraumaassessmentandaninterviewwithatleastoneindividualwhohasknowledgeaboutthechild’songoingmentalhealthneeds.Alsorequireschildwelfaresystemstakeholdertrainingontraumaandontheassessmenttool,includinghowtoemploythetoolandtomaketrauma-informeddecisionsonbehalfofchildrenandfamilies.

84th HB781 RequiresDFPStodetermineandevaluatethehomescreening,assessment,andpre-servicetrainingrequirementsusedbysubstitutecareprovidersbeforetheverificationandapprovalofcaregivers.RequiresDFPStoadoptcertainpoliciestoensurecertaincaregiversreceiveatleast35hoursofpre-servicetrainingbeforebeingverifiedasafostercareoradoptivehome.

FederallegislationonTIChasbeenproposedincurrentandpreviouslegislativesessionsbutnolegislationhasbeenenactedto-date.Trauma-Informed Training in Texas

ThefirststepindeliveringTICistoensurethateveryindividualwhoencountersachildoryouthcanrecognizeandunderstandtrauma.Mostchild-servingagenciesinthestateoffersomeworkforcetrainingontraumaandTIC.Areviewoftrainingopportunitiesthroughoutthestateindicatesthatthereisavarietyoftrainingavailableinvariousformats(seeAppendixTwo).TICtrainingisofferedthroughcommunity-widefaith-basedinitiatives,onlinetraining,smallgroups,andlargeconferencesandtrainings(TICofCentralTexas,ReachingTeens©-ElPaso,TBRI®SummerSeminar,FosteringConnections-Teleconference,BouncingForward).Theyvaryinlength,quality,targetaudience,andcost.Alldiscusstheimpactoftraumaonthebrain,the

73PortaltoTexasHistory.83rdTexasLegislative,RegularSession,SenateBill152,Chapter395.Retrievedfromhttps://texashistory.unt.edu/ark:/67531/metapth438186/m1/3/?q=children

needtounderstandhowtraumaimpactsbehaviors,andtheuseofaccepteddefinitionsandresearch.Legislativemandatesrequireallchildwelfarepersonnel,juvenilejusticestaff,caregivers,andfosterfamiliestoreceivetrainingonTIC.Inaddition,mostmentalhealthprofessionalsareintroducedtotheACEstudy74andTIC.Schoolpersonnelsuchasteachersandothercommunityproviders,dependingonthecommunityanddistrict,havemuchlessexposureoraccesstoTICtraining.Despitetheavailabilityoftrainingandcurrenttrainingrequirements,respondentstotheTexasCASA201575surveyonTICselected“increasingmandatedtrainingrequirementsforfosterparentsandCPSworkers”astheirtoprecommendationsforpolicymakers.ThetableinAppendixTwooffersanoverviewofTICtraininginTexas.Asnotedabove,sometrainingshaveresultedfromlegislationreferencedinthepriorsection.Thislistisnotexhaustive.Trauma-Informed Approaches in Texas

ThreeapproachespermeatetheTIClandscapeinTexas.Twoofthem,NeurosequentialModelTherapeutics/NeurosequentialModelofEducationandTrust-BasedRelationalIntervention(TBRI®),originatedinTexas.Thethird,ReachingTeensã,originatedinPennsylvaniabutwasadoptedbyMentalHealthConnectionsinFortWorth,TexasandhasbecomethefoundationfortheirTICefforts.Allthreemodelsshareacommonunderstandingofhowtraumaimpactsthebrainandafocusonsafety,attachment,control,andself-regulation.Anoverviewofeachapproach,trainingrequirements,andhowtheapproachisbeingimplementedinTexasisprovidedbelow.ChildTraumaAcademy–NeurosequentialModelofTherapeutics(NMT)andNeurosequentialModelofEducation(NME)ChildTraumaAcademy(CTA)isanot-for-profitorganizationinHouston,Texas.Dr.BrucePerryisitsfounderandSeniorFellow.JanaRosenfeltistheExecutiveDirector.CTAwasfoundedin1990asa“centerforexcellence”attheUniversityofChicagoandlaterBaylorCollegeofMedicine.In2001,itbecameanot-for-profitthatfunctionsasa“communitypractice”thatpromotessocialchange.CTA’sworkfocusesonthedevelopmentofnon-medicalmodelsofcareandcross-agencycollaborationwithintherapeutic,childprotection,andeducationsystems.CTA’sstatedmissionis“tohelpimprovethelivesoftraumatizedandmaltreatedchildren…by

74Felitti,V.J.,Anda,R.F.,Nordenberg,D.,Williamson,D.F.,Spitz,A.M.,Edwards,V.,&Koss,M.P.(1998)Relationshipofchildhoodabuseandhouseholddysfunctiontomanyoftheleadingcausesofdeathinadults:AdverseChildhoodExperiences(ACE)Study.AmericanjournalofPreventiveMedicine,14(4),245–258.75TexasCASA(2015).Understandingtrauma-informedcareintheTexaschildwelfaresystem:Dataandrecommendationsfromthefield.Retrievedfromhttps://texascasa.org/understanding-trauma-informed-care-in-texas/

improvingthesystemsthateducate,nurture,protectandenrichthesechildren.[Theyfocustheir]effortsonservicedelivery,programconsultation,researchandinnovationsinclinicalassessment/treatment.”76NMTintegratesthecoreprinciplesofneurodevelopmentandtraumatology.Itisgroundedintheawarenessthatthebraindevelopssequentiallyandcanbenegativelyimpactedbyneglect,chaos,attachmentdisruption,andtraumaticstress.NMTisnotatherapeuticapproach.Itisamultidimensionalassessment“lens”thatguidesclinicalproblem-solvingandoutcomemonitoringbyprovidingapictureofachild’scurrentstrengthsandvulnerabilitiesinthecontextofhisorherdevelopmentalhistory.Itisawaytoorganizeachild’shistoryandcurrentfunctioning.Themodelhasbeenwidelyusedwithchildrenandyouthpresentingthemostcomplexcasesofmaltreatmentandpsychologicaltrauma.TheNMTprocessgathersinformationonachild’spastandcurrentexperiencesandfunctioningincludingtraumaandrelationshiphistory.Thisinformationcreatesanestimateoftheseverityandtimingofriskandresiliencyfactorsthatmayhaveinfluencedachild’sbraindevelopment.Thisestimateispairedwithareviewofachild’scurrentfunctioning.Theinformationisthenorganizedintoafunctionalmapofthebrainthatidentifieswhichpartsofthebrainappeartohavefunctionalordevelopmentalproblems.Thefunctionalbrainmapisusedtoguidetheselectionandsequencingofinterventionsthataredevelopmentallysensitive.NMTislistedasevidence-based.NeurosequentialModelforEducation(NME),77aspin-offofNMT,isdesignedtohelpeducatorscreateoptimallearningbyactingontheprinciplesofdevelopmentandbrainfunctioning.NMEisamultifacetedapproachthatprovidesa“picture”ofthechild’sbraininrelationtosame-gradepeers.Themini-maplooksatreading/verbalskills,mathskills,reactivity/impulsivity,communication/languageskills,relationalskills,self-regulation,threatresponse,coordination,finemotorskills,andattention/distractibility.NMEoffersteachersclassroommanagementtoolsincludingtakingbrain/regulationbreaks,havingstudentsmonitortheirheartrateduringafightorflightstate,anddailyjournaling.Teachersarealsotaughttomanagechallengingbehaviorsbyfirstprovidingregulatingopportunities,relatingtothestudent,and,finally,reasoningwiththestudent.

76ChildTraumaAcademy.(n.d.).Retrievedfromhttp://childtrauma.org/about-childtrauma-academy/mission/77Walters,S.(2016).Earlyexperiencesintheneurosequentialmodelineducation.TheCanadianJournalforTeacherResearch:TeachersleadingTransformations.Retrievedfromhttp://www.teacherresearch.ca/blog/article/2016/10/30/314-early-experiences-in-the-neurosequential-model-in-education

TrainingRequirements

NMTisdesignedtobedeliveredbylicensedsocialservicesprofessionalswhoarecurrentlyworkingwithchildren,youth,orfamilies.Itfeaturesmulti-mediatrainingthatrequiresparticipantstoviewonlinematerials,readassignedarticles,andcompletereportsthatarewrittentofidelity.CTAstaffestimatethatittakesapproximately15months(atotalof90–120hours)tocompleteallrequiredtraining.AllcertifiedNMTpractitionersarerequiredtocompletebi-annualfidelityexercises.TexasImplementationofNMTandNMECTAhasoneflagshiporganization,CalFarley’sBoy’sRanchinTexas.Thisorganizationhas19certifiedsitesinthenation,and3ofthemareinTexas:theCenterforChildProtection,theDallasChildren’sAdvocacyCenter,andtheRegionalCaseyFamilyProgramsHeadquarters.TheCenterforChildProtectionandCaseyFamilyProgramsarealsoNMTTrainers.TherearetwoNMEsitesinTexas:AustinTexasAreaSchoolsandTalithaKoumInstitute.TheCTAdescribesitsfootprintinTexasas“quietly”growingovertime.BecausebothNMTandNMErequireasignificanttimecommitment,andbothstressfidelitytothemodel,CTAiscarefultoworkonlywithorganizationsthathaveastrongorganizationalcommitmenttoimplementation.TheyalsoareintheprocessofdevelopingaNeurosequentialModelforCaregivers(NMC).CTAstaffindicatethatitwillbeayearortwobeforetheformalizedtrainingforthisnewmodeliscomplete.FosteringResilience–ReachingTeens©–Dr.KennethGinsburgReachingTeens©isatextbook/videoprojectpublishedbytheAmericanAcademyofPediatricsfornon-physicianprofessionals.Dr.KennethGinsburgisapediatricianspecializinginadolescentmedicineattheChildren’sHospitalofPhiladelphiaandaprofessorofpediatricsattheUniversityofPennsylvaniaSchoolofMedicine.HeisalsotheDirectorofHealthServicesatCovenantHousePennsylvania.ThethemethattiestogetherDr.Ginsburg’sclinicalpractice,teaching,research,andadvocacyeffortsisthatofbuildingonthestrengthofyouthbyfosteringtheirinternalresilience.FosteringResiliencetranslateswhatisknownfromresearchandpracticesintopracticalapproachesthatparents,professionals,andcommunitiescanusetopreparechildrenandyouthtothrive.78Dr.Ginsburgworkswithcommunitiestodevelopafoundationalframeworktopromoteresilienceinyouth.ThisframeworkdrawsfrompositiveyouthdevelopmentandTICpracticestohelpcareprovidersintegrateanunderstandingofwhatayouthhasbeenthroughwithhighexpectationsfortheyouth.Dr.Ginsburgbelievesthatunderstandingtraumaiscritical.78FosteringResilience:PreparingchildrenandteentoTHRIVEthroughbothgoodandchallengingtimes.Retrievedfromhttp://www.fosteringresilience.com/professionals/about.php

However,Dr.Ginsburgargues,TICalonecanbetooflexibleanddoesnotholdyouthaccountable.Thepositiveyouthdevelopmentapproachseesyouthastheexpertsintheirlife,considersthemexcellentrolemodelsforotheryouth,encouragesindependence,understandstheimportanceofacaringandtrustedadultinthehealingprocess,andprovidesalternativecopingstrategies.79ReachingTeens©80

ReachingTeensãisacomprehensive,interdisciplinary,evidence-informedandexpert-drivenapproachtoaddressingriskbybuildingonayouth’sstrengths.ItistheoreticallygroundedinpositiveyouthdevelopmentandresilienceapproachesandTIC.Thecurriculumconsistsofatextbook,445videos,livelinkstoresources,anddownloadsforyouth,parents,andprofessionals.Itprovidesstrategiesforparaprofessionalsandprofessionalstoengageyouthintrustingrelationships,promotepositivebehaviors,engageandinformparents,andaddressspecificemotionalandbehavioralconcerns.ReachingTeensãispublishedbytheAmericanAcademyofPediatrics.TrainingRequirements

Therearenospecifictrainingrequirementsforthiscurriculum.The69chapters,videos,andadditionalresourcescanbenavigatedbyindividualsorwithagroup.Chaptersandadditionalcontentcanbeselectedandprioritizedbasedonrelevanceandpopulation.TheReachingTeens©websiteprovidestipsforindividuallearnersandgroupsoflearners.TheAmericanAcademyofPediatricsandtheNationalAssociationofSocialWorkersoffer65hoursofcontinuingprofessionaleducationcreditsforprofessionals.TexasImplementation

ItisdifficulttodeterminethescopeorimpactofReachingTeensãinTexasbecauseallorpartofthecurriculumcanbeusedbyindividualsoragencieswithouttrainingorcertificationbyDr.GinsburgortheNationalAcademyofPediatrics.However,twocommunity-wideimplementationeffortswereidentified:ElPaso,whichisintheinitialstagesofcommunityengagementandimplementation,andFortWorth,whichhasledthecountryinpilotingReachingTeensãatacommunitylevel.In2014,withthesupportoftheRees-JonesFoundation,MentalHealthConnections(MHC)andDr.KenGinsburglaunchedathree-yearpilotprojectofReachingTeensãintheFortWorthcommunity.Thegoaloftheprojectwasthat“[a]llpeoplewhoworkwithteens–fromparentstomentalhealthproviderstopediatricianstolawenforcement–couldspeakthesamelanguage

79Excerptsfrom“OurKidsarenotBroken:RecognizingandBuildingontheStrengthofMarginalizedandTraumatizedYouth”apresentationgivenbyDr.GinsburginElPaso,TexasonMay7,2017.80FosteringResilience.http://www.fosteringresilience.com/professionals/

andprovideconsistenttrauma-informedandstrength-basedapproachestoteensacrossmultiplesystems.”81ThirteenMHCpartnersagreedtoparticipateinthepilot,whichtrained250communitymembersduringitskick-offworkshop.TheprojectconcludedinJuneof2017.KarynPurvisInstituteofChildDevelopment–Trust-BasedRelationalIntervention(TBRI®)–Dr.KarynPurvisandDr.DavidCrossTheKarynPurvisInstituteofChildDevelopmentishousedinthecollegeofScienceandEngineeringatTexasChristianUniversity(TCU).DavidCross,Ph.D.istheRees-JonesFoundationDirector.TBRI®isdescribedasacaregivingmodel,notaclinicalmodel.Itcanbeusedinallenvironmentswithchildrenandyouthfrom“hardplaces.”82Itisatrauma-informed,whole-child,ecologicallyvalidmodel.TBRI®isrootedintheworkofBesselvanderKolk,M.D.andalignswiththethreefactorsheidentifiedasbeingnecessaryinanyprogramdesignedtotreatcomplextrauma-development:safety,promotionofhealingrelationships,andteachingofself-managementandcopingskills.TheoverarchinggoalsofTBRI®aretohelpcaregivers“see”(compassionateunderstanding)theneedsofchildrenwhohaveexperiencedrelationaltraumaand“do”(knowledgeandskills)whatisnecessarytomeettheseneeds.83Trust-BasedRelationalIntervention(TBRI®)84,85

TheTBRI®modelcomprisesaclearsetofdevelopmentalprinciplesthataredesignedtobringhealingtoat-riskchildrenandyouth.TBRI®encompassesthreeinteractingandsynergisticsetsofprinciplesandpractices:empowering,connecting,andcorrecting.Eachprinciplehastwosetsofstrategies.

• EmpoweringPrinciples:Caregiverscanenhanceachild’scapacityforself-regulation,decreasethelikelihoodofdisruptivebehaviors,andincreasethelikelihoodofsuccessfullyconnectingandcorrectingiftheyattendtoexternal(ecological)andinternal(physiological)strategies.Thisprinciplesetsthestageforpositivechangebycreatinghealthyconditionsandanenvironmentthatfosters”feltsafety.”Ecologicalstrategiesincluderecognizingandmanagingtransitionsandestablishingrituals.Physiologicalstrategiesincluderegularphysicalexerciseandsensoryexperiencesandmeetingnutritionalneeds.

81MentalHealthConnectionsofTarrantCounty.ResiliencyCommittee.(n.d.).Retrievedfromhttp://www.mentalhealthconnection.org/committees/resiliency-committee82Purvis,K.B.,Cross,D.R.,Dansereau,D.F.,&Parris,S.R.(2013).Trust-basedrelationalintervention(TBRI®):Asystematicapproachtocomplexdevelopmentaltrauma.Child&YouthServices,34:360–386.83Purvis,K.,Call,C.,&Cross,D.(2014).TBRI®andtheTCCC.84Purvis,K.B.,Cross,D.R.,Dansereau,D.F.,&Parris,S.R.(2013).Trust-basedrelationalintervention(TBRI®):Asystematicapproachtocomplexdevelopmentaltrauma.Child&YouthServices,34:360–386.85Purvis,K.,Call,C.,&Cross,D.(2014).TBRI®andtheTCCC.

• ConnectingPrinciples:TheTBRI®connectingprinciplesarebasedonattachmenttheoryandaretheessentialmechanismsforbuildingtrustingrelationshipsandensuringthattheempoweringandcorrectingprincipleswork.Theyareconsideredthesourceof“feltsafety”andself-regulation.Therearetwoconnectingprinciples:mindfulawarenessandengagementstrategies.MindfulnessisaTBRI®’scorecapacity.Ithelpsacaregiverseeboththechild’sandtheirownneeds.MindfulnessAwarenessPractice(MAP)strategiesincludeyoga,taichi,enteringprayer,mindfulwalking,andmindfulnessmeditations.Empowermentassumesthatmostcommunicationisnon-verbal.

• CorrectingPrinciples:TheTBRI®correctingprinciplesareusedtoshapebehaviors.Inordertobeeffective,theseprinciplesmusthaveafirmfoundationofconnectingandempowering.Thecorrectingprinciplesareproactivestrategiesandresponsivestrategies.Proactivecorrectingprinciplesinclude“LifeValueTerms”and“BehavioralScripts.”

TBRI®iscurrentlylistedontheCaliforniaEvidence-BasedClearinghouse(CEBC)forChildWelfare.Itisratedasbeing“highly”relevantbecauseitisdesignedtobeusedwithchildren,youth,youngadults,and/orfamiliesreceivingchildwelfareservices.TheCEBCgaveitascientificratingofthreeandconsidersittohavepromisingresearchevidence.TrainingRequirements

TBRI®isdesignedtoprepareprofessionals(e.g.,therapists,caseworkers,fosterandadoptioncarespecialists,occupationaltherapists,medicalprofessionals,counselors,CASAworkers,andearlychildhooddevelopmentspecialists)toworkwithchildrenandyouthwhohaveexperiencedtraumaandtheirfamilies.Phase1ofthetrainingconsistsoffiveunitsofonlinecourseworktobecompletedinthe10weekspriortotheon-sitetraining.Thisinitialworkestablishesaknowledgebasefortheon-sitetraining.Phase2ofthetrainingrequiressuccessfulcompletionofPhase1andconsistsoffivedaysofintensiveon-sitetraining.TexasImplementationAlmost700professionals,paraprofessionals,caregivers,andfaith-basedleadersareidentifiedasTBRI®campalumni.Morethan75havecompletedthetrainingrequirementstobecomeeducators.Child-placingagencies,emergencyshelters,generalresidentialoperations,andtreatmentfacilitiesthroughoutthestatehavechosentoimplementTBRI®.Inadditiontoagency-wideimplementation,therearetwocommunity-basedsystemeffortstoimplementTBRI®,oneinTravisCountyandoneinFortWorth.MentalHealthConnections(MHC)isexaminingthefeasibilityofaTBRI®collaborationwithTarrantCountyandTexasChristianUniversity(TCU)andtheKarenPurvisInstituteofChildDevelopment(KP-ICD).TheTravisCountyCollaborativeforChildren(TCCC)waslaunchedin2014toimproveoutcomesforfosterchildrenthroughthepowerofcollectiveimpact.

Summary of Key Informant Interviews

MMHPIconducted75keyinformantinterviewsfromFebruary2017toJune2017togainabetterunderstandingoforganizationalandsystemeffortstoimplementTICinTexas.KeyinformantswereaskedtodefineTIC,todiscusshowtheywereoperationalizingtheirdefinition,toidentifythekeycomponentsrequiredtobeatrauma-informedagency,todiscussthebarrierstheyhadexperiencedwhenimplementingTIC,andtodescribetheirsuccesses.Weengagedawidearrayoforganizationsandsystemsthatworkwithchildreninfostercare,includingstateagencies,childwelfareagencies,fostercareagencies,CourtAppointedSpecialAdvocates(CASAs),judges,researchersandtrainersfromTICmodelsandapproaches,andothercommunityagencies.TheorganizationaldiversityoftheseinterviewswasintendedtoincorporatetheexperiencesandperspectiveofmultiplechildwelfareentitiesintoacommonunderstandingofTICinTexasandtoalignprioritiesforimplementingTICinTexaswhenappropriate.Belowisasummaryoftheirresponses.AlistofallkeyinformantscanbefoundinAppendixThree.HowTexasDefinesTrauma-InformedCare(TIC)WeaskedkeyinformantshowtheydefineandimplementTIC.Allrespondentseasilydefinedthisconceptanddemonstratedasolidunderstandingoftheprevalenceandimpactoftraumaonthechildrenandyouththeyserved.Theirresponsesalignedwiththecorecomponentsoftheprimarydefinitionsprovidedaboveandincludedreferencestovariousnationalandregionaldefinitionsandmodels,includingthosebytheSubstanceAbuseMentalHealthServicesAdministration(SAMHSA),theNationalChildTraumaticStressNetwork(NCTSN),theCenterforHealthCareStrategies(CHCS),theThreePillarsforTraumaWiseCare,86DanSiegel’sWholeBrainChild,87theNationalCoalitionforTrauma-InformedCare,theTrauma-InformedCareConsortium(TICC)ofCentralTexas,andtheTravisCountyCollaborativeforChildren(TCCC).Thefollowingcorecomponentswereidentifiedconsistentlyacrossthemajorityofkeyinformants.

• TICstartswiththeawarenessthattraumaexistsandanunderstandingoftheimpacttraumahasonchildren,youth,andtheirfamilies.

Trauma-informedcare“startswithadeepunderstandingofACEsandtheimpactoftrauma,includinghowtraumaimpactsachild'sabilitytocope.”DallasChildAdvocacyCenterkeyinformant

86Bath,H.(2015).Threepillarsoftraumawisecare:Healingintheother23Hours.ReclaimingChildrenandYouth.23(4).Retrievedfromhttp://traumebevisst.no/kompetanseutvikling/filer/23_4_Bath3pillars.pdf87Dr.DanSiegel.Inspiretorewire.Retrievedfromhttp://www.drdansiegel.com/about/biography/

Allindividualsinterviewedwereknowledgeableoftheeffecttraumahasonthedevelopingbrainandhowtraumacanresultincopingbehaviorsthatcanbemisunderstoodasdefianceoraresultofattentionproblems.TheworkofDr.DanSiegel,founderandco-directoroftheMindfulAwarenessResearchInstituteatUCLA,wasmentionedseveraltimestounderscoretheimportanceofthisawareness.Keyinformantsstressedhowimportantitwasforeveryoneinachild’ssphere—includingparents,fosterfamilies,caseworkers,advocates,attorneys,mentalhealthandfostercareproviders,andprobationofficers—tounderstandtraumaandtheimpactsoftrauma.Inaddition,severaldiscussedtheintergenerationalimpactoftraumaandtheimportanceofworkingwiththewholefamilytoeliminatethenegativeimpactsoftraumaandsetthestageforhealing.Oncethereisanunderstandingoftraumaanditsimpact,assessingfortraumaandrecognizingrelatedbehaviorsandsymptomsisneededtoimplementTIC.Thiscanbedonethroughformalassessmentsorconversationswiththechildandfamily.AfewkeyinformantssuggestedthatuniversalscreeningsandassessmentsarenecessarytoimplementTIC.

• TICmustbeacoreorganizationalvalueandanintegralpartoftheculture.

“You[organization/agency]cannotgothroughonetrainingandthinkyouaretrauma-informed.Itisashiftinculture.”TheVillageNetwork-Ohiokeyinformant

ThemajorityofrespondentsstressedthatTIChastobepartofthefoundationanorganizationisbuilton.Itneedstobeatthecoreofeverythinganorganizationoragencydoes.Thisrequiresashiftinorganizationalcultureandoperations.TICshouldbewoventhroughitspolicies,procedures,training,andservicedelivery.Everydecisionanorganizationmakesshouldbeintentionalandtrauma-informed.Allstaffintheorganization,fromthefrontdesktoleadership,shouldrecognizethewidespreadimpactoftrauma.IntegratingTICintoalllevelsofanorganizationimprovestheorganization’sabilitytoeffectivelyrespondtotheimpactsoftraumaonitsworkforceandonthechildren,youth,andfamiliesitserves.

• Organizationsmustprovideservicesandsupportsinawaythatistransparent,instillstrust,andensuresthatchildren,youth,theirfamilies,andthestaffthatservethemfeelsafe.

Trauma-informedcare“startsatthefrontdoorandcontinuesthroughmultiplelevels.”AustinTravisCountyIntegralCarekeyinformant

Themajorityofkeyinformantsmentionedsafety,transparency,andtrustwhendefiningTIC.ManyindicatedthattheyachievetheseaspectsofTICbyprovidingservicesinasafeand

confidentialenvironment,usingclearlanguagetocommunicateexpectationsandnextsteps,andtreatingpeoplewithdignityandrespect.Respondentsunderscoredtheimportanceofensuringthatstaffandclientsfeltphysicallyandemotionallysafewhenenteringthebuilding,seekingservices,orbeingprovidedsupport.Therewasageneralconsensusthatinordertoachievethis,allstaffmemberswhointeractwithachildoryouth,includingfront-linestaff,neededtobetrainedinTIC.Severalkeyinformantsdescribethisasviewingallchildren,youth,andtheirfamiliesthrougha“trauma-informedlens.”

• Relationshipsareintegraltotrauma-informedcare.

“Themembersofthecourtconsidertrustandattachmentascriticaltohavingpositiverelationshipswithchildrenandtheirfamilies.”The321stCourtofSmithCountykeyinformant

Developingandmaintainingrelationshipswasidentifiedbymanyofthekeyinformantsasthefoundationfortreatingtrauma.Severalrespondentsdescribedrelationshipsashealingandreparative.Othersnotedthatastrongconnectionorattachmenttoanadultcaregiverwasnecessarytodevelopingfeelingsofsafetyandtrust.Stillothersstressedthatinordertoconnectwithachildoryouth,theyfirsthadtounderstandthattheirbehaviorswerenotpersonallydirectedtocaregiversandstaff;rather,theseinformantsnotedtheneedtobemindfuloftheirownabilitytoconnect.

• Providingtrauma-informedcaremeansprovidingindividualizedcare.KeyinformantssaidthatTICrequiresmeetingchildrenandyouth“wheretheyare.”Eachchildisunique,includingthetraumatheyhaveexperienced,theimpactithashadonthem,andtheneedsthatresultfromit.Atrauma-informedtreatmentplantakesintoconsiderationachild’shistoryoftrauma,isholistic,andaccountsfortheemotional,educational,physical,andbehavioralneedsofthechild.Selectedinterventionsneedtotakeintoconsiderationachild’sbraindevelopmentandshouldaddressthetraumathechildhasexperienced.Thisapproachrequiresindividualizedcareandtreatmentoptions.Nosingleinterventionwillmeettheneedsofeverychild.

• Servicesandsupportsshouldnotre-traumatizeachildoryouth.

Whenprovidingservices,providers“wanttopreventtraumaandpreventre-traumatization.”TexasChildrenRecoveringfromTraumakeyInformant

Finally,afewkeyinformantsdiscussedtheimportanceofavoidingre-traumatizationwhenprovidingservicesandsupportstochildren,youth,andtheirfamilies.Severalrelayedconcernsthatthechild-servingsystemsinTexasoftenminimizetheimportanceofattachmentandcommunity,therebyre-traumatizingthechildrentheyserve.ASharedCommunityDefinitionKeyinformantsfromTravisCountyusetheTICdefinitionthatwascreatedbytheTravisCountyCollaborativeforChildren(TCCC).Thiscollaborative,cross-disciplinarydefinitionprovidesacommonunderstandingofTICacrossmultipledisciplines,child-servingagencies,andcommunitymembers.TheTCCCdefinitionoftrauma-informedcareiscontainedinAppendixSix.HowTrauma-InformedCareIsOperationalizedWhenkeyinformantswereaskedhowtheyoperationalizedorimplementedTIC,allrespondentsindicatedthattheytrainedstaffinrecognizingandunderstandingtheimpactoftrauma;formallyorinformallyscreenedandassessedfortrauma;providedasafeenvironment;andimplementedtrauma-focused,evidence-basedapproaches.Someofthekeyinformantsdiscussedtheneedtounderstandhowtraumaimpactstheworkforce.However,thesestepswerenotcoordinatedorintegratedintosomeorganizations’missions,strategicplans,policies,andprocedures,norweretheyreflectedinorganizationalculture.Onlyahandfultalkedabouttakingstepstodrivetrueorganizationalorsystemchange.Themajorityofrespondentsthatdidtakethesestepswereinvolvedinabroadersystem-wideefforttoaddressTICthatprovidedalenstoviewtrauma,acommonlanguage,andasetoftoolstoaddresstraumathatcouldbeusedbyabroadcross-sectionofstaffandcommunitymembers.Trauma-InformedTraining

KeyinformantsemphasizedthatinitialandongoingtrainingwerenecessarytoimplementTIC.Allidentifiedtheneedtotraineveryone,includingsupportstaff,front-linestaff,leadership,andboardmembers.MostrespondentsreportedthattheyprovideTICtrainingaspartoftheirnewemployeeorientation,andsomenotedthattheyprovideannualrefreshertraining.Allkeyinformantsstressedthefactthatagency-widetrauma-informedtrainingeffortsrequireleadershipsupportandacommitmentofresources.ScreeningandAssessmentBeingtrauma-informedrequiresstafftorecognizethesignsandsymptomsoftrauma.Themajorityofthekeyinformantsdiscussedtheneedtoscreenandassessfortrauma.SeveralkeyinformantsrecognizedtraumascreeningtoolssuchastheAdverseChildhoodExperience(ACE)Questionnaire,ChildandAdolescentTraumaScreening(CATS),ChildandAdolescentNeedsandStrengthsAssessment(CANS),ortheChildhoodTrustEventSurveytoassessfortrauma.Other

respondentsnotedthattheyinformallyscreenedandassessedfortraumabyintegratingquestionsontraumaintotheircurrentassessment.Safety

WhenkeyinformantswereaskedabouthowtheyoperationalizedTIC,theirmostfrequentresponseswererelatedtosafety.Mostrespondentsdescribedcreatingawelcoming,comforting,safe,andpredictableenvironmentforchildrenandfamilies.Thiswasaccomplishedinavarietyofways,includingaddingmoreseatingandatelevisiontowaitingareas,confirminglightsinparkinglotsfunctioned,offeringsnacksandwater,fillingroomswithstuffedanimals,bringinginservicedogs,andensuringchildrenandyouthhadaccesstoaprivate,quietspace.Organizationswithresidentialfacilitieshavecreatedplayrooms,regulationsrooms,chillspaces,andcomfortzonesforchildrenandyouth.SecondaryTraumaticStressandCompassionFatigue

Mostkeyinformantsfeltstronglyabouttheneedtoaddresssecondarytraumaticstressandcompassionfatiguewithintheirworkforce.Describedstrategiesincludeprovidingregularsupervision,implementingbreaks,adjustingcaseloads,beingflexiblewithworkschedules,andencouragingself-care.Severalkeyinformantsdescribedpromotingteam-buildingactivities,usingagroupapproachtohandlechallengingsituations,andofferingstaffwellnessprogramsthatpromotephysicalactivityandprovideaccesstocounselingservices.However,amajorityofrespondentsindicatedthatregulatorystatutes,stateandorganizationalpolicies,andfundingconstraintslimitedtheirabilitytoeffectivelyaddressthelevelsofsecondarytraumaticstressexperiencedbystaff.Trauma-InformedCulture

SuccessfulimplementationofTICrequiresachangeinorganizationalculture.KeyinformantsdescribedTICasachangeinphilosophyandculturethatisfullyembracedbytheorganization’sleadership;isrootedintheorganization’smission,vision,values,policies,andprocedures;isdrivenbyanorganizationchampion;andhasstaffbuy-in.Theyprovidedmultipleexamplesofhowtheirorganizations’culturesandoperationsshiftedtobemoretrauma-informed.TheseshiftsincludedincorporatingTICtrainingintonewemployeeorientation,changingjobtitlesandjobdescriptionstobemoretrauma-informed,updatingagencyforms,creatingTICstudyguidesforsupervisorsanddirectcarestaff,creatingTIC-specificformstoproblem-solveday-to-daysituations,andadjustingstaffcaseloadsizeanddistribution.Informantsfromresidentialfacilitiesalsodiscussedtakingmeasurestoreduceseclusionsandrestraints,doingawaywithlevelsystems,andpromotingrelationshipbuildingasameanstoindividualizecare.SeveralofthekeyinformantsnotedthatorganizationalchangesaroundTICwerenotalwaysuniversallyacceptedandcouldresultinsomeinitialstaffturnover.

SomekeyinformantsidentifiedTICchampionswithintheirorganizationwhohelpedspearheadTICefforts.TICchampionshelpimplementTICwithinanorganizationoragencybyfosteringinterestandgrowth,boostingmorale,providinginspiration,andsupportingandcoachingstaff.SomeorganizationshaveTICnewslettersore-mailsthatincludetipsandexamples,whileothershavedesignatedspaceintheirbuildingwherestaffcanwritedownTICideasandlessonslearned.OrganizationshavealsocreatedcoreTICinternalteamsthatmeetconsistentlyandprovidemonthlypeerlearningactivitiesandbi-monthlycoachingsessions.TheseadjustmentsensurethatTICcontinuestoexpandwhithinanorganizationoragency.Collaboration

KeyinformantsemphasizedtheimportantceofcommunitycollaborationtoimplementingTIC.Thecourtsdescribedtheneedtoengagecommunitiestosupportfoster,kinship,andbiologicalparents.Severalchild-placingagenciesexpressedtheneedtodevelopasupportivewebofpositiverelationshipsthatreachedbeyondtheserviceprovidersandincludedeveryoneachildorfamilymightencounter.ThebackboneagenciesforTravisCountyandFortWorthdescribedthecommunitycollaborative’sroleinsupportingtheimplementationofasingletrauma-informedintervention.Theydescribedtheprocessofselectingasingleapproachasacatalystforcommunitybuy-in.Thistacticprovidedthecommunitywithacommonlanguagethatwasunderstoodacrossdisciplinesandservicesystems.KeyinformantsincommunitieswhereasingleapproachhadbeenidentifiedoperationalizedTICwithinthecontextofthatapproach.Evidence-BasedTrauma-FocusedApproaches

Basedoninformationprovidedbykeyinformants,thereareareasonablenumberoftrauma-focusedapproachesandinterventionsavailableinTexas.However,accesstotheseapproachesandinterventionsislimitedbylocation,fundingstreams,reimbursement,prioritypopulations,andprovidercapacity.Themostcommontrauma-focusedapproachidentifiedbykeyinformantsisTBRI®,anattachment-based,trauma-informedinterventiondevelopedbyDr.KarynPurvisandDr.DavidCross.TheTravisCountyCollaborative(TCCC)identifiedTBRI®astheframeworkforreachingtheirgoalofacceleratinghealinganddecreasingtimetopermanencyforchildreninfostercare.Asaresult,variouschild-placingagenciesandproviderswhoservechildrenandyouthinfostercareinTravisCountysharedthesuccesstheyexperiencedthroughthisapproach.Trauma-FocusedCognitiveBehavioralTherapy(TF-CBT),anevidence-basedtreatmentforchildrenandadolescentsimpactedbytrauma,isthemostcommonlyprovidedtrauma-focusedinterventionofferedthroughoutvariouspartsofTexas.TF-CBTisofferedbyawidevarietyofproviders,includingLocalMentalHealthAuthorities(LMHAs),ChildAdvocacyCenters,mentalhealthproviders,childwelfareagencies,andfostercareagencies.SomeproviderspartnerTF-CBTwithotherevidence-basedpractices,suchasEyeMovementDesensitizationand

Reprocessing(EMDR).Othertrauma-focusedinterventionscommonlyprovidedincludeParentChildInteractionTherapy(PCIT),SeekingSafety,andSolutionFocusedTherapy.Manykeyinformantssharedthatwhenchoosingtrauma-focused,evidence-basedinterventions,itisimportanttoindividuallyassesschildrenandfamiliesandseektheirinputtodevelopthebesttreatmentbecausenosingleinterventionmeetseveryone'sneeds.Acompletelistoftrauma-informedframeworksandinterventionsutilizedbykeyinformantscanbefoundinAppendicesFourandFive.WhatAretheBenefitsofTIC?Accordingtokeyinformants,childrenandfamiliesintrauma-informedenvironmentsaregainingunderstandingoftraumaandwhathashappenedtothem.Familiesarelearninghowtopredicttheirowncycleofcrisis,prepareforstressfultimes,andreducereactionstotrauma.Theyarealsobecomingmoreresilientandopentoservices.Theservicesprovidedarebeingmatchedtothechildandtheirneeds.Assuch,childrenandfamiliesarefeelingmoresecureandknowledgeableintheservicestheyarereceiving.Childrenaredevelopinglong-lastingrelationshipsthatwillcontinuetosupportandempowerthem.Themajorityofkeyinformantsidentifiedmeasurablebenefits,suchasadecreasesinphysicalholds,restraintsandseclusions,runaways,medicationuse,psychiatrichospitalizations,andno-shows.Theyalsosawincreasedreunificationsandchancesofpermanency.TherearealsostaffbenefitsfromimplementingTIC.Keyinformantsstatedthatstafffeelincreasedempathyforthechildrenandfamiliestheyserve.AlthoughsomeagencieshaveexperiencedturnoverwhenfirstimplementingTIC,mostkeyinformantsnotedthattheyhavehigherstaffretentionandjobsatisfaction.Stafffeelempoweredandinvestedintheirroles.Theytakeprideintheirworkandfeeltheyaremakingadifference,creatingadeepersenseofvalueandsupport.TICalsoimpactshowstafftreateachother;staffhaveamorerelationalapproachandsupportoneanotherintheworkthattheydo.Finally,keyinformantssaidthatTIChelpsdecreaseinstitutionaltraumaandreducesthechanceofre-traumatizingchildrenandfamilies.BarrierstoImplementationKeyinformantsidentifiedvariousbarrierstoimplementingTICwithintheirorganizationoragencyincludinglimitedresources,staffingneeds,regulatorystandards,andstafftrauma.AdditionalbarriersincludedchallengesdefiningTIC,measuringprogresstowardbecomingtrauma-informed,andovercomingalackoftrauma-informedcommunityproviders.Noneofthebarriersidentifiedwererelatedtodeliveringbillableservicesandsupports.

Developingandsustainingtrauma-informedcarerequireschangeatmultiplelevelsoftheorganizationandthefundingstructuresthatsupporttheprinciplesunderlyingthisapproach.Traditionalfundingstreamsallowfortheprovisionofevidence-basedtraumascreening,assessment,treatment,andrecoverysupports.Texas’sMedicaidStatePlanfundstraditionaltrauma-focusedoffice-basedtherapies.Thelocalmentalhealthauthority(LMHA)providestraditionaltrauma-focusedtherapies,casemanagement,rehabilitationskillstraining,andfamilysupportservices.TheYouthEmpowermentServices(YES)Waivercoversnon-traditionalservicesandsupportforchildrenatriskofpsychiatrichospitalizationorout-of-homeplacement.Communityprovidershaveaccesstofreetrainingontrauma-focusedtherapies,andgeneralrevenuecoversaportionoftheLMHA’scostfortrainingandsupervision.However,thesefundingstructuresdonotsupportthedevelopmentofappropriateandsafefacilities;peerandsupervisorysupportforprofessionals,staff,andcaregivers;thedevelopmentandimplementationofgeneraltraumatrainingforallstaff;thedevelopmentofcross-agencycollaborations;andtheevaluationoftrauma-informedprogramsandservices.Keyinformantsindicatedthattherearecoststodevelopingandimplementingorganization-widetrainingonTIC.TheydescribedthestafftimerequiredtoattendtrainingsingeneralTICandintrauma-informedevidence-basedpracticesandtoparticipateinthesupervisionrequiredforcertification.Theydiscussedthecostoftrainingprofessionals,staff,caregivers,andcommunitymembersintrauma-informedcommunicationstrategies(ReachingTeensã)andmodelsofcaregiving(TBRIâ).Tworespondentsindicatedthattheyneededafull-timepositiondedicatedtoTIC.ThispositionwouldensurethatTICisconsideredinallorganizationaldecisionsandisinterwoventhroughtheagencies’policiesandpractices.Organizationsthataretrauma-informedprovideasupportiveworkenvironmentthatrecognizes,andguardsagainst,theimpactsofsecondarytraumaticstressandcompassionfatigueontheirstaffmembers.Thisawarenessincludesensuringthatstaffarefairlycompensatedfortheworktheydo,caseloadsizesaremanageable,intensivecasesarebalanced,andstaffareprovidedwithadequatesupportandsupervision.Someoftherespondentsindicatedthatthiscanbedifficultduetolimitedagencyresources,regulatorystandards,andstateservicerequirements.KeyinformantsalsoindicatedthatunresolvedstafftraumaandresistancetochangecanbebarrierstoimplementingTIC.Attachmentandattachmentstylesplayaroleinastaffperson’sabilitytodeveloppositiverelationshipswiththechildrenandfamiliestheyworkwith.Inaddition,staffresistancetochange,adherencetocontradictorymodels,orbeliefthatTICismerelyanadditionaljobdutycanmakeimplementingTICverydifficult.SeveralrespondentsnotedthatTICismostsuccessfulwhenallchild-servingentitiesandstakeholderswhoworkwithchildrenandfamiliesembraceandimplementTIC.Theysharedthatitcanbechallenging

tooperatewithotherentitiesinthechild-servingsystemthatarenoteducatedonTICordonotbelieveintheTICphilosophy.SuccessfulCommunity-BasedCross-SystemEffortsThereareseveralnoteworthycommunitiesacrossTexasthathavebeensuccessfulindevelopingcross-systemeffortstoimplementTIC.Sixarehighlightedbelow.Thesecommunityeffortsshareahandfulofcharacteristicsthatappeartohaveledtotheirsuccess.Allofthecommunityeffortsareledbyanindividualororganizationinaleadershiproleinthecommunity.Allthecross-systemeffortsaresupportedbygrantorfoundationfunding.Threeofthesixeffortsarerootedinatrauma-focused,evidence-informedapproachthatiseasilyunderstoodandcanbeutilizedbyprofessionals,families,andcommunitymembers.TwoweresupportedbytheNCTSN—oneatastatelevelandonethroughauniversity.Finally,twotookanecologicalorcollectiveimpactapproachtocommunitychange.MentalHealthConnections(MHC)–FortWorth,Texas88

MHCisuniqueinthestateofTexas.Itisacommunityofnot-for-profitorganizationsthatusesacollectiveimpactmodeltoaddresscommunityneed.MHCissustainedbyadues-basedmembership.Itslong-termstrategicapproachtochangeismultifacetedanddesignedtoensuresustainability.BelowisabriefoverviewofselectMHCinitiativestoaddressTIC.

• Evidence-BasedPractices:In2008,MHCprovidedtrainingonTF-CBTto59practitionersfrom13agenciesandthreehospitals.Thispilotwastheresultofalearningcommunityontrauma.AnthonyMarrino,PhD,co-developerofTF-CBT,providedtraining,andMollyLopez,PhD,fromtheUniversityofTexasatAustinconductedanevaluationoftheyear-longproject.ThisprojectprovidedthefoundationforMHC’sgoaltobecomeatrauma-informedcommunity.

• SocialMediaCampaignonTrauma:Asafoundationforitstrauma-informedefforts,MHClaunchedathree-yearsocialmarketingcampaignin2013designedtoeducatethecommunityabouttrauma.Thecampaigneducatedparents,teachers,andprofessionals.

• TraumaSymposiums:MHCconductedcross-agencytrainingsonevidence-basedtraumapracticesandheldthreesymposiumsontrauma.In2013,KennethGinsburg,MD,presentedinformationonbuildingresiliencewithtraumatizedchildren.In2014,StuartAblon,PhD,provided1,000practitionerswithanoverviewofCollaborativeProblemSolving.In2016,VincentFelitti,MD,founderoftheDepartmentofPreventativeMedicineforKaiserPermanenteandco-principalinvestigatoroftheAdverseChildhoodExperienceStudy,providedapresentationonACEStoover1,000communityproviders.

• Resilience:AfterhostingaReachingTeens©trainingwithDr.KenGinsburg,MHCenteredintoathree-yearpilotproject.In2014,theMHCResiliencySubcommitteeand

88MentalHealthConnectionsofTarrantCounty.Retrievedfromhttp://www.mentalhealthconnection.org/committees

“ReachingTeensCaptains”from10partneringagenciesbeganmeetingtocoordinateimplementation.EmilySpence-Almaguer,PhD,fromtheUniversityofNorthTexasHealthScienceCenter,developedandconductedanevaluationwiththesupportoftheRees-JonesFoundation.AfinalreportwillbepresentedtothecommunityinSeptember2017.TheseeffortshavebeensosuccessfulthatMHCiscurrentlyworkingwithseveralcommunitiesoutsideofTexastoimplementtheReachingTeensãcurriculum.Inaddition,MHCiscompletingthedevelopmentofa“TarrantCountyGuide”toimplementingReachingTeensã,acompaniontoReachingTeensãthatwillbepublishedbytheAmericanAcademyofPediatricians.

• Trust-BasedRelationalInterventions(TBRI®):TheMHCTraumaTransitionCommitteeisfocusedonthreeareas:determiningtheneedforfurthercommunityeducationandtraining,completingtheanalysisofacommunity-wideimplementationoftheACEsscreeningtool,anddetermininginterestinandfeasibilityofdoingacollaborativepilotwithTexasChristianUniversity’sKarynPurvisInstituteforChildDevelopment.

• AdverseChildhoodExperiences:MHChasavisiontomakeFortWorththefirstcityintheUnitedStateswithacomprehensiveapproachtoaddressingAdverseChildhoodExperiences.IthasbeenimplementingACEquestionnairesacrossthecountyandhasinternsanalyzingthisdata.MHChasbroughtinDr.VincentFelitti,oftheCaliforniaInstituteofPreventativeMedicine,andisplanningamulti-stakeholderplanningmeetinginthesummerof2017.

• Resilient/Trauma-InformedCommunityStrategicActionPlan:InJune2017,MHCapprovedastrategicactionplantoadvanceitsgoaltobecomeaResilient/Trauma-InformedCommunity.InadditiontoTBRIâimplementation,theplanwillfocuson(1)creatingacomprehensivetrauma-focusedsocialmarketingandcommunicationsplanformultiplestakeholdergroups;(2)creatingalearningcommunitytoidentifyandreviewassessmentandscreeningtoolsforresilienceandtraumaandmakerecommendationstoappropriatedisciplinesforutilizationinTarrantCounty;(3)creatingalearningcommunitytostudybestpracticesforself-careandmakerecommendationsforutilizationacrossagenciesinTarrantCounty;and(4)creatingacentralizedrepositoryofallresilienceandtraumatrainingoptionsinTarrantCounty.

SmithCounty’s321stDistrictCourtwithJudgeCaroleClark–Tyler,Texas

JudgeCaroleClarkleadsthe321stDistrictCourtinTyler,Texas,whichhandlesfamilylawcases.JudgeClarkandherteambegantheirtrauma-informedjourneyabout10yearsago,afterhearingthelateKarenPurvisfromTCUpresentontraumaandonTBRI.TheCourt’sunderstandingoftraumaisrootedintheprinciplesofTBRI(Connecting,Correcting,andEmpowering),anditisthroughthislensthatthecourtroomisrun.AllofthecourtstaffandattorneysaretrainedintraumaandTBRI.

JudgeClarkandherteamrecognizetheimpactoftraumaonbraindevelopmentandhowitaffectschildrenandtheirparents.Theyviewthefamilyastheclientandaimtoprovideasafeandpredictableenvironmentinthecourtroom.Theyviewattachmentandtrustascriticaltohavingpositiverelationshipswithchildrenandtheirfamilies.Tomakecompletetreatmentplanandachievingreunificationlessoverwhelmingforfamilies,theCourthasmodifiedittreatmentplanintothreephases.Phase1addressessafety,includingdrugtreatment.Phase2addressesriskfactorsandincludesapsychologicalassessmentandenrollmentinservicesandsupportssuchasEMDR,trauma-informedtherapy,TraumaGroup,CircleofSecurity,parentinggroups,andAA.Phase3ismonitoredreturn,duringwhichthecourtprovidesin-homeservicesandsupportstoparentstohelpthemmanagechildren’sbehaviorswhentheyreturnhome.Theprogramtriestoensurebondingbetweeninfantsandtheirmothersthroughincreasedvisitations.TheCourthasalsoincorporatedatransitionperiodinwhichfosterparentsandbiologicalparentscanmeettodiscusstheroutineofthechild,hisorherlikes,triggers,andthingsthathelpsoothehimorher.AllserviceprovidersandfosterparentsutilizedbythecourtaretrainedinTBRIandprovideservicesandsupportsinmannersthatalignswiththetrauma-informedvaluesofthecourt.ParentsandfosterparentsareencouragedtoreadTheConnectedChildandviewthevideoseriesasaresourcetounderstandtraumaandwaystoaddressit.Acoremanagementteammeetstwiceamonthtodiscussprocesses.ThecourtteamalsoholdsbookclubsduringwhichmembersreviewbooksrelatedtoTIC.Resourcesarededicatedtothedevelopmentoftrauma-informedservicesandsupportsinthecourtroomandinthecommunity.TexasChildrenRecoveringfromTrauma(TCRFT)–DepartmentofStateHealthServices(DSHS)89Throughafour-yearcooperativeagreementfromtheNationalChildTraumaticStressNetwork(NCTSN),DSHS’sTCRFTestablishedthefollowinggoals:

• Transformthepublicchildren’smentalhealthservicesystemintoatrauma-informedsystembytrainingtheworkforce,enhancingtrauma-informedpoliciesandpractices,increasingtheuseoftrauma-informedscreeningtools,providingtrauma-specificpracticesandtreatments,andincreasingaccesstotrauma-informedservices

• CreatepartnershipsthatpromoteaccesstoTIC• Evaluateoutcomesoftrauma-informedtreatment

89Lopez,M.A.,Borah,E.,Oh.,S.,Patmore,J.(2016,December).Texaschildrenrecoveringfromtrauma:finalevaluationreport.TexasInstituteforExcellenceinMentalHealth,SchoolofSocialWork,UniversityofTexasatAustin.

• Increasechildfunctioning,increasechildandcaregiverstrengths,anddecreaseneedsandriskbehaviorsthroughtheprovisionoftrauma-focusedtreatments

• Increasethenumberofchildrenscreenedbyintegratingtraumascreeningpracticesintocommunity-basedmentalhealthorganizations

TheTCRFTinitiativeofficiallyendedin2016.Theinitiative’sfinalprogramevaluationbytheTexasInstituteforExcellenceinMentalHealthyieldedseveralfindingsandrecommendations.Notablefindingsrelevanttotrauma-informedsystemchangeincludedthefollowing:

• Thecreationofastrongimplementationteamwasacriticalfactorintrauma-informedorganizationalchange.

• Organizationsbegantheirchangeinitiativesbybuildingbuy-infromleadershipandbytrainingtheworkforce.

• OrganizationscouldachievemoderateprogressacrosstwoorthreeofSAMHSA’strauma-informedorganizationaldomains.

Relevantsystem-levelrecommendationsincludedthefollowing:

• Amodestamountoffiscalsupportresultedinsignificantgainsinbuildingatrauma-informedsystem.Thestateshouldconsiderutilizingasmallamountofdiscretionaryfundingtocontinuesupportingtheimplementationoftrauma-informedtreatmentapproachesandtrauma-informedpracticeswithinthesystem.

• Texasshouldconsiderencouragingtheuseofhigh-quality,highfidelity,evidence-basedtreatmentapproachesthroughfinancialincentivessuchastheuseofhigherreimbursementratesforcounselingprovidedbycertifiedTF-CBTorPCITproviders.

• Opportunitiesforcommunitiesorregionsofthestatetoshareresourcesandbuildcompetencyintrauma-informedapproachesshouldbesupportedastheseapproachesarelikelytomaintainbuy-inofkeychampionsacrossthestateandcreateefficienciesintransformationalefforts.

TravisCountyCollaborativeforChildren(TCCC)–Austin,Texas90,91

TCCCwaslaunchedin2013withthesupportofseveralcommunityfoundations.Itisintendedtocreatesystem-widechangetoimprovetheoutcomesofchildreninTravisCountythroughtrainingandcollaborationinthedeliveryoftrauma-informedservices.ThefollowingareTCCC’sobjectives:92

• Provideintensivetrainingandfollow-upsupportintrauma-informedpracticessuitableforthispopulation

90TCUInstituteofChildDevelopment(2016).Helpingat-riskchildren:Learningtochangetheworld…forchildren.YearinReview:2015–2016.91TravisCountyCollaborativeforChildren.Retrievedfromhttps://www.tccc-tx.org92Purvis,K.,Call,C.,&Cross,D.(2014).TBRI®andtheTCCC.

• Buildtrauma-informedcollaborativeagenciesandindividualsthatcanimplementandsustainahighlevelofTIC

• Evaluatethiseffortsothatthisprojectandsubsequentprojectsareinformedandimprovedbywhatislearned

Thecollaborativeisguidedbythreeconceptualmodels:authoritativecommunity,bioecologicalmodel,andcollectiveimpact.Theauthoritativecommunitymodelpurportsthatthebrainisprimedforrelationshipsandcommunity,therootofhumancommunitycanbefoundinearlyrelationships,andrelationshipsandcommunityarethewellspringtowell-being.Keycriticalfeaturesofthebioecologicalmodelaretransitions,connections,and“proximalprocess”(interactionsbetweenanindividualandenvironments).Finally,thecollectiveimpactmodelsupportsfundingsystemsofcaretoachievethesynergynecessarytoaddressasocialproblem.93TCCCisledbytheKarynPurvisInstituteforChildDevelopmentandMissionCapital.Itisoverseenbyasteeringcommitteeandanadvisorycouncilrepresentingnearly40differentagencies.Notableaccomplishmentsincludedraftingacommunity-widedefinitionofTIC,providingTBRI®trainingtoover1,550professionalsrepresentingmorethan350organizations,andimplementingthe“MeetingtheNeedsofChildreninCare”researchstudyinpartnershipwithTCU’sInstituteforChildDevelopment,theTravisCountyModelCourtforChildrenandFamilies,andCASATravisCounty.Trauma-InformedCareConsortiumofCentralTexas(TICC)–Austin,Texas94

TheTICCofCentralTexaswasfoundedin2013withthesupportoftheSt.David’sFoundation.LedbytheAustinChildGuidanceCenter,theTICC’smissionistocreateacomprehensivetrauma-informedcommunityforchildren,families,andprovidersthrougheducation,outreach,andtraining.ThegoaloftheTICCistoincreaseknowledgeoftraumathataffectschildrenandfamilieswithinthecommunity.Morethan60organizationsrepresentingmentalhealthproviders,medicalprofessionals,lawenforcement,school,andchildwelfarearemembersoftheTIC.TheTICChasdevelopedtraumascreeningstandardsforavarietyofdifferentsettings,providestraumatraining,onlineresourcesfortraumascreeningsandassessments,distributesamonthlynewsletter,maintainsaconsolidatedcalendaroftrauma-informedtraining,andholdsquarterlymeetings.Inadditiontothesecommunityeducationefforts,theconsortiumhoststheCross-DisciplineTraumaConferenceofCentralTexas.Thisbiannualconferenceshowcasesnationalexpertsandcommunityefforts.

93Purvis,K.,Call,C.,&Cross,D.(2014).TBRI®andtheTCCC.94TheTrauma-InformedCareConsortiumofCentralTexas.Retrievedfromhttps://www.traumatexas.com

TheTICCdevelopedanddistributedaTrauma-InformedOrganizationalReadinessSurveyin2014,2015,and2016.Eighty-sevenindividualsfrom70agenciesrespondedtothe2015survey.Keyfindingsindicatedthateventhoughmorethanhalfoftheorganizationsthatrespondeddescribedthemselvesastrauma-informed,justover10%hadanofficialtrauma-informedpolicy.Onlyonethirdofagenciesscreenedfortrauma.Costandadministrativebuy-inwerethebiggestbarrierstoimplementingTIC.Finally,229trainingswerereportedtotrain7,553professionalsinTIC.95TraumaandGrief(TAG)CenterforYouth–Houston,Texas

TheTexasTraumaandGrief(TAG)CenterforYouth,housedwithinTexasChildren’sHospital,isoneof25SAMHSA-funded,CategoryIITreatmentandServicesAdaptationCentersoftheNationalChildTraumaticStressNetwork.ItistheonlyCategoryIICentertospecializeinchildandadolescentbereavement.Itsprimarymissionistoincreasethestandardofcareandaccesstobest-practicecareamongtraumatizedandbereavedchildren,youth,andtheirfamilies.TheTAGCenterusesstate-of-theart,empiricallyvalidatedscreeningtoolstoensurethatyouthreceivethemostappropriateandeffectiveintervention.TheirprimarytreatmentsincludeTrauma-FocusedCognitiveBehavioralTherapy(TF-CBT)andTraumaandGriefComponentTherapy(TGCT).Theyservedapproximately300childrenandyouthbetweentheages7-17in2016.TheTAGCenterhastrainedtheHoustonIndependentSchoolDistrict,YESPrep,andtheSpringBranchIndependentSchoolDistrictonassessmentofchildhooldtraumaandbereavementandTGCT.TheyarecurrentlytalkingwiththePasadena,Alief,andHumbleIndependentSchoolDistricts.Inadditiontoitsworkwiththeschools,theTAGCenterhasinitiatedtheHoustonChildTraumaConsortiumtopromotenetworkingrelatedtotraumaandtoconductacommunity-widetraumaneedsassessment.Thegrouphasmetfourtimesoverthepastyear.Finally,asaNCTSNCategoryIICenter,theTAGCenteriscurrentlypreparingtofacilitatealearningcommunitycomprisedof10differentorganizationsacrosstheUnitedStates.LocalMentalHealthAuthorities(LMHAs)TICEffortsRepresentativesfromfiveTexasLocalMentalHealthAuthorities(LMHAs)thatservechildrenparticipatedinkeyinformantinterviewsfortheMMHPIresearchdescribedinthisreport.AlltheLMHAsareinvolvedinactivities,consortiums,orcollaborativestomovethemtowardsprovidingTIC.TheirexperiencesinimplementingTICwerelikethoseofotherkeyinformants,buttheysharedadditionalbarriersthatarespecifictoLMHAs.

95Crosbie,S.(2015).TICC’sTrauma-InformedOrganizationalReadinessSurvey.Retrievedfromhttps://www.traumatexas.com/publications-newsletter/

TICatanOrganizationalLevel

ThreeoftheLMHAsthatparticipatedinkeyinformantinterviewswerelearningcommunitiesintheTexasChildrenRecoveringfromTrauma(TCRFT)LearningCommunitiesinitiativethroughtheTexasDSHS.TheinitiativewasfundedbySAMHSAandincludedcollaborationwithNCTSN.ThelearningcommunitieswerepartofastatewidetransformationofbehavioralhealthsystemsintendedtohelpcommunitiesimplementTIC.Thecommunitiescreatedcoreimplementationteams,whichincludedpeoplewithlivedexperience.Theyselectedareaswithintheirorganizationsthattheywantedtofocusonimproving.Theyreceivedtraining,participatedinnetworkingevents,andparticipatedinmonthlycallswiththeNationalCouncilonBehavioralHealth.TheKlara’sCenterforFamilies,oftheHeartofTexasRegionMHMRCenter,wasanearlygranteeinthisinitiative.ItreceivedsupporttobecomeaNCTSNCategoryIIICommunityTreatmentServiceCenter.Aspartoftheinitiative,theKlara’sCenterforFamiliesprovidedservicestochildrenandyouthwhohadbeenexposedtotraumaticeventsorwhowerechildrenofmilitaryfamiliesimpactedbymilitarytransitions.TheLMHAkeyinformantsindicatedthattraumaawarenessneededtobeembeddedintheirorganizationsatalllevels.Theyareallmakingorhavemadeeffortstoensurethatallstaff(fromadministrativetoleadership)aretrainedinTIC.Theybelievethatitisimportanttounderstandtraumawheninteractingwithandprovidingservicestotheirclients.Informantsalsodiscussedtheireffortstowardsbecomingatrauma-informedagency,notjustonethatprovidesservicesthataddresstrauma.Theydiscussedtheimportanceofensuringthatstafffeelsupportedinfindingawork-lifebalancegiventhedemandsoftheircontracts.Somestressedtheimportanceofhavingbuy-infromleadershipandaddressingpoliciesandproceduresasnecessarycomponentstowardsbecomingatrauma-informedagency.LMHArepresentativesdiscussedhowmakingchangesintheiragenciestobemoretrauma-informedimpactsclientoutcomesandstafflongevity.LMHATrauma-FocusedApproachesLMHAshavebeentrainedinandareimplementingseveralevidence-basedpractices.TheytypicallyprovidetheinterventionsthathavebeenapprovedbytheTexasDSHS,whichformostLMHAsincludeSeekingSafety,Trauma-FocusedCognitiveBehavioralTherapy(TF-CBT),andParentChildInteractionTherapy(PCIT).SomearealsotrainedinAttachment,Regulation,andCompetency(ARC);EyeMovementDesensitizationandReprocessing(EMDR);andTraumaAffectRegulation:GuideforEducationandTherapyforAdolescents(TARGET-A).OneLMHAexpressedinterestinhavingcliniciansandstafftrainedinTrust-BasedRelationalInterventions(TBRI®).

LMHA-SpecificBarriers

LMHAsfacesimilarbarriersasotherprovidersinbecomingtrauma-informedagencies,includingthecostoftrainingandthetimeneededforstafftoparticipateintraining.Whenstaffareattraining,theyarenotavailabletoprovideservicestoclients,andthisinavailabilityimpactsdirectservicehours.Largescaleoragency-widetrainingisalsoachallengeforthisreason.Additionally,staffturnoveraffectsthetraininginvestmentagenciesmake.Whenstaffwhohavebeentrainedinspecificinterventionsleave,agenciesmustinvestintrainingfornewstaff.LMHAsalsofacechallengesingettingallstafftobuyintobeingtrauma-informed.Staffmayhavebeentaughtindifferentmodelsormaynotaccepttheimpactoftraumaonpeople’slives.LMHAsalsofaceinsufficientstaffingfordedicatingonestaffpersontoensurethattheagencyremainsfocusedonTIC.Somehavedevelopeda“champions”modelinwhichonepersonateachlocationisresponsibleforensuringthattrauma-informedprinciplesareinfusedintoeverythingthatfacilitydoes.Severalhaveembeddedtraumaawarenesstrainingintotheirnewemployeeorientations.LMHAsalsofacebarriersthataremoreparticulartoindividualagencies.DSHSapprovestrainingthroughspecifictrainingproviders,andonlyspecificinterventionsareauthorizedfortraining.Theapprovedinterventionsdonotincludealltheevidence-basedinterventionsthataddresstrauma.LMHArepresentativesindicatedthatthereshouldbemoreflexibilityinthetrauma-focusedinterventionstheycanprovidesincethatflexibilitywouldresultinmoreindividualizedservices.LMHAstaffaretrainedinotherinterventions,buttheycannotimplementthemthroughtheircontractwiththestate.LMHAscannotbereimbursedforinterventionsthatarebeyondthescopeofwhattheyareauthorizedtoprovide.InterventionssuchasEMDRarenotpaidforthroughMedicaid.OthernontraditionalinterventionsthataclientmayneedarenotreimbursablethroughMedicaidunlesstheyouthiscoveredundertheYESWaiver.

Funding TIC

Texas’sMedicaidStatePlanfundssomeofthetraditionaloffice-basedtherapiesforchildrenandyouthwhohaveexperiencedtrauma.TheseincludeservicessuchasTF-CBT,EMDR,Theraplay,andPCIT.CaregiversseekingservicesandsupportthroughanLMHAandahandfulofchild-placingagenciesalsohaveaccesstotargetedcasemanagement,rehabilitationskillstraining,andfamilysupportservices.AsofSeptember2016,childreninDFPSconservatorship,throughtheYouthEmpowermentServices(YES)Waiver,haveaccesstoservicesandsupporthistoricallynotfundedbyMedicaid.Areviewofthestate’sMedicaidplanisprovidedbelow.MedicaidStatePlan

ThebasisfortheTexasMedicaidprogramistheMedicaidStatePlan,acontractbetweenthestateandtheCentersforMedicareandMedicaidServices(CMS)thatoutlinesMedicaideligibility,benefits,providerqualifications,andreimbursementsallowedbythestate.ThefederalgovernmentmatchesstatefundingthroughitsFederalMatchAssistancePercentages(FMAP).InTexas,thismeansthatthefederalgovernmentpays$56.18oneverystatedollarusedforMedicaid.Underthefederalplan,therearemandatoryandoptionalMedicaidStatePlanservices.Statesmustcovermandatorybenefitssuchasinpatientandoutpatientmedicalservicesandmaycoveralternativebenefitssuchasrehabilitationandpharmacyservices.CMSallowsstatestoamendtheirstateplantomodifyproviderqualificationsandprovidetargetpopulationswithservicesnotallowedforallconsumersunderthestateplan.Forexample,the“1115demonstration”waiverinTexasmodifiesthestateplanbyaddingpopulationsandservicesnototherwisepermittedunderMedicaid.TherearealsowaiverstoimplementMedicaidmanagedcare.MCOsunderTexasMedicaidManagedCareManagedcareorganizations(MCOs)havetheresponsibilitytooverseetheservicedeliveryofphysicalhealthandbehavioralhealthcare.MCOsmaydirectlymanagebehavioralhealthcareormaycontractwithbehavioralhealthmanagedcareorganizations(BHOs)tooverseetheutilizationandqualityofservices.Also,MCOsandtheirrespectiveBHOs(ifany)maycontractfordifferentMedicaidprogramsthatcoverdifferentpopulationsanddifferenthealthandmentalhealthbenefitsforchildren,youthandadults.Theseprogramsaredescribedbrieflybelow.

• STARisaMedicaid-managedcareprogramforwomenandchildrenwithlowincomeswhoreceiveTemporaryAssistanceforNeedyFamilies(TANF)and/orforpregnantwomenandnewbornswithlimitedincome.Theprogramalsocoversyoungadultsfromages21to26yearswhoareeligibleforMedicaidforFormerFosterCareChildren(FFCC).

• STAR+PLUSisaMedicaid-managedcareprogramforadultswithSupplementalSecurityIncome(SSI)ordisabilities,whoareage65orolder,andwhoareeligibleforSTAR+PLUSHomeandCommunity-BasedServices(HCBS)Waiverservices.

• STARHealthisaMedicaid-managedcareprogramforchildrenunderage18whoareinDFPSconservatorship,youngadultsinDFPSextendedfostercare,andyoungadultswhowerepreviouslyunderDFPSconservatorshipandhavereturnedtofostercarethroughvoluntaryfostercareagreements(ages18to20).SuperiorHealthPlanistheonlyMCOtoofferSTARHealthandcoverschildrenandyouthinfostercarestatewide.

• STARKidsisaMedicaid-managedcareprogramforyouthandyoungadultsundertheageof21whohaveSSIordisabilities;areeligibleforMedicallyDependentChildrenProgram(MDCP)HomeandCommunity-BasedServices(HCBS)WaiverservicesorYouthEmpowermentServices(YES)Waiverservices;liveinacommunity-basedintermediatecarefacility(ICF)oranursingfacilityforindividualswithanintellectualordevelopmentaldisability(IDD)orrelatedcondition;receiveservicesthroughaMedicaidbuy-inprogram;orreceiveservicesthroughDepartmentofAgingandDisabilityServices(DADS)intellectualanddevelopmentaldisability(IDD)waiverprogramssuchasCommunityLivingAssistanceandSupportServices(CLASS),DeafBlindwithDisabilities(DBMD),HomeandCommunity-BasedServices(HCBS),andTexasHomeLiving(TXHmL).

ExpandedAccesstoAdditionalMedicaidMentalHealthServicesBefore2013,community-basedorganizations(CBOs)couldonlybillMedicaidforMentalHealthRehabilitativeServicesandTargetedCaseManagement(TCM)throughLMHAs.In2013,SenateBill(SB)58,83rdLegislature,RegularSession,integratedMentalHealthRehabilitativeServicesandTCMintothestate’sMedicaidmanagedcareprogram—reimbursedthroughcapitated(orfixed,predetermined)rates—andenabledproviderentitiesotherthanLMHAstobecomecredentialedandobtainreimbursementforprovidingtheseservices.Thiswasanimportantfirststepinexpandingthecapacitytoprovidetheseservicesstatewide.OnlyLMHAsandproviderentitiesthatareorganizations—notindividualpractitioners—canbillforTCMandMentalHealthRehabilitativeServices.Today,allMentalHealthRehabilitativeServicesandTCMproviderentities(notindependentpractitioners)enrolledinMedicaidmustutilizetheTexasHealthandHumanServicesCommission’s(HHSC)TexasResilienceandRecoveryUtilizationManagementGuidelines(RRUMG),whichwereoriginallydesignedforLMHAuse.InformationonhowtobecomeaMentalHealthRehabilitativeServicesandTCMproviderandhowtoaccessthecurrentHHSCMedicaidmanagedcarecontractsandmanualisincludedintheRecommendationssectionofthisreport.Duringthe85thLegislature,RegularSession,additionaleffortsweremadetohelpincreasethestate’scapacitytoassistchildrenlivinginpovertyandinvolvedinfostercarewhohaveacute

mentalhealthneedsgainaccesstoMentalHealthRehabilitativeServicesandTCM.SB74,whichstreamlinestheMedicaid-managedcarecredentialingprocess,increasingthestate’scapacitytoconnectchildrenandyouthtotheintensivetreatmenttheyrequire,overwhelminglypassedbothhousesofthelegislatureandnowawaitsGovernorAbbot’ssignature.Keyprovisionsofthebillincludeclarifyingthatnon-LMHAproviderscancontractwithMCOstoprovideMentalHealthRehabilitativeServicesandTCMtochildren,youth,andtheirfamilies.Thebillalsoclarifiesthatnon-LMHAprovidersarenotrequiredtoprovidecrisisservicessuchascrisishotlinesormobilecrisisteams.ItalsorequiresHHSCtoupdateMedicaid-managedcarecontractsandrelatedmanualsandguidelines.Inaddition,SB74isassociatedwithabudgetriderthatmakes$2millionavailabletoestablishagrantprogramtoincreaseaccesstoMentalHealthRehabilitativeServicesandTCMtochildrenandyouthinthechildwelfaresystem.Thisone-timegrantprogramwillprovidefundstoLMHAsandothernonprofitentitiesthataremakinginvestmentseithertobecomeprovidersofTargetedCaseManagementandMentalHealthRehabilitativeServicesforchildreninfostercareattheIntenseServiceLevelortoexpandtheirexistingcapacitytoprovidetheseservices.Toreceivegrantfunds,anentitymustprovidelocalmatchingfundsinanamountdefinedbyHHSC,basedontheentity’sgeographicallocation.Fundsmayonlybeusedtopayforcostsdirectlyrelatedtodeveloping,implementing,andtrainingteamstoprovideTargetedCaseManagementandMentalHealthRehabilitativeServicestochildreninfostercareattheIntenseServiceLevel.TheHealthandHumanServicesCommission,incollaborationwiththeDepartmentofFamilyandProtectiveServices(DFPS),mustestablishtheinitiativenolaterthanNovember1,2017.

YouthEmpowermentServices(YES)MedicaidWaiver96,97

Asnotedabove,mostchildrenandyouthinvolvedinthechild-servingsystemhaveaccesstotrauma-focusedortrauma-specifictherapeuticinterventions.ThemostcommonisTF-CBT.However,manyoftheexpertsontraumaanditsimpactonthedevelopingbrain(Perry,98vanderKolk,99Siegel100)recommendinterventions,services,andsupportsthatarenottraditionallypaidforbyMedicaid.TheYESWaivercanprovideaccesstotheseinterventions.

96TexasDepartmentofStateHealthServices(2016).YouthEmpowermentServices(YES)Waiver:PolicyManual.Retrievedfromhttps://www.dshs.texas.gov/mhsa/yes/Resources-for-Families.aspx97TexasDepartmentofStateHealthServicesYESWaiverwebsite.(n.d.).ResourcesforFamilies.Retrievedfromhttps://www.dshs.texas.gov/mhsa/yes/Resources-for-Families.aspx98Cross,D.,&Purvis,K.B.(2013).Non-pharmacologicalinterventionsforchildrenandyouthincare.InstituteofChildDevelopmentTexasChristianUniversity.Retrievedfromhttp://texascasa.org/wp-content/uploads/2013/11/Non-pharmacological-Interventions-Dr.-Purvis.pdf99VanderKolk,B.(2014).Thebodykeepsthescore:brain,mind,andbodyinthehealingoftrauma.PenguinBooks.NY,NY.100InformationbyDr.SiegelattheTrauma-informedCareConsortiumofCentralTexas.May2017.

TheYESWaiverprovidescomprehensivehome-andcommunity-basedmentalhealthservicestochildrenandyouthaged3–18whohaveaseriousemotionaldisturbance(SED).Italsooffersflexiblesupportsandspecializedservicetochildrenandyouthatriskofinstitutionalizationorout-of-homeplacementduetotheirSED.Anditusesthewraparoundplanningprocesstocreateaplanspecificallyforeachchildoryouthwithservicesdesignedtoidentifyandsupportthestrengthsofthechildoryouth.AnoverviewofYESWaiverservicesisprovidedbelow.

• AdaptiveAidsandSupports:Adaptiveaidsandsupportsaredesignedtohelpchildrenimprovetheirfunctioningindifferentsettingssuchashome,school,andthecommunity.Theseservicesincludeconsumablegoods(e.g.,artsupplies,psychoeducationalmaterials),durablegoods(e.g.,exerciseequipment,musicalinstruments),lessons,classes,seasonalactivities,memberships,andcamps.

• CommunityLivingSkills(CLS):Thisgroupofservicesisdesignedtohelpafamilyadjusttothespecialchallengesrelatedtothechild’smentalhealthneed.Skillstrainingcanberelatedtodailylivingskills,socialization,communication,relationshipbuilding,andintegrationintocommunityactivities.Inadditiontoskillsforthechildoryouth,CLScanprovidethefamilycaregiverwithskillstraining,includingbasicparentingandotherformsofguidancetoassistthecaregiverincopingwithandmanagingthechild’soryouths’symptoms.

• EmployeeAssistanceandSupportedEmployment:Theseservicesspecificallyaimtoassistyouthinfindingemployment.

• FamilySupports:FamilySupportsprovidepeermentoringandsupporttoprimarycaregiversofachildoryouthwhohasreceivedservicesandsupportfromacommunitymentalhealthproviders.Thefamilysupportproviderdeliverspeermentoringandcanmodelself-advocacyskills,provideinformation,assistintheidentificationoftraditionalandnontraditionalsupport,andoffernon-clinicalskillstraining.

• MinorHomeModifications:Thesearemodificationstohelpkeepchildrenoryouthandtheirfamiliessafe.Theycanincludealarmsystems,alertsystems,andothersafetydevices.

• Non-MedicalTransportation:ThisserviceensuresthatachildoryouthenrolledintheYESWaiverhasaccesstoanynon-medicalYESWaiverserviceswhenthereisnootheravailabletransportation.

• ParaprofessionalServices:Theseareskillstrainingandmentoringtoaddressachild’soryouth’ssymptomsthatmayinterferewithfunctioninginhisorherlivingandlearningenvironment.

• RespiteServices:In-andout-of-homerespiteservicescanbeprovidedonashort-termbasisbecauseoftheneedforreliefforthecaregiverofachildoryouthenrolledintheYESWaiverprogram.

• SpecializedTherapies:Thesearetherapiesthatincludeart,recreational,music,andanimal-assistedtherapy.Theymayalsoincludenutritionalcounseling.

• SupportiveFamily-BasedAlternatives:Theseinterventionsprovidesupportandmodelappropriatebehaviorsforthecaregiverofachildoryouthresidinginahomeotherthanthatofhisorhercaregiver.Theobjectiveistoenablethechildoryouthtosuccessfullyreturnhometoliveinthecommunitywithhisorherfamily.Servicescanincludeguidancewithdailylivingskills,counselingreinforcement,therapyorrelatedactivities,supervisionofthechildoryouthforsafetyandsecurity,facilitiationofinclusionincommunityactivities,socialinteraction,naturalsupportsuse,andassistancewithcommunityandschoolresources.

• TransitionalServices:Transitionalserviceshelpwiththecostsassociatedwithayoungadultmovingintohisorherownhome.

Findings Finding1:Child-servingsystemsaretrainingstaffintrauma-informedcare.Asaresultofmultiplelegislativemandates,statutes,andorganizationalpolicies,allchildwelfare,juvenilejustice,andfosterfamiliesaretrainedonTIC.Themajorityofmentalhealthstaffareintroducedtotheadversechildhoodexperiencestudyandtrauma-informedcare.However,schoolpersonnelsuchasteachersandothercommunityproviders,dependingonthecommunityanddistrict,havemuchlessexposure/accesstotrauma-informedcaretraining.Finding2:Despitetheavailabilityoftrainingthataddressesunderstandingandtreatingtrauma,thereremainsawidelyexpressedneedtotrainchildwelfarestaffandfosterparents.

TheTexasCourtAppointedSpecialAdvocates(CASA)withthesupportoftheSupremeCourtofTexasPermanentJudicialCommissionforChildren,Youth,andFamilies(TheChildren’sCommission)andtheTexasInstituteforExcellenceinMentalHealthattheUniversityofTexasatAustin(TIEMH)developedanddistributedtheTexasCASAWorkforceSurveyonTrauma-InformedCareWithintheChildWelfareSysteminTexasin2015.Atotalof1,758professionalsfromacrossthestateresponded.Theyself-identifiedasCASAstaffandvolunteers,mentalorbehavioralhealthproviders,attorneys,CPScaseworkers,fosterparents,ChildAdvocacyCenterstaff,judges,medicalhealthprovidersorpsychiatrists,kinshipcaregivers,orother.TheresultingTexasCASAReportonUnderstandingTrauma-InformedCareintheTexasChildWelfareSystemisananalysisofthedataandinformationgatheredfromthesurvey.Thereportstatesthatthemajorityofrespondentsbelievetheyneedmoretrainingandwouldrecommendpolicymakersincreasetrainingrequirements.Responsestoanopen-endedquestionregardingworkforceneedsstressedtheneedforin-person,practical,accessibletraining.Surveyparticipantswerealsoprovidedwithalistofrecommendationsforpolicy-makerstohelpmakethechildwelfaresysteminTexasmoretrauma-informedandwereaskedtoselecttheirtopthree.AreviewoftheresponsesindicatedthatrespondentsbelievethereshouldbeincreasedtrainingforfosterparentsandCPScaseworkersandincreasedaccesstotrauma-focusedtreatmentforchildreninchildwelfare.Respondentsplacedlessfocusonimprovingorchangingstate-levelpolicyandsupportingcommunitiesandagenciestoimproveandchangetheirpoliciestobemoretrauma-informed.Minimalemphasiswasplacedoncreatingaplantomakethechildwelfaresystemmoretrauma-informed.Littletonoemphasiswasplacedbyrespondentsondevelopingprogramstoincreaseself-careforchildwelfarestaff.Participantsidentifiedneedforfurthertraining,andthewaytheyprioritizedtherecommendationsdoesnotrecognizetheneedtobuildanorganizationalframeworkthatwillsupportstaff,families,andcommunitymembersinapplyingthisinformation.

Finding3:Themainchild-servingsystemsinthestateofTexashavetakensomestepstowardsbecomingtrauma-informed.

• ChildWelfare:TheDepartmentofFamilyandProtectiveServices(DFPS)hasadoptedtheCANSassessment,whichscreensfortrauma;hasaddedaTICtrainingtoitspreservicetrainingrequirements;hasmandatedresidentialfacilitiesandchild-placingagenciestotrainallstaffandfosterfamiliesinTIC;andisworkingwiththeKarynPurvisInstituteofChildDevelopment(KP-ICD)atTCUtodevelopatrainingonsecondarytraumaticstress.

• JuvenileJustice:TheTexasJuvenileJusticeSystem,inresponsetolegislationtotrainallstaffinTIC,hasdevelopedanintensiveTICtraininginpartnershipwiththeNCTSN.Somedepartmentshaveimplementedatraumascreening,andWilliamsonCountyhastrainedallitsstaffinTBRIâ.

• MentalHealth:TheLocalMentalHealthAuthoritieshaveaddedTICtrainingtotheiremployeeorientation.ManyoftheLMHAshaveintroducedtraumascreening,andsixLMHAshaveparticipatedinthestate’sSAMHSAgrantTexasChildrenRecoveringfromTrauma,whichprovidedsupportinbecomingtrauma-informed.ThemajorityoftheLMHAshaveclinicianswhoaretrainedinTF-CBT.AhandfulhavestaffwhoaretrainedinEMDR,AggressionReplacementTherapy,SeekingSafety,Solution-FocusedTherapy,andParentChildInteractionTherapy.However,theirabilitytoimplementtheseinterventionsislimitedbytheTexasResiliencyandRecovery(TRR).

Inadditiontotheseinitiatives,childwelfare,juvenilejustice,andmentalhealthprofessionalshaveworkedtoincreasethenumberofevidence-based,trauma-focusedtreatmentprovidersavailabletochildrenandyouthintheirsystems.Training,screening,andevidence-basedpracticesneedtobeembeddedinacultureofTICinwhichpoliciesandpracticesaddresstheexperienceoftheworkforcealongwiththeexperienceofthechildrenandyouthseekingservicesandsupports.Mostofthecurrenttrainingisprovidedduringpre-servicetrainingornewemployeeorientation,withashorterrefresherofferedannually.Tobesuccessful,thistrainingmustbesupportedbyleadershipinanenvironmentwherepolicies,procedures,andpracticesaretrauma-informed.Feworganizationshavedevelopedformalizedeffortstoprovidestaffwithtrauma-informedapproachesandcontinuedsupporttoimplementthem.Theseapproachesandsupportincludetrainingontrauma-informedinterventionsandongoingsupervisionandcoachingtobuildstaffunderstandingandskills.Inaddition,staffarefacedwithhighcaseloads;therefore,itisdifficulttoachieveservicedeliverystandards.Staffalsoarefacedwithunsupportiveworkenvironmentsandexperiencesecondarytraumaticstressandcompassionfatigue.Staffareprovidedinformationaboutrecognizingandrespondingtotrauma;however,giventhedemandsplaced

onthem,itcanbedifficulttoutilizethisknowledge.Theseconditionscanleadtohighstaffturnoverandburnout,impactingthechild’sabilitytobuildpositiverelationshipswithhisorherprovidersandultimatelydecreasingthequalityofcare.Finding4:Theprimarycross-systemtrauma-informedapproachesbeingimplementedinTexasareallbasedontheAdverseChildhoodExperiences(ACEs)researchandaregroundedinthesametrauma-informedframework.Commonthemesincludethefollowing:

• Traumaandbraindevelopment:Childhoodtraumacanimpactbraindevelopment,whichcanresultinavarietyofchallengingbehaviorsandcanaffectachild’soryouth’sabilitytobuildpositive,trustingrelationshipswithcaringadults.

• Safety:Childrenandyouthneedtofeelsafebothpsychologicallyandphysically.Predictabilityandperceivedcontrolcanprovideasenseofsafety.

• Connection:Trustingrelationships/attachmentarecriticaltohealing.Childrenandyouthcanhealwhentheyareinaloving,stablerelationshipwithanurturingcaregiver.Adultcaregiversneedtobeawareoftheirownabilitytoconnect.

• Control:Childrenandyouthwhohavebeentraumatizedhavehadcontroltakenawayfromthem.Therefore,itisimportanttoreturncontrol.

• Self-managementandcorrecting:Childrenandyouthbenefitfrombeingtaughtself-regulation,self-awareness,andstressmanagementskills.

• DevelopmentallyappropriateInterventions:Interventionsandtherapeuticapproachesneedtomeetachildoryouthatdevelopmentallyappropriatelevelsinordertobesuccessful.

• Strength-based:Allapproachesarestrength-based.Finding5:ReachingTeensãandTBRIâprovideaphilosophicalframework,sharedlanguage,andcommonsetofapproachesthatallowprovidersinacommunitytooperationalizetheconceptoftrauma-informedcare.Thesetwoapproachesareeasytounderstandandcanbeimplementedbyalargecross-sectionofprofessionals,parents,andfosterparents.Thecommunities,systems,andorganizationsthathavebeenthemostsuccessfulinimplementingTIChaveagreedtostartwithasingleinterventionthatiseasilyunderstoodbyallstaffandfamiliesandthatisembeddedinastrongphilosophyandculture.Nocommunityorcollaborativehaschosenatherapeuticapproach(i.e.,TF-CBT,PCIT).FoundationalapproachesbeingusedacrossthestateareTrust-BasedRelationalIntervention(TBRIâ)andReachingTeensã.SimilarinterventionsbeingutilizedoutsideofTexastochangephilosophicalapproachandbuildatrauma-informedcultureincludeCooperativeandProactiveSolutions(Dr.Greene,CaliforniaEvidence-BasedClearinghouse)andDanSiegel’swork.

TheNeurosequentialModelofTherapeutics(NMT)approachalignswiththemodelsmentionedabovebutistargetedspecificallytoprofessionals,requiresasignificantamountoftrainingtobeimplementedtofidelity,andismuchmoreexpensivetoimplement.TheNeurosequentialModelinEducation(NME)iseasiertounderstandandisdesignedforteachers,buttrainingandcostremainabarriertowidespreadimplementation.TheChildTraumaAcademyisworkingondevelopingamodelforparentsandcaregivers.Finding6:Inadditiontoasharedapproach,successfultrauma-informedcross-systemeffortsinTexasallhaveanexternalfunderandacommunitychampion.

Allcross-systemeffortsinthestatehaveutilizedfoundationdollarsandothercommitmentsofresourcestosupporttheirefforts.FoundationsthathavecontributedtoTexasinitiativesincludebutarenotlimitedtoSt.David’sFoundation,Rees-JonesFoundation,MichaelandSusanDellFoundation,andSAMHSA.InarecentTravisCountyCollativeforChildren’s(TCCC)meeting,Dr.DavidCrossreportedthattheKP-ICDatTCUhasdonatedover$2.5millionintrainingandtechnicalassistanceoverthepastfiveyears.Eachcommunity-widecollaborativeisledbyarespectedorganizationorpassionatecommunityleaderwithavisionforchildrenandyouth.Dr.DavidCrossfromTCUleadstheTCCC,JudgeCarolClarkleadsSmithCounty’sefforts,andAustinChildGuidancehasspearheadedtheTCCC.Finding7:Thelocalmentalhealthauthoritiesarelimitedtoacoresetoftrauma-focusedinterventionsthatlimittheirabilitytoselectaninterventionbasedonthechild’soryouth’straumahistory,needs,orbraindevelopment.

TheTexasResilienceandRecovery(TRR)Guidelineslimitthetrauma-focusedevidence-basedtreatments(TF-EBTs)throughLMHAstoART,PCIT,TF-CBT,andSeekingSafety.SeveraloftheLMHAsindicatedtheyhavestafftrainedinotherTF-EBTsandwouldliketheTRRtoexpandthelistofallowableservicesandsupport.Thecurrentlimitationscancausedifficultyforcasemanagerstoselecttheservicesandsupportnecessarytoeffectivelymeettheneedsofchildrenoryouth.Verbalorcognitivetherapyaloneforchildrenoryouththathaveexperienceddevelopmentalorcomplextraumaisnotalwaysthebestintervention.101Alternativeinterventionssuchasphysicaltherapy,occupationaltherapy,artandmusictherapy,equinetherapy,yoga,andmartialartshavebeenfoundtoeffectivelyaddresstheneedsofchildrenandyouthwhohaveexperiencedcomplexordevelopmentaltrauma.102,103NMTwasfoundedonthepremisethattherapeutic

101Walters,F.(2005).Whentreatmentfailswithtraumatizedchildren…Why?JournalofTrauma&Dissociation,6(1).DOI:10.1300/J229v06n01_01102Perry,B.D,&Szalavitz,M.(2008).Theboywhowasraisedasadog:Andotherstoriesfromachildpsychiatrist’snotebook:Whattraumatizedchildrencanteachusaboutloss,love,andhealing.NewYork:BasicBooks.103VanderKolk,B.A.(2014).Thebodykeepsthescore:Brain,mind,andbodyinthehealingoftrauma.NewYork:Viking.

interventionsmustfollowthesequenceofnormaldevelopmentalmilestonesofbraindevelopment.104Inadditiontotheactivitiesabove,thefollowingtherapeuticactivitiesandorganizingeventshavebeenfoundtoeffective:healthymassage,EMDR,canineinteractions,socialplay,andperformingandcreativearts.Theonlywayforchildrenandyouthinthechildwelfaresystemtoaccessthesemore“nontraditional”servicesiscurrentlythroughtheYESWaiver.Approximately1,700youthinTexasarepresentlyenrolledinthisprogram,and50ofthemareinCPSconservatorship.Finding8:Medicaid(StarHealth)paysfortraditionaloffice-basedtrauma-informedservicesandsupports,andSTARHealthprovidestraininginTF-CBTandPCIT.However,providersstillidentifiedfundingasabarriertoexpandingTF-EBTcapacity.Thereareseveralissuesassociatedwiththecostofexpandingtrauma-focusedevidence-basedtreatmentsinTexas.First,Medicaidandfreetrainingdonotnegatethecostassociatedwiththelossofarevenuestreamwhilestaffareattendingtraining,nordotheycompensatefortheadditionalcostofcoachingandsupervisionrequiredtoensurestaffaredeliveringtheservicetofidelity.Second,STARHealthonlyprovidesTF-CBTtrainingandalimitedamountofPCITtraining.Consequently,ifaproviderwantstodeliveradditionalTF-EBT,itmustassumethefullcostoftrainingstaff,coaching,andsupervisingstaff.Third,Medicaiddoesnotcoverthecostoftraininganddeliveringevidence-informedapproachessuchasTBRIâ,ReachingTeensã,andDr.DanSiegel’swork.Anumberofresidentialfacilitiesandchild-placingagencies(CPA)traintheirstaff,clinicians,andfosterparentsduringtheirpre-serviceorannualtraining.Otherorganizationshaveusedgrantorphilanthropicdollarstotrainalargenumberofcommunitystakeholders,courts,providers,DFPSstaff,parents,andfosterparentsintheseinterventions.Finally,asnotedabove,theonlyMedicaidfundingstreamavailablefornontraditionalapproachesisthroughtheYESWaiver.

104Cross,D.R.,&Purvis,K.B.(2013).Non-pharmacologicalInterventionsforchildrenandyouthincare.Retrievedfromhttp://texascasa.org/wp-content/uploads/2013/11/Non-pharmacological-Interventions-Dr.-Purvis.pdf

Appendix One: National Evidence-Based Practices Repositories TheNationalRegistryforEvidence-BasedProgramsandPractices(NREPP)andtheCaliforniaEvidence-BasedClearinghouseforChildWelfare(CEBC)areregistriesforevidence-basedpractices.Theoverridingpurposeofbothistopromotetheimplementationofevidence-basedpractices.Therepositorieseachfocusonadifferentsetofinterventionsandusedifferentratingscalestodistinguisheffectiveness.Abriefoverviewofthepurposeandcontentofeachdatabaseandadescriptionoftheirratingscalesisprovidedbelow.TheNationalRegistryforEvidence-BasedProgramsandPractices(NREP)isSAMHSA’sNationalRegistryofEvidence-basedProgramsandPractices.105Overview:NREPPisarepositoryandreviewsystemformentalhealthandsubstanceuseinterventions.Itspurposeistohelppeopleidentifyandlearnmoreaboutavailableevidence-basedprogramstodeterminewhichonesbestmeettheirneeds.Itisdesignedtogivereliableinformationoneachprogram’seffectonindividualoutcomes.AllinterventionsareindependentlyassessedandratedbycertifiedNREPPreviewers.NREPPassessestheresearchthatevaluatestheoutcomesofaprogramorpracticeandprovidesinformationoneffectivedisseminationandimplementation.Allratingstakeintoaccountthemethodologicalrigoroftheevaluationstudies,thesizeofimpactoftheprogramonoutcomes,thedegreetowhichtheprogramwasimplementedasintended,andthestrengthoftheprogram’sconceptualframework.Aprogramprofileisprovidedforeachpracticeandincludesadescriptionoftheintervention,itsgoals,itsmajorcomponents,andaside-barsnapshotwithoutcome-levelratings.RatingScale:106NREPPusesgreen,yellow,red,andblackcircleswithcorrespondingsymbolstodepicttheoutcomeevidencerating.Theoutcomeratinglevelsaredescribedbelow.

• Effective:Theevaluationevidencehasstrongmethodologicalrigor,theshort-termeffectsfavortheinterventiongroup,andthesizeoftheeffectissubstantial.

• Promising:Theevaluationevidencehassufficientmethodologicalrigor,andtheshort-termeffectontheoutcomeislikelytobefavorable.

• Ineffective:Theevaluationevidencehassufficientmethodologicalrigor,butthereislittletonoshort-termeffect.

105NationalRegistryforEvidence-basedProgramsandPractices:SAMHSA’sNationalRegistryofEvidence-basedProgramsandPractices.http://nrepp.samhsa.gov/about.aspx.106NationalRegistryforEvidence-basedProgramsandPractices:SAMHSA’sNationalRegistryofEvidence-basedProgramsandPractices.http://nrepp.samhsa.gov/about.aspx

• Inconclusive:Aprogramisclassifiedasinconclusiveiftheevaluationevidencehasinsufficientmethodologicalrigororthesizeoftheshort-termeffectcannotbeclassified.

TheCaliforniaEvidence-BasedClearinghouseforChildWelfare(CEBC)Overview:TheCaliforniaEvidence-BasedClearinghouse’smissionisto“advancetheeffectiveimplementationofevidence-basedpracticesforchildrenandfamiliesinvolvedwiththechildwelfaresystem.”107Evidence-basedpracticesaredefinedbytheCaliforniaClearinghouseaspracticesthatincorporatethebestresearchevidenceandthebestclinicalexperienceandareconsistentwithfamily/clientvalues.108AprogramiseligibletoberatedontheCEBCscientificratingscaleifithasbeenreportedinapublished,peer-reviewedjournal;thereisabookormanualthatdescribeshowithasbeenadministered;itmeetstherequirementsofoneofCEBC’stopicareas;ithasoutcomemeasuresthathavebeendeterminedtobereliableandvalid;andtheprogramhasbeenadministeredwithconsistencyandaccuracy.CEBChasascientificratingscale(describedbelow)andaChildWelfareRelevanceLevel.ScientificRatingScale:109

• 1-Well-supportedbyResearchEvidence:Theprogrammusthaveatleasttworigorousrandomizedcontrol(RCTs)trialsindifferentusualcareorpracticesettingsandhavebeenfoundtobesuperiortoanappropriatecomparisonpractice.AtleastoneoftheRCTshasshownasustainedeffectofayearormorebeyondtheendoftreatmentwhencomparedwiththecontrolgroup.

• 2-SupportedbyResearchEvidence:TheprogrammusthaveatleastonerigorousRCTinausualcareorpracticesettingandmusthavebeenfoundtobesuperiortoanappropriatecomparisongroup.

• 3-PromisingResearchEvidence:Theprogrammusthaveatleastonestudyutilizingsomeformofcontrolgroup(untreated,placebo,matchedwaitlist)andhaveestablishedthebenefitsofthepracticeoverthecontrol.oritmustbefoundcomparabletoapracticerated3orhigherontheCEBCorsuperiortoanappropriatecomparisonpractice.

• 4-EvidenceFailstoDemonstrateEffect:TheprogramhasnotresultedinimprovedoutcomeswhencomparedtousualcareinRCTs.

• 5-ConcerningPractice:OverallevidencefromRCTssuggeststheprogramhasanegativeeffectontheclientsitserved.Orthecasedatasuggeststhereisariskofharmorthere

107CaliforniaEvidence-basedClearinghouseforChildWelfare.http://www.cebc4cw.org108CaliforniaEvidence-basedClearinghouseforChildWelfare.Practice-basedevidenceandhowitisdifferentfromevidence-basedpractice.http://www.cebc4cw.org/files/PBEvsEBP.pdf109CaliforniaEvidence-basedClearinghouseforChildWelfare.OverviewoftheCEBCScientificRatingScale.http://www.cebc4cw.org/files/OverviewOfTheCEBCScientificRatingScale.pdf

isalegalorempiricalbasissuggestingthatcomparedtoitslikelybenefits,thepracticeconstitutesariskofharm.

• NR-NotAbletobeRated:Theprogramdoesnothaveanypublished,peer-reviewedstudyutilizingsomeformofcontrolgroup.

ChildWelfareSystemRelevanceLevels:110

• High:Theprogramwasdesignedoriscommonlyusedtomeettheneedsofchildren,youth,andadultsorfamilieswhoarereceivingchildwelfareservices.

• Medium:Theprogramwasdesigned,orcommonlyused,toservechildren,youth,youngadults,and/orfamilieswhoaresimilartothechildren,youth,andfamiliesinthechildwelfaresystemandarelikelytoincludecurrentandformerrecipients.

• Low:Theprogramisdesignedorcommonlyused,toservechildren,youth,youngadultsand/orfamilieswithlittleornoapparentsimilaritytothechildwelfarepopulation.

Thereareanumberoforganizationsthathavedevelopedscalestoratetheresearchevidencethatsupportstheeffectivenessofprogramsandpractices.Forthesakeofefficiencyandconcision,theselevels,ratings,andgradingscalesarenotincludedwithinthisdocument.

110CaliforniaEvidence-basedClearinghouseforChildWelfare.ChildWelfareSystemRelevanceLevels.http://www.cebc4cw.org/home/how-are-programs-on-the-cebc-reviewed/child-welfare-relevance-levels/

Appendix Two: Trauma-Informed Care Training OrganizationandTrainingName

DesignatedAttendees

TrainingDescription

BeyondConsequencesInstitute

Parents,professionals,andschools

Nationallyavailableprogramthatprovideseducationalmaterials,trainingprograms,andresources.Trainingisthroughbooks,webinars,coaching,andonsiteworkshops.http://www.beyondconsequences.com/about-bci

ChildTraumaAcademy

Anyoneworkingwithsomeoneaffectedbytrauma

Offersfouronlinecoursesforallparticipants.However,theacademydoesnotofferCertificatesofCompletionorCEUsforanyoftheonlinecourses.Resourcelibraryisalsoavailablefromhttp://childtrauma.org.http://www.childtraumaacademy.com

CircleofSecurity Parentsandprofessionals

CircleofSecurityInternationalofferstrainingaroundtheworldfocusingontheearlyinterventionmodelstoincreaseattachmentandsecuritydevelopedbyGlenCooper,KentHoffman,andBertPowell.https://www.circleofsecurityinternational.com/training

CognitiveBehavioralInterventionforTraumainSchools(CBITS)

Schools TheCognitiveBehavioralInterventionforTraumainSchools(CBITS)programisaschool-based,groupandindividualintervention.https://cbitsprogram.org

CommunitiesinSchoolsofCentralTexasTraumaTraining

Educators Freeonlinetrainingresourcedesignedtogiveinformationabouthowstudentlearningandbehaviorisimpactedbytrauma.http://www.ciscentraltexas.org/resources/traumatraining/

DanSiegel’sNoDramaDiscipline

Caregiversandparents

TrainingisavailableonlineandthroughabookbyDanSiegelcalledNo-DramaDiscipline:TheWhole-BrainWaytoCalmtheChaosandNurtureYourChild’sDevelopingMind.Dr.Siegelalsohoststrainingeventsnationally.http://www.drdansiegel.com/books/no_drama_discipline/

DepartmentofAgingandDisabilityServices(DADS)andDepartmentofStateHealthServicesTraumaInformedCareforIndividualswithDevelopmentalDisabilities(IDD)

AnyonewhosupportssomeonewithIDD.

Onlinetrainingmoduleaspartofcomprehensiveonlinecourse,"MentalHealthWellnessforIndividualswithIntellectualandDevelopmentalDisabilities(IDD).”ResultedfromHB2789,84thRegularLegislativeSession.https://tango.uthscsa.edu/mhwidd

OrganizationandTrainingName

DesignatedAttendees

TrainingDescription

DepartmentofFamilyandProtectiveServices(DFPS)Trauma-InformedCareTraining

Parents,fosterparents,counselors,therapists,andshelterworkers

AsaresultofSB219,82ndRegularSession,DFPSnowprovidesthistrainingopportunitytoassistfamilies,caregivers,andothersocialserviceprovidersinfosteringgreaterunderstandingoftrauma-informedcareandchildtraumaticstress.Thistrainingaimstohelpunderstandtheeffectsthattraumacanhaveonchilddevelopment,behaviors,andfunctioningaswellasrecognize,prevent,andcopewithcompassionfatigue.Thetrainingalsodoesthefollowing:Providespracticalinformationthatpreparesthecaregivertoputintopracticewhatheorshehaslearned;Includesacomponentonadversechildexperiences(ACEs);andIncludestrainingandresourcesrelatedtopreventionandmanagementofsecondarytraumaticstressandcompassionfatigue.Thistrainingisonlineandisestimatedtotaketwohours.https://www.dfps.state.tx.us/training/trauma_informed_care/https://www.dfps.state.tx.us/Training/Trauma_Informed_Care/begin.asp

DFPSCaseworkerInitialTraining

DFPSCaseworkers AsaresultofSB219,82ndRegularSession,DFPScaseworkersarerequiredtocompleteaninitialtrainingontrauma-informedcareduringtheirbasicskillsdevelopmenttrainingandcompleteanonlinerefreshercourseannually.Thistrainingisofferedin-person.Thereisalsoatwo-houronlinerefreshercourseforCPSprogramandcontractstafftocompleteannually.TrainingrequirementsareincludedinTexasFamilyCode§264.015.http://www.statutes.legis.state.tx.us/Docs/FA/htm/FA.264.htmhttp://www.dfps.state.tx.us/About_DFPS/Title_IV-B_State_Plan/2010-2014_State_Plan/Health_Care_Oversight_and_Coordination_Plan.pdf

DFPSSecondaryTraumaticStressTraining

DFPSCaseworkersandcaregivers

TexasChristianUniversity(TCU)developedatrainingspecificforDFPScaseworkersandcaregiversonsecondarytraumaticstress.ThetrainingwasrolledoutSummer2017andiscalled,“BuildingResilienceintheFaceofTrauma.”

DesignatedAttendees

TrainingDescription

DFPSSTARHealthCenpaticoTrauma-InformedCareTrainingandCenpaticoU

Fosterfamilies,caregivers,CASAworkers,educators,schoolcounselors,judges,andattorneys

STARHealthisthestatewideMedicaid-managedcareprogramforchildreninDFPSconservatorshipandyoungadultsinDFPSpaidplacements.CenpaticomanagesthebehavioralhealthbenefitsforSTARHealth.CenpaticotrainersareregionallyassignedacrossTexastopartnerwithlocalchildwelfarestakeholderstoprovidefreein-persontrainingtocaregivers,caseworkers,teachers,therapists,judges,andotherswhoareinvolvedinlivesofchildreninfostercare.CenpaticoU,anonlineresource,alsooffersfreetrainingtoallfostercarestakeholders.TrainingisalsoavailableinSpanish.https://www.cenpaticointegratedcareaz.com/providers/education-training/trauma-informed-care.htmlhttps://www.envolveu.com

EducationKinesiologyFoundation’sBrainGym

Primarilyforeducators

TrainingisavailablenationallythroughcoursestaughtbylocalBrainGymfacilitators.http://www.braingym.org/schedule?level=1

EmpoweredtoConnect(ETC)

Pre-andPost-adoptiveandfosterparents

BasedheavilyonTBRI®,thistrainingisspecificallyforadoptiveandfosterparents.ThetrainingistaughtfromaChristianperspective.Therearetwocourses:“Prepare”isforpre-placementparents,and“Connect”isforpost-placementparents.Eachcourseistaughtinnineweeklytwo-hoursessionsforsmallgroups.http://empoweredtoconnect.org/training/

EyeMovementDesensitizationandReprocessing(EMDR)Institute

MentalHealthPractitioners

TheEMDRTherapyBasicTraining(Weekend1and2)isdesignedforlicensedmentalhealthpractitionerswhotreatadultsandchildreninaclinicalsetting.http://www.emdr.com/us-basic-training-overview/

KarenPurvisInstituteofChildDevelopmentatTCUTBRI®Training

Caregivers,parents,caseworkers,medicalprofessionals,counselors,CASAworkers,andteachers

Attachment-based,trauma-informedintervention.Trainingiscenteredonchildrenfromplacesofabuse,neglectand/ortrauma.PractitionerTrainingisavailableforcaseworkers,fosterandadoptioncarespecialists,medicalprofessionals,counselors,andCASArepresentatives.ParenttrainingandresourcesareavailableonlineandinabookbyDr.PurviscalledTheConnectedChild.https://child.tcu.edu/professionals/tbri-training/#sthash.vDnwozxB.dpbs

TheNationalChildTraumaticStressNetwork

Mentalhealthprofessionals,parents,caregivers,educators,andpolicymakers

Onlinelearningcenterthatoffersfreewebinarsandcontinuingeducationcertificatesonvarioustopics,includingtrauma-informedcare.TrainingofferedincludesChildTraumaToolkitforEducators,ChildWelfareTraumaTrainingToolkit,ResourceParentCurriculumOnline,andTrauma-InformedJuvenileJusticeSystemResourceSite.https://learn.nctsn.org

DesignatedAttendees

TrainingDescription

TheNationalChildTraumaticStressNetworkPsychologicalFirstAid

Firstresponders Onlinesix-hourinteractivecoursethatputstheparticipantintheroleofaproviderinapost-disasterscene.https://learn.nctsn.org/course/index.php?categoryid=11

ProblematicSexualBehaviorCognitiveBehavioralTherapy(PSB-CBT)

Childadvocacycenters,lawenforcement,clinicians,andpractitioners

TrainingisprovidedthroughtheNationalCenterontheSexualBehaviorofYouth(NCBY)http://www.ncsby.org/content/about-us

SatoriLearningDesignsSatoriAlternativestoManagingAggression(SAMA)

Schools,lawenforcement,fostercareproviders,RTCs,andhospitals

SAMAisa16-hourtrainingprogramthatfocusesonriskmanagementofaggressivebehavior.Programisnational;however,itisheadquarteredinTexas.http://www.satorilearning.com/index

Solution-FocusedTherapyattheInstituteforSolution-FocusedTherapy

Practitioners Nationalprogramtaughtasanonlinehybridcourseconsistingofthreein-personclassdaysand14classesusingaweb-basedprogram.https://solutionfocused.net/training/

StarrCommonwealthNationalInstituteforTraumaandLossinChildren(TLC)StructuredSensoryInterventionProgramforTraumatizedChildren,AdolescentsandParents(SITCAP)

Educators,caseworkers,counselors,andpractitioners

Nationalonlineandin-persontrainingdesignedtoenableschools,crisisteams,childandfamilycounselors,andprivatepractitionershelptraumatizedchildrenandfamilies.https://www.starr.org/training/tlc/courses-training

TexasCenterfortheJudiciary

Texasjudges AnnualChildWelfareConferenceisacontinuingeducationprogramforTexasjudgeswhohearchildprotectioncases.Pastconferencesincludedageneralsessionon“CreatingTrauma-InformedCourts.”http://www.yourhonor.com/Web/Online/Events/2016_Conferences/2016ChildWelfareConference/Event_Details.aspx?EventTabs=2&EventKey=16CWC#EventTabs%20class

TexasHealthStepstrainingonChildhoodTraumaandToxicStress

Healthcareproviders FreeonlinecontinuingeducationtrainingavailabletoTexasHealthStepsprovidersandotherinterestedhealthcareprofessionals.https://www.txhealthsteps.com/cms/?q=node/250

DesignatedAttendees

TrainingDescription

TexasJuvenileJusticeDepartment(TJJD)TraumaInformedCareTraining

Juvenileprobationandsupervisionofficers

AsaresultofSenateBill1356,83rdTexasLegislature,whichrequiresalljuvenileprobationandsupervisionofficerstohaveTICtrainingpriortocertificationorrenewal(forexistingofficers),theJuvenileJusticeTrainingAcademy(JJTA)createdandimplementedaTICtraining.TJJDworkedwithNationalChildTraumaticStressNetwork(NCTSN)todevelopthetraining.TJJDdevelopedtwotrainings:oneforStateProgramsandFacilitiesandoneforCommunity-BasedPrograms.DepartmentscansubmitaTrainingTechnicalAssistanceRequestorassistincoordinatingaRegionalTrainingeffortforTICTraining.Todate,alloftheregionaltrainingacrossthestatehaveofferedtheTICtraining.https://www.tjjd.texas.gov/regionaltraining/training_news.aspx#trauma-informed-care

TexasLawyersforChildren

Attorneysandjudges FreeonlinetrainingandsupportresourceforTexasjudgesandattorneysforchildwelfarecases.www.texaslawyersforchildren.org

TreatmentInnovationsTrauma-InformedCareandSeekingSafety

Cliniciansandagencies

Providestrainingandotherresourcestoclients,clinicians,andagencieswhoservepeoplewithsubstanceabuseandtrauma-relatedproblems.Trainingcanbeonsite,onlinewebinar,orDVDs.

TraumaAffectRegulation:GuideforEducationandTherapyforAdolescents(TARGET)

Correctionsfacilities,healthprovidersandchildren’sserviceproviders

TrainingisthroughAdvancedTraumaSolutions.http://www.advancedtrauma.com/Services.html

TheTraumaCenteratJusticeResourceInstituteAttachment,RegulationandCompetency(ARC)Training

Clinicians,schools,andRTCs

TheARCframeworkisbuiltaroundthefollowingcoretargetsofintervention.Thesetargetsareaddressedinclient-andsystem-specificways,withanoverarchinggoalofsupportingthechild,family,andsystem’sabilitytoengagethoughtfullyinthepresentmoment(TraumaExperienceIntegration).http://www.traumacenter.org/research/ascot.php

Trauma-InformedCareConsortiumofCentralTexas

Professionalsandparents

TraumatrainingisofferedthroughtheAustinChildGuidanceCenteronavarietyoftopicscenteredontrauma.ThewebsitealsohasacalendarlistingofallupcomingprofessionaldevelopmentopportunitiesandpublictrainingrelatetotraumaintheCentralTexasregion.https://www.traumatexas.com/trauma-training/

TraumaRecoveryandEmpowermentModel(TREM)

Clinicians SAMHSArecommendstrainingthroughCommunityConnections.CommunityConnectionsprovidesmanuals,training,andongoingconsultations.https://www.samhsa.gov/nctic/trauma-interventionshttp://www.communityconnectionsdc.org/training-and-store/training

DesignatedAttendees

TrainingDescription

UniversityofCaliforniaDavisChildren’sHospitalParentChildInteractionTherapy(PCIT)

MentalHealthAgencies

ThePCITTrainingCenterprovidestrainingandsupporttohelpagenciesdevelopeffectivementalhealthprograms.Trainingisavailableaswebinars.https://pcit.ucdavis.edu/training/

Appendix Three: Key Informants 2017KeyInformantParticipants

Name Title Organizational/DepartmentalAffiliationGeneralResidentialOperation-ChildWelfare

RayBaca BehavioralResourceCounselor

CalFarley’sBoysRanch

MichelleMaikoetter SeniorVicePresidentofPrograms

JimTaylor AssistantAdministratorforResidentialServices

RobertMarshall AdministratorofResidentialHomes

JoyfulandJudithBrown HouseParents CalFarley’sBoysRanch

TiffanyCarpenter DirectorofCounseling CalFarley’sBoysRanch

CarolHumbert Counselor CalFarley’sBoysRanch

ShannaTipton NeurofeedbackCounselor

KatherineClay Counselor CalFarley’sBoysRanch

MikeWilhelm Chaplin CalFarley’sBoysRanch

RayBaca SchoolSupportSpecialist

JoshSprock Trainer CalFarley’sBoysRanch

SuzanneWright DirectorofTraining CalFarley’sBoysRanch

RachelKing Trainer CalFarley’sBoysRanch

JohnHazle AdministratorofCaseWorkServices

TedKeyser ExecutiveDirector HelpingHandHomeforChildren

VanessaDavila DirectorofStrategicInitiatives,ResearchandGrants

HelpingHandHomeforChildren

DavePaxton ChiefClinicalOfficer TheVillageNetwork

JerryHartman ClinicalDirector TheVillageNetwork

MarkWelty,PhD DirectorofResearchandInnovation

TheVillageNetwork

RandySpencer VicePresidentofOrganizationalImpact

PresbyterianChildren’sHomesandServices

Name Title Organizational/DepartmentalAffiliationMentalHealthServices

BridgetSpeer ChildandFamilyServicesManager

AustinTravisCountyIntegralCare

TelawanaKirbie DirectorofClinicalServices

HeartofTexasRegionMHMRCenter

RonKimbell DivisionDirector,Klara’sCenterforFamilies

HeartofTexasRegionMHMRCenter

TriciaBoodhoo SocialServicesDirector YsletadelSurPueblo

AngelMontoya AlcoholandSubstanceAbuseProgramCoordinator

YsletadelSurPueblo

ViridianaSigala Therapist YsletadelSurPueblo

CathyGaytan ExecutiveDirector ElPasoChildGuidanceCenter

BradSchwall,PhD ExecutiveDirector PastoralCounselingCenter

SeannaCrosby DirectorofServicePrograms

AustinChildGuidanceCenter

EvelynLocklin ProgramDirector HarrisCenterMCOT

RossRobinson ExecutiveDirector HillCountyMHDDCenters

AnneTaylor DirectorofBehavioralHealthServices

HillCountryMHDDCenters

TheresaThompson Children’sDirector HillCountryMHDDCenters

JulieKaplow AssociateProfessorDirector

TraumaandGriefCenterforYouth

KayBrotherton DirectorofSpecialProjectsandChangeInitiatives

CentralPlainsCenter

AnnBradford CEO CentersforChildrenandFamilies,Inc.(CENTERS)

KristiEdwards ClinicalDirector CentersforChildrenandFamilies,Inc.(CENTERS)

RobinBirkla PostAdoptionDirector CentersforChildrenandFamilies,Inc.(CENTERS)

MichaelGomez,PhD DirectorofChildandAdolescentMentalHealth

DepartmentofPedicatrics-CenterforSuperheros,TexasTechUniversityHealthScienceCenter

PattiPatterson,MD Professor DepartmentofPedicatrics-CenterforSuperheros,TexasTechUniversityCenter

Name Title Organizational/DepartmentalAffiliationDepartmentofFamilyandProtectiveServices

LindseyVanBuskirk Region7DeputyRegionalDirector

DepartmentofFamilyandProtectiveServices

FosterCareAgencies

JessicaKilpatrick DirectorofTrainingandProgramDevelopment

StarryCounselingandFosterCareProgram

ReneeCalderPrice DirectorofChildWelfareServices

DePelchinChildren’sCenter

DarcieDeSchazo ExecutiveDirector TheSettlementHomeforChildren

CourtAppointedSpecialAdvocates(CASA)

AndyHomer PublicAffairsExecutiveDirector

TexasCASA

SarahCrockett PublicPolicyCoordinator

TexasCASA

LauraWolf ExecutiveDirector CASAofTravisCounty

DonBinnicker ChiefExecutiveOfficer CASAofTarrantCounty

OtherCommunityAgencies

IvonneTapia ChiefExecutiveOfficer Aliviane

SandyCouder ExecutiveAssistantforCEO

Aliviane

CarolinaGonzalez DivisionalDirector Aliviane

IreneSilva MethadoneClinicSupervisor

Aliviane

JuliePriego PreventionandInterventionServicesSupervisor

Aliviane

JudgeCaroleClarkandCoreTICTeam

PresidingJudgeand30pluscommunitypartners,providers,contractlawyers,andCPSstaff

321stDistrictCourtofSmithCounty

AnuPartap,MD(takenfrompreviousinterviews)

Pediatrician;MedicalDirector

Rees-JonesCenterforFosterCareExcellenceatChildren’sMedicalCenter

LenaZettler BehavioralHealth CookChildren’sHealthCareSystem

ChristineGendron ExecutiveDirector TexasNetworkofYouthServices(TNOYS)

JulieKouri FounderandExecutiveDirector

FosteringHopeAustin

Name Title Organizational/DepartmentalAffiliationKatyBourgeois SeniorConsultant MissionCapital(BackboneagencyTravisCounty

Children’sCoalition)

NicholeAston GrantManager MichaelandSusanDellFoundation

MarisolAcosta ProgramSpecialistV/ProjectDirector

TexasHealthandHumanServices/TexasChildrenRecoveringfromTrauma

CandaceAylor Owner CandaceAylorConsulting

IanSpechler RegionalAttorney DisabilityRightsTexas

KristenHowell ChiefProgramsOfficer DallasChildren’sAdvocacyCenter(CAC)

GwendolynDowning ManagerofHopeandResilience

OklahomaDepartmentofMentalHealth

Trauma-InformedCareApproaches

Dr.DavidCross Reese-JonesDirector TexasChristianUniversity(TCU)

JanaLihnRosenfelt ExecutiveDirector ChildTraumaAcademy

EmilyPerry DirectorofTrainingandEducation

ChildTraumaAcademy

KenGinsburg,MD(Presentation)

Pediatrician Children’sHospitalofPhiladelphia

DanSiegel,MD(Presentation)

ChildandAdolescentPsychiatristandExecutiveDirector

MindfulAwarenessResearchCenteratUCLAandtheMindsightInstitute.

SarahMercado TrainingSpecialist KarynPurvisInstituteofChildDevelopment

BehavioralHealthManagementCompany

RoyVanTassel DirectorofTraumaandEBPInterventions

Cenpatico

DavidAllen SeniorDirectorofTrainingandEducation

Cenpatico

CherylFisher SeniorDirectorforFosterCareandSpecialtyPopulation

Cenpatico

KarenRogers DirectorofFosterCare Cenpatico

CourtSystem

TheHonorableAuroraMartinezJones

AssociateCourtJudge TravisCountyDistrictCourts

TheHonorableDarleneByrne

Judge TravisCountyDistrictCourts126thCivilDistrictCourt

JuvenileJustice

KristyAlmager DirectorofTraining TexasJuvenileJusticeDepartment(TJJD)

Name Title Organizational/DepartmentalAffiliationMattSmith AssistantExecutive

DirectorDirectorofMentalHealthServices

WilliamsonCountyJuvenileDetentionCenter

LynnKessel AssistantDirectorMentalHealthServices

WilliamsonCountyJuvenileDetentionCenter

Appendix Four: Trauma-Focused Approaches Utilized by Key Informants ChildandAdolescentEvidence-BasedandEvidence-InformedPracticesAcrossKeyInformantsTrauma-InformedPractice Agencies/OrganizationsTrauma-InformedFoundationalFrameworks NeurosequentialModelofTherapeutics(NMT)TheChildTraumaAcademyreportsthatitmeetstheevidence-basedcriteriaLevelIII(Opinionsofrespectedauthorities,basedonclinicalexperience,descriptivestudies,orreportsfoexpertcommittees),LevelII(Evidenceobtainedfromwell-designedcohortorcase-controledanalyticstudies),andLevelI(Evidenceobtainedfromwell-designedcontrolledtrial).

CalFarley'sBoysRanch;HelpingHandsHomeforChildren

NeurosequentialModelofEducation(NME)NMEisnotanintervention;itisawaytoeducateschoolstaff.

CalFarley'sBoysRanch

Trust-BasedRelationalIntervention(TBRI®)CEBCRatingsTBRIOn-lineCaregiverTraining:ScientificRating(SR)-3,ChildWelfareSystemRelevanceLevel(CWL)-HighTBRICaregiverTraining:SR-3,CWL-HighTBRITherapueticCamp:SR-NR,CWL-High

KarenPurvisInstituteofChildDevelopment-Texas;ChristianUniversity;321stDistrictCourtofSmithCounty-JudgeCaroleClark;AssociateJudgeAuroraMartinezJones;AustinTravisCountyIntegralCare;CalFarley'sBoysRanch;CASAofTarrantCounty;CASAofTravisCounty;CentersforChildrenandFamilies;DePelchinChildren'sCenter;HelpingHandsHomeforChildren;PresbyterianChildren'sHomeandServices;SettlementHome;STARRY;WilliamsonCountyJuvenileDetentionCenter

Trauma-SpecificInterventions AggressionReplacementTherapy(ART)CEBCRatingsART:SR-3,CWL-Medium

AustinTravisCountyIntegralCare;WilliamsonCountyJuvenileDetentionCenter

Attachment,Regulation,andCompetency(ARC)CEBCRatingsARCClient-LevelIntervention:SR-NR,CWL-High

CentersforChildrenandFamilies;HeartofTexasRegionalMHMR

Trauma-InformedPractice Agencies/OrganizationsCircleofSecurityCECBRatingCSParenting:SR-NR,CWL-MediumCSHome-visiting:SR-3.CWL-Medium

321stDistrictCourtofSmithCounty-JudgeCaroleClark;AssociateJudgeAuroraMartinezJones;PresbyterianChildren'sHomeandServices

CognitiveBehavioralInterventionsforTraumainSchools(CBITS)NREPPRatingCBITSBounceBack:Effectivefortraumaandstress-relateddisordersandsymptoms.CECBRatingsCBITSBounceBack:SR-3,CWL-MediumCBITS:SR-3,CWL-Medium

PastoralCounselingCenter

DanSiegel-NoDramaDisciplineThisisaparentingapproachandisnotrated.

AustinChildGuidanceCenter;CalFarley'sBoysRanch;HelpingHandsHomeforChildren;PresbyterianChildren'sHomeandServices;STARRY

EyeMovementDesensitizationandReprocessing(EMDR)NREPPRatingEMDR-Includedasalegacyprogramnotcurrentlyratedinthenewsystem.CECBRatingsEMDRChildandAdolecent:SR-1,CWL-Medium

321stDistrictCourtofSmithCounty;AustinTravisCountyIntegralCare;CentersforChildrenandFamilies;DallasCAC;ElPasoChildGuidanceCenter;HelpingHandsHomeforChildren;PastoralCounselingCenter;SettlementHome;STARRY

ManagingAggressiveBehavior(MAB)MABisacrisismanagementprogram.NotratedintheNREPPorCECBdatabases.

PresbyterianChildren'sHomeandServices

MindUpMindUpisreportedtobeandevidence-basedsocialandemotionallearningprogram.

HelpingHandsHomeforChildren

NurturingParentingCECBRatingsNPSR-3,CWL-High

Trauma-InformedPractice Agencies/OrganizationsParentChildInteractionTherapy(PCIT)CECBRatingsPCIT:SR-1,CWL-Medium

AssociateJudgeAuroraMartinezJones;AustinChildGuidanceCenter;CentersforChildrenandFamilies;CentralPlainsCenter;DallasCAC;ElPasoChildGuidanceCenter;HeartofTexasRegionalMHMR;PresbyterianChildren'sHomeandServices

PathwaystoPermanenceNotcurrentlyevidence-based.DFPSwithUTAustinisintheprocessofconductingastudyonitseffectiveness.

DFPS-Region7

PlayTherapyNoratingforplaytherapyingeneral.Theraplayisratedbelow.

ProblematicSexualBehaviorCognitiveBehavioralTherapy(PSB-CBT)NCTSNprovidesandoverviewofPS-CBT’sclinicalandanecdotalevidence.

DallasCAC

PsychologicalFirstAidCECBRatingsPFA:SR-NR,CWL-Medium

321stDistrictCourtofSmithCounty-JudgeCaroleClark;PresbyterianChildren'sServices

SandtrayThewebsiteforEvidence-basedChildTherapyindicatesthatSandtrayplaytherapyhasonerandomized-waitlistcontrolledstudy,andtwononrandomized-waitlistcontrolledstudies.

SatoriAlternativestoManageAggressiveBehavior(SAMA)SAMAfocusesonriskmanagementofaggressivebehaviors.ThispracticeisnotcontainedintheNREPPortheCECBdatabase.

CalFarley'sBoysRanch;HelpingHandsHomeforChildren

SeekingSafetyNREPPSS:Islistedasalegacyprogramandhasnotbeenratedusingthenewratingscale.CECBRatingsSS:SR-3,CWL-Medium

Aliviane;AssociateJudgeAuroraMartinezJones;AustinChildGuidanceCenter;AustinTravisCountyIntegralCare;CentersforChildrenandFamilies;CentralPlainsCenter;PresbyterianChildren'sHomeandServices

Trauma-InformedPractice Agencies/OrganizationsSensoryIntegrationTherapySITisnotincludedinNREPPorCECB.TheAmericanOccupationalTherapyAssociationsupportstheimplementationofSITfordisagnosissuchasautism.

AssociateJudgeAuroraMartinezJones;CentralPlainsCenter;HelpingHandsHomeforChildren

Solution-focusedBriefTherapyCECBRatingSFBT:SR-NR,CWL-HighSFBTnotratedbyNREPPorCECB.Itwasratedas“promising”bytheOfficeofJuvenileJusticeandDelinquencyPrevention.

AssociateJudgeAuroraMartinezJones;AustinChildGuidanceCenter;CentersforChildrenandFamilies;PastoralCounselingCenter;PresbyterianChildren'sHomeandServices;WilliamsonCountyJuvenileDetentionCenter

TheraplayNREPPRatingTheraplay:Effectiveforinternalizingproblems.CECBRatingTheraplay:SR-3,CWL-Medium

TraumaAffectRegulation:GuideforEducationandTherapyforAdolescents(TARGET-A)NREPPRatingTARGET:Effectiveforanxietydisordersandsymptoms,coping,generalfunctioningandwell-being,internalizingproblems,andtraumaandstress-relateddisorders.CECBRatingTARGET:SR-3,CWL-Medium

HeartofTexasRegionalMHMR

Trauma-FocusedCognitiveBehavioralTherapy(TF-CBT)NREPPRatingTF-CBT:EffectivefortraumaandstressrelateddisordersCECBRatingsTF-CBT:SR-1,CWL-High

Aliviane;AssociateJudgeAuroraMartinezJones;AustinChildGuidanceCenter;AustinTravisCountyIntegralCare;CentersforChildrenandFamilies;CentralPlainsCenter;DallasCAC;HeartofTexasRegionalMHMR;HelpingHandsHomeforChildren;PastoralCounselingCenter;PresbyterianChildren'sHomeandServices;SettlementHome;TexasTechUniversityHealthSciencesCenter;WilliamsonCountyJuvenileDetentionCenter;YsletaDelSurPueblo

Appendix Five: Trauma-focused Approaches Utilized by Key Informants ChildandAdolescentEvidence-BasedandEvidence-InformedPracticesbyAgency

Agencies/Organizations Trauma-InformedPractice

321stDistrictCourtofSmithCountyCircleofSecurity,EMDR,PsychologicalFirstAid,andTBRI®

Aliviane SeekingSafetyandTF-CBT

AssociateJudgeAuroraMartinezJones

CircleofSecurity,EMDR,NMT,PCIT,SeekingSafety,SensoryIntegrationTherapy,SolutionFocusedTherapy,TF-CBT,TBRI®,andvariationsofCBT

AustinChildGuidanceCenterDanSiegel-NoDramaDiscipline,PCIT,SeekingSafety,SolutionFocusedTherapy,andTF-CBT

AustinTravisIntegralCare ART,EMDR,SeekingSafety,TF-CBT,andTBRI®

CalFarley’sBoysRanchDanSiegel-NoDramaDiscipline,NMT,NME,SatoriAlternativestoManageAggressiveBehavior,andTBRI®

CASAofTarrantCounty TBRI®

CASAofTravisCounty TBRI®

CentersforChildrenandFamiliesARC,EMDR,PCIT,SeekingSafety,SolutionFocusedTherapyandTF-CBT,andTBRI®

CentralPlainsCenterPCIT,SeekingSafety,SensoryIntegrationTherapy,andTF-CBT

DallasChildAdvocacyCenter EMDR,PCIT,PSB-CBT,andTF-CBTDePelchinChildren’sCenter TBRI®ElPasoChildGuidanceCenter EMDRandPCITHeartofTexasMHMR ARC,PCIT,TARGET-A,TF-CBT

DanSiegel-NoDramaDiscipline,EMDR,Mindup,NMT,SatoriAlternativestoManageAggressiveBehavior,SensoryIntegrationTherapy,TBRI®,TF-CBT,andTheraplay

PastoralCounselingCenterCBITS,EMDR,SolutionFocusedTherapy,andTF-CBT

PresbyterianChildren’sHomeandServices

CircleofSecurity,DanSiegel-NoDramaDiscipline,ManagingAggressiveBehavior,NurturingParenting,PCIT,PlayTherapy,PsychologicalFirstAid,Sandtray,SeekingSafety,SolutionFocusedTherapy,TF-CBT,andTBRI®

SettlementHome EMDR,TBRI®,andTF-CBT

STARRY DanSiegel-NoDramaDiscipline,EMDR,andTBRI®

Agencies/Organizations Trauma-InformedPractice

TexasTechUniversityHealthSciencesCenter TF-CBT

WilliamsonCountyJuvenileDetentionCenter ART,SolutionFocusedTherapy,TBRI®,andTF-CBT

YsletaDelSurPueblo TF-CBT

Appendix Six: Travis County Collaborative for Children: Defining a Trauma-Informed Organization, Program, or System

Anorganization,program,orsystemthatistrauma-informeddoesthefollowing:

• Realizestheimpactoftrauma,includinghowitcanemotionally,behaviorally,andphysicallyaffectchildren,families,staff,volunteersaswellastheorganizationsthatworkwiththem.- Understandsaperson’sbehaviorinthecontextofcopingstrategiesthatare

designedtosurviveadversity,includingresponsestoprimaryandsecondarytrauma.Forinstancewhatpresentsasangermaybefear,andwhatpresentsasdisruptivebehaviormaybeself-preservation.

- Understandsthattheneedforatrauma-informedresponseisnotlimitedtomentalandbehavioralhealthspecialtyservicesbutisintegraltoallorganizationsandsystemsinvolvedinchildren’slives.Itmaypreventhealingandwellnessifnotaddressedacrosstheentirewebofthesesystems.

- Understandsthatapharmacologicalresponseand/orreducingtheriskofrepeattraumaalonecannotmeettheneedsofvulnerablechildren.Buildingrelationships,community,andthefeelingofsafetyarenecessaryforneuro-developmentandhealingfromearlytrauma.

• Recognizesthesignsoftraumaandconsistentlyincorporatestraumascreeningandassessmentintoallaspectsofwork,includinginteractionswithchildren,families,staff,andvolunteers.

• Respondsbyapplyingtheprinciplesofatrauma-informedapproachtoallareasoffunctioning.Theseincludethefollowing:- Staffandvolunteertrainingontraumaandtrauma-informedpractices.- Leadershipthatrealizestheroleoftraumaintheirstaffandthechildren/families

theyserve.- Policiesandpracticesthatensurethefollowingthreecorepillarsoftrauma-

informedcareareaddressed:o Connection:focusingontherelationalneedsofchildren,withspecialattention

towardsbuildingandstrengtheningsecureattachmentsbetweencaregiversandchildren

o Safety:creatinganenvironmentofphysical,social,andpsychologicalsafetyandmeetingthechild’sphysiologicalneeds;theseneedsincludegoodnutrition,adequatesleep,attentiontosensoryneeds,andregularphysicalactivity.

o Regulation:providingstructuredexperiencestoenhanceemotionalandbehavioralself-regulationinchildren,enhancingcaregivers’mindfulawarenessandtheirabilitytouseproactivestrategiesforbehavioralchange.

• Avoidsre-traumatizingchildren,caregivers,andstaffbyrecognizinghoworganizationalandsystempracticessuchasplacementdisruptions,seclusion,restraints,andabrupt

transitionscancauseadditionalharmandinterferewithhealing.Relationshipsandnutritionarenotusedaspartofasystemofawards/consequences.

ExamplesofWhatTrauma-InformedCareLooksLikeIn…

CourtRooms

• Judgesandattorneysareinformedofresearch-based,trauma-informedresponses.

• Wherepossible,courtordersallowadequatetimeforchildrenandfamiliestoprepareforatransitiontoanewplacement.

• Placementdecisionsarebasedonensuringconnection,safety,andregulation.

CaseworkerEnvironment

• Caseworkersareconnectedemotionallywiththechildrentheyserve.

• Caseworkershavesensoryitemsavailableforchildrentouseifdesired.

• Nutritioussnacksandwaterareavailable.

• Caseworkershaveskillsetsthatareinformedbyresearch-based,trauma-informedresponseandpractices.

MedicalProviderOffices

• Medicalprovidersareawareofhowtraumacanemotionally,behaviorally,andphysicallyaffectchildren.

• Medicalprovidersunderstandthatapharmacologicalresponsealonecannotmeettheneedsofvulnerablechildren.

ResidentialTreatmentCenters

• Nutritioussnacksareavailableonrequest,notlockedorusedasrewardsforgoodbehavior.

• Sensoryroomsareavailableforchildrentousewhentheyrequestorchooseto.

• Allstaffandvolunteersaretrainedonresearch-based,trauma-informedresponsesandpractices.

• Behavioralcorrectionstrategiesaretrauma-informed;caregiversandstaffunderstandtheroleoffearinbehavior.

• Childrenmayusesensorytechniques/itemsduringinstructionaltime;theymaymoveanduseotherstrategiestohelpthemfeelincontrolphysically.

ExamplesofWhatTrauma-InformedCareLooksLikeIn…

Homes • Caregiversfocusontherelationalneedsofchildrenwithspecialattentiontowardsbuildingandstrengtheningsecureattachments.

• Behavioralcorrectionstrategiesaretrauma-informed;caregiversunderstandtheroleoffearinbehavior.

• Caregiverscreateanenvironmentofphysical,psychological,andsocialsafety.

• Childrenhavenutritiousfoodandwateravailableatregularintervalsthroughoutthedaytomaintainstaminaandfocus.

• Childrenaregiventheopportunityforabreakand“re-do”afterdisruptivebehavior.

• Caregiversareself-awareandareabletouseproactivestrategiesforbehavioralchange.

HousesofWorship

• Wraparoundsupportisavailableforchildrenandfamilieswhohaveexperiencedtrauma.

• Learningandworshipsettingsareconducivetophysical,psychological,andsocialsafety.

Classrooms • Studentsmayusesensorytechniques/itemsduringinstructionaltime;theymaymoveanduseotherstrategiestohelpthemfeelincontrolphysically.

• Studentshavenutritiousfoodandwateravailableatregularintervalsthroughoutthedaytomaintainstaminaandfocus.

• Studentsaregiventheopportunityforabreakand“re-do”afterdisruptivebehaviorratherthanhavingamarkmovedorotherpenaltyimposed.

TIC Report - 07 26 17texaschildrenscommission.gov/media/83503/trauma-informed-care-fi… · We...

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