Developing a Trauma-Informed Child Welfare System WHAT WOULD IT TAKE? Bryan Samuels, Commissioner Administration on Children, Youth and Families

Developing a Trauma-Informed Child Welfare SystemWHAT WOULD IT TAKE?

Bryan Samuels, CommissionerAdministration on Children, Youth and Families

Most States Have the Capacity to Get Smaller

Data Source: Adoption and Foster Care Reporting and Analysis System (2002-2010). Children’s Bureau, Administration on Children, Youth, and Families (USDHHS, ACF)

2May 3, 2012 Neuroscience & Child Maltreatment

Smaller Is Not Always Better

REUNIFICATION

• “Children who went home and stayed home had a four fold increase in internalizing behavior problems from baseline to 18-month follow-up. Though the percentage of children with behavior problems at 36-month follow-up decreased, still twice as many children met or exceeded clinical levels as compared to baseline”(1).

KINSHIP CARE

• “Kinship placements were not predictive of mental health outcomes regardless of the amount of time in kinship care. …[M]ultiple causes of mental health problems often occur previous to placement in care and may not be mediated by the child’s foster care experience enough to show significant differences” (2).

ADOPTION• In assessments of

children at 2, 4, and 8 years following adoption, “Adopted foster youth were more behaviourally impaired than their non-FC counterparts, although a striking number of non-FC youth displayed behaviour problems as well” (3)

3

1.Bellamy, J. (2008). Behavioral problems following reunification of children in long-term foster care. Children and Youth Services Review. 30:216.

2.Fechter-Leggett, MO & O’Brien, K. (2010). The effects of kinship care on adult mental heath outcomes of alumni of foster care. Children and Youth Services Review. 32(2):206.

3.Simmel, C.; et al. (2007). Adopted youths psychosocial functioning: A longitudinal perspective. Child and Family Social Work. 12(4):336. BPI: Behavior Problems Index

May 3, 2012 Neuroscience & Child Maltreatment

Typical Programs for Youth Yield Poor OutcomesChaffee Foster Program Type Outcomes Measures FindingsTutoring and Mentoring

Age percentile in reading and math, school grades, high school completion, highest grade completed, and school behavior problems

No statistically significant difference on key outcomes

Life Skills Training

High school completion, current employment, earnings, net worth, economic hardship, receipt of financial assistance, residential instability, homelessness, delinquency, pregnancy, possession of personal documents, any bank account, and sense of preparedness in 18 areas of adult living


Employment High school completion, college attendance, current employment, earnings, net worth, economic hardship, receipt of financial assistance, residential instability, homelessness, delinquency, pregnancy, possession of personal documents, any bank account, and sense of preparedness in 18 areas of adult living


Intensive Case Management and Mentoring

High school completion, college enrollment and persistence, current employment, employment past year, earnings, net worth, economic hardship, receipt of financial assistance, residential instability, homelessness, delinquency, pregnancy, possession of personal documents, any bank account, and sense of preparedness in 18 areas of adult living

Higher rates of college attendance and persistence among treatment than control group youth but difference was largely explained by continued child welfare system involvement among youth in the treatment group

Koball, Heather, et al. (2011). Synthesis of Research and Resources to Support At-Risk Youth, OPRE Report # OPRE 2011-22, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.


“Simply removing a child from a dangerous environment will

not by itself undo the serious consequences or reverse the

negative impacts of early fear learning. There is no doubt that

children in harm’s way should be removed from a dangerous

situation. However, simply moving a child out of immediate

danger does not in itself reverse or eliminate the way that

he or she has learned to be fearful. The child’s memory

retains those learned links, and such thoughts and memories

are sufficient to elicit ongoing fear and make a child anxious.”

May 7, 2012 FFTA 5

National Scientific Council on the Developing Child (2010). Persistent Fear and Anxiety Can Affect Young Children’s Learning and Development: Working Paper No. 9. Retrieved fromwww.developingchild.harvard.edu

Challenges Associated with Trauma

Cook, et. al., 2005

BIOLOGY

• Sensorimotor developmental problems• Analgesia• Problems with coordination,

balance, body tone• Somatization• Increased medical problems

across a wide span (e.g., pelvic pain, asthma, skin problems, autoimmune disorders, pseudoseizures)

AFFECT REGULATION

• Difficulty w/ emotional self-regulation• Difficulty labeling &

expressing feelings• Problems knowing and

describing internal states• Difficulty communicating

wishes, needs

DISSOCIATION

• Distinct alterations in states of consciousness• Amnesia• Depersonalization and

derealization• Two or more distinct states of

consciousness• Impaired memory for state-

based events

BEHAVIORAL CONTROL

• Poor modulation of impulses• Self-destructive behavior• Aggression toward others• Pathological self-soothing

behaviors• Sleep disturbances• Eating disorders• Substance abuse• Excessive compliance• Oppositional behavior• Reenactment of trauma in

behavior or play ( e.g., sexual, aggressive)

ATTACHMENT

• Problems with boundaries• Distrust and suspiciousness• Social isolation• Interpersonal difficulties• Difficulty attuning to other

people’s• emotional states• Difficulty with perspective

taking

COGNITION

• Difficulties in attention regulation and executive functioning• Lack of sustained curiosity• Problems with processing

novel information• Problems focusing on and

completing tasks• Problems with object

constancy• Difficulty planning and

anticipating• Problems understanding

responsibility• Learning difficulties• Problems with orientation in

time and space

SELF CONCEPT

• Lack of continuous, predictable sense of self• Poor sense of separateness• Disturbances of body image• Low self-esteem• Shame and guilt

May 7, 2012 6FFTA

Abusive or Neglectful Parenting

Insecure Attachments, Emotional

Dysregulation, Negative Internal Working Models

Maladaptive Coping

Strategies

Poor Social Functioning,

Disturbed Peer Relationships

Psychological Distress

Adult/Peer Relationship Dysfunction

Pat

h o

f M

altr

eatm

ent’

s Im

pac

t o

n R

elat

ion

ship

s th

rou

gh

ou

t L

ife


http://www.acf.hhs.gov/programs/cb/laws_policies/policy/im/2012/im1204.pdf May 7, 2012 8FFTA

http://www.acf.hhs.gov/programs/cb/laws_policies/policy/im/2012/im1204.pdf

http://www.acf.hhs.gov/programs/cb/laws_policies/policy/im/2012/im1204.pdf

Taking a Different Approach• “Acute care” forms of child and adolescent mental health services

are poorly matched to the service needs of a disadvantaged child population presenting with complex attachment- and trauma-related psychopathology, and unstable living arrangements.

• Promoting well-being for children who have experienced maltreatment requires evidence-based screening and interventions that address their unique behavioral and mental health needs, as well as:

– Help them understand their experiences– Support the development of new coping strategies– Address developmental stages and delays– Strengthen environmental buffers

• For children who have experienced complex interpersonal trauma, attention must be paid to their capacity to establish and maintain healthy relationships

• Resilience is not seen as good fortune arising from chance encounters with a supportive friend, peer or partner, but rather as an ongoing process of developing the competencies necessary to form, maintain and benefit from supportive interpersonal relationships.

Leslie, LK; Kelleher, KJ; Burns, BJ; Landsverk, J & Rolls, JA. (2003). Foster care and Medicaid managed care. Child Welfare. 82(3):367.


Framework for Well-being

10

Environmental Supports

Personal Characterist

ics

Developmental Stage (e.g., early childhood, latency)

Cognitive Functionin

g

Physical Health and Developme

ntEmotional/Behavioral Functionin

g

Social Functionin

g

The framework identifies four basic domains of well being: (a) cognitive functioning, (b) physical health and development, (c) behavioral/emotional functioning, and (d) social functioning. Within each domain, the characteristics of healthy functioning relate directly to how children and youth navigate their daily lives: how they engage in relationships, cope with challenges, and handle responsibilities.


Elements of Social & Emotional Well-being

11

Self-awareness—Identification and recognition of one’s own emotions, recognition of strengths in self and others, sense of self-efficacy, and self-confidence.

Social awareness—Empathy, respect for others, and perspective taking.

Self-management—Impulse control, stress management, persistence, goal setting, and motivation.

Responsible decision making—Evaluation and reflection, and personal and ethical responsibility.

Relationship skills—Cooperation, help seeking and providing, and communication.


Measure Outcomes, Not Services“It is common for child welfare systems to gauge their success based on whether or not services are being delivered. One way to focus attention on well-being is to measure how young people are doing behaviorally, socially, and emotionally and track whether or not they are improving in these areas as they receive services” (ACYF-CB-IM-12-04).

12

Stop Measuring ServicesHow many children received…?How many hours of training were delivered?What percent of children got…?

Start Measuring OutcomesAre trauma symptoms reduced?

Did services increase relationship skills?

Do children have healthier coping strategies?


Trauma Screening, Functional Assessment & Progress Monitoring

• “Functional assessment—assessment of multiple aspects of a child’s social-emotional functioning (Bracken, Keith, & Walker, 1998)—involves sets of measures that account for the major domains of well-being.”

• “Child welfare systems often use assessment as a point-in-time diagnostic activity to determine if a child has a particular set of symptoms or requires a specific intervention. Functional assessment, however, can be used to measure improvement in skill and competencies that contribute to well-being and allows for on-going monitoring of children’s progress towards functional outcomes.”

• “Rather than using a “one size fits all” assessment for children and youth in foster care, systems serving children receiving child welfare services should have an array of assessment tools available. This allows systems to appropriately evaluate functioning across the domains of social-emotional well-being for children across age groups (O’Brien, 2011) and accounting for the trauma- and mental health-related challenges faced by children and youth who have experienced abuse or neglect.”

May 7, 2012 FFTA 13

Valid and reliable mental and behavioral health and developmental screening and assessment tools should be used to understand the impact of maltreatment on vulnerable children and youth.

TRAUMA SCREENING

• Child and Adolescent Needs and Strengths (CANS) Trauma Version

• Childhood Trauma Questionnaire (CTQ)

• Pediatric Emotional Distress Scale (PEDS)

FUNCTIONAL ASSESSMENT

• Strengths and Difficulties Questionnaire (SDQ)

• Child Behavior Checklist (CBCL), the Social Skills Rating Scale (SSRS)

• Emotional Quotient Inventory Youth Version (EQ-i:YV)

Shifting Resources to Support What Works

RESEARCH-BASED APPROACHES

INEFFECTIVE APPROACHES

14

De-scaling

what doesn’t

work

Investing in what does


EBPs for Social & Emotional Well-beingDiagnosis/Concern Evidence-Based Interventions (Examples) Age

Screening ActivitiesIdentification of Mental Health & Behavioral Health Issues

SCREENING TOOLS

• Child & Adolescent Needs & Strengths—Trauma (CANS)

• Pediatric Symptom Checklist (PSC)• Strengths and Difficulties Questionnaire (SDQ)• Child Behavior Checklist (CBCL)

0-184-164-174-18

Most Common Mental Health Diagnoses for Children in Foster Care

Conduct Disorder/Oppositional Defiant Disorder

• Parent-Child Interaction Therapy (PCIT)• Strengthening Families Program (SFP)• Early Risers – Skills for Success• Brief Strategic Family Therapy (BSFT)• Multisystemic Therapy (MST)• Familias Unidas• Multidimensional Treatment Foster Care (MTFC)

2-73-166-126-179-1712-

1712-

17

Attention Deficit Hyperactivity Disorder

• Parent–Child Interaction Therapy (PCIT)• Triple P• Children’s Summer Treatment Program (STP)

2-70-166-12

Major Depression

• Adolescents Coping with Depression (CWD-A)• Cognitive Behavioral Therapy (CBT) for

Adolescent Depression• Alternative for Families-Cognitive Behavioral

Therapy (AF-CBT)

13-17

13-25

4-16


EBPs for Social & Emotional Well-beingDiagnosis/Concern/Activity

Evidence-Based Interventions (Examples) Age

TraumaActionable Trauma Symptoms Posttraumatic

Stress Disorder

• Child-Parent Psychotherapy (CPP)• Parent-Child Interaction Therapy (PCIT)• Combined Parent-Child Cognitive Behavioral

Therapy for Families at Risk for Child Physical Abuse (CPC-CBT)

• Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

• Alternatives for Families/Abuse Focused Cognitive Behavioral Therapy (AF-CBT)

• Cognitive Behavioral Intervention for Trauma in Schools (CBITS)

• Trauma Affect Regulation: Guide for Education and Therapy

• Structured Psychotherapy for Adolescents Responding to Chronic Stress

• Prolonged Exposure (PE) Therapy for Youth

0-62-173-17

4-555-17

6-1210-5513-2118-25

Behavioral

Internalizing/Externalizing Behaviors Behavioral Problems and Relational Concerns

• Child Parent Psychotherapy (CPP)• Promoting Alternative Thinking Strategies• Incredible Years• Triple P• Parenting Wisely • Nurturing Parenting Programs (NPP)• Brief Strategic Family Therapy (BSFT)• Fostering Healthy Futures (FHF) – mentoring +

skills training• Functional Family Therapy (FFT)

0-60-120-120-160-176-126-179-1110-18


Making Meaningful and Measurable Improvements in Outcomes

17

Anticipating the challenges that

children will bring with them when they enter the child welfare

system

Rethinking the structure of

services delivered throughout the

system

De-scaling practices that are

not achieving desired results

while concurrently scaling up

evidence-based interventions


Final Thoughts: Where We Are Going

The child welfare performance proposal incentivizes the development of a child welfare workforce marked by:

• Focus on child & family level outcomes

• Progress monitor for improved child/youth functioning

• Proactive approach to social and emotional needs

• Developmentally specific approach

• Promotion of healthy relationships

18

IMPLICATIONS FOR CASE-LEVEL WORK WITH YOUTH

• Caseworkers are more aware of trauma, mental health needs, and evidence-based practices to get youth the right services at the right time.

• Caseworkers better understand the trauma-related relational challenges that youth bring with them when they enter care and screen for social-emotional problems.

• Transition planning and promotion of social/emotional skills for adulthood begin well in advance of exit from care.

• Service plans include activities to promote relational competencies and efforts to find/engage siblings, relatives, etc.


Final Thoughts: Where We Are Going

The goal of the proposal is to propel the child welfare system towards greater:

• Organization around positive outcomes

• Emphasis on continuous quality improvement to include review of child functioning indicators

• Allocation of existing resources from ineffective, generic practice to an array of specific, evidence-based interventions

• Workforce is prepared to support installation and implementation of evidence-based practices that promote social-emotional well-being

19

IMPLICATIONS FOR SYSTEM’S WORK WITH YOUTH

• Data describing trauma and social and emotional well-being of youth are collected and analyzed regularly

• Research and data are used to drive decision-making, policies, program design, and contracting services.

• Evidence-based services that promote healing and recovery from truama and build key skills and capacities in youth are available.


Vehicles for Promoting Social and Emotional Well-Being

• Flexible Funding Waivers• Discretionary Funding:

– Trauma and Mental Health Screening, Assessment, and Treatment

– Educational Stability – Early Childhood-Child Welfare Linkages– Youth Services– Child Welfare-Supportive Housing

• Regional Partnership Grants• High Priority Goal on Trauma• Psychotropic Medication Oversight and

Monitoring• President’s Budget Proposal - $2.5 billion/10

years20May 3, 2012 Neuroscience & Child Maltreatment

Documents

Developing a Trauma-Informed Child Welfare System WHAT WOULD IT TAKE? Bryan Samuels, Commissioner Administration on Children, Youth and Families