Introductions:

1. Getting Ahead of the Storm: Using Trauma Informed Care and Behavior Management to Address Crisis Before it Occurs

2. Introductions: Ariana Drew LMHC Associate Director of Residential Clinical Services adrew@childrenshomenetwork.org Hannah Skillman MS, BCBA Associate Director of Residential Campus Life hbuck@childrenshomenetwork.org

3. Who is in the room? In order to best meet the needs of the individuals in the room we would like to take a show of hands of who we have represented: • Foster Parents • Group Homes • Service Provider to Foster Care Youth • CBC • Administrators • Other?

4. Current programs or interventions? • Is anyone here using any type of behavior management system or techniques? • Which ones? • Is anyone practicing Trauma Informed Care? • If so what program or intervention do you use?

5. Goals for Today • This presentation will not teach you how to address crisis situations, instead we will be discussing the tools needed for your agency to begin looking at implementation of TIC and behavior support practices that will reduce those crisis from happening in the first place. • The tools outlined today could be used to set up a personalized system of prevention supports for your setting that will help you get ahead of the storms.

6. Goals For Today • Objective 1: Benefits of implementing Trauma Informed Care and Positive Behavior Supports in a residential setting. • Objective 2: How integrating clinical services and behavioral services benefits youth, staff, and the entire residential setting on all levels. • Objective 3: Essential pieces for successful implementation and maintenance of the integrated system. • Objective 4:How to gain more information about Trauma Informed Care and PBIS.

7. Objective 1: • Benefits of Trauma Informed Care

8. Trauma-Informed Care A program, organization, or system that is trauma informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs of and symptoms of trauma in clients, families, staff, and others involved with the systems; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization. - Trauma Informed Care is not the same as Trauma informed Interventions • SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach Prepared by SAMHSA’s Trauma and Justice Strategic Initiative (July 2014), p9.

9. What we know about TIC • Treatment that includes caring corrective relationships allows for the brain to repair damage caused by early trauma (neuroplasticity) • Neither punishment nor rewards systems heal trauma and can in fact cause re-traumatization if done in a manner not in line with TIC. • Relationships are often the foundation of hurt and trauma but are also the foundation for healing that hurt and trauma.

10. What we know about trauma and behavior • Children and families who have experienced trauma often exhibit challenging behaviors and reactions. • Children with a history of trauma: • Have valid fears about their own safety or the safety of loved ones • Have difficulty trusting adults to protect them • Have problems controlling their reactions to perceived threats (perception is key!) • Trauma is often displayed through behavior which can include: • Aggression and defiance • Sleep disturbances (in older youth this can often be masked as late-night television watching, video games, or partying in an attempt to avoid sleep) • Inability to identify, express, or manage their emotions • Substance abuse • Self-harming behaviors (e.g., cutting) • School difficulties • Difficulty sustaining attention • Hypervigilance, or over/under-estimation of danger • Difficulty forming relationships, trouble trusting others Source: Grillo, C. A., Lott, D. A., & Foster Care Subcommittee of the Child Welfare Committee, National Child Traumatic Stress Network. (2010). Caring for children who have experienced trauma: A workshop for resource parents – Facilitator’s guide. Los Angeles, CA & Durham, NC: National Center for Child Traumatic Stress. Retrieved from http://nctsn.org/products/caring-for-children-who-have-experienced-trauma

11. What we know about trauma and behavior • In TIC it is important to remember that many of these challenging behaviors served a purpose at one time and may have helped them survive. As caregivers and professionals it is important that we do not label these behaviors as “good” or “bad” • Trauma causes the brain to enact the fight or flight responses as a survival instinct. We know that relationships can help repair the damage caused to the brain but it will take time for that survival response to be unlearned … be patient. Source: Grillo, C. A., Lott, D. A., & Foster Care Subcommittee of the Child Welfare Committee, National Child Traumatic Stress Network. (2010). Caring for children who have experienced trauma: A workshop for resource parents – Facilitator’s guide. Los Angeles, CA & Durham, NC: National Center for Child Traumatic Stress. Retrieved from http://nctsn.org/products/caring-for-children-who-have-experienced-trauma

12. How will becoming trauma informed help you • Help you communicate with your youth as well as your staff in a manner that is supportive and minimizes re-traumatization • It will help you manager behaviors and attitudes, particularly those that may appear challenging • By understanding the impact of trauma you will be better equipped to meet your youth’s needs at their level • Will assist you with managing your own mental health and minimizing the risk of secondary trauma. • TIC helps create a feeling of physical and psychological safety and security within your program which is a critical element for youth that have experienced trauma. This is a core piece for beginning the healing process. • Creating a culture of TIC within your organization will increase safety, trust, and support for the healing process for both your youth and your employees.

13. Objective 1: • Benefits of utilizing Behavior Management strategies- specifically Positive Behavior Support practices in order to improve youth lives

14. ABAApplied Behavior Analysis PBSPositive Behavior Supports OBM Organizational Behavior Management

15. Positive Behavior Support (PBS) • PBS emphasizes the individual’s values • Uses person centered planning • Utilizes research-based strategies to make a change that improves an individuals quality of life • Applied within each setting the individual accesses -What is Positive Behavior Support, 2008.Association for Positive Behavior Support, www.apbs.org

16. Benefits of PBS Practice, Strategies, and Techniques • Focus on function of behavior in order to • Teach a functionally equivalent behavior • Ensure the problem behavior no longer receives reinforcement • Individual approach • Improve quality of life • Multi-component planning • Involve ongoing evaluation • Involves entire team or caregivers, family members, therapists, GAL, and team members. • Can be applied at a systems level change to use data to change every level of a system instead of just one individual and aspect of a system. • Example: School Wide, District Wide, or Agency wide PBS • We apply this agency wide with the PBIS program model which provides assistance and support to every step of application. • - What is Positive Behavior Support, 2008,Association for Positive Behavior Support, www.apbs.org

17. Benefits of PBS on Youth Helps youth understand expectations Provides consistencyBuild up youth self-concept, self-esteem, and self-worth Increase Positive Personal Power in youth as they learn to engage in positive behavior to appropriately meet their needsEmpower youth and decrease power strugglesYouth realize that their behavior has an effect on what happens to them and what they get to access. This is a very new concept for our youth!

18. Benefits of Positive Behavior Intervention and Supports • Multi-Tiered System of Supports • Utilizes data based decision making • Provides an evidence based tool for problem solving issues that arise at the systems level • Team based approach requires participation from of all levels of staff inherently incorporating buy in • Is a tool for implementing organization wide change • It has been found to be effective in schools across the country and it’s effectiveness in group home settings has begun to be researched • It can be applied to any setting our youth engage with or live within • It can be implemented by any service provider and serves as a guide to utilize PBS techniques to your setting at every level (youth and staff) • There is not a need to be a BCBA, BCaBA, or RBT to implement

19. Objective 2: • Benefits of integrating clinical and behavioral services

20. How to Integrate Clinical and Behavioral Services • The end goal for both is the same. • To improve the youth’s quality of life. • They support each other inherently. • The speak the same language but with different terms • Both refer to avoiding power struggles, giving options, and both use Premackprinciple: First __ then__, we just have different names for terms • Examples of different terms: Distraction - Redirection, Triggers-Antecedent, Why the behavior is happening - Function of behavior. • Example: Clinical services help children identify preferred tools for de-escalation, behavioral services help prompt and reinforce use in the applied setting

21. Integration Benefits • By addressing the trauma through trauma informed approaches and services, we will ultimately impact the behavior • By addressing the behavior using Positive Behavior Supports, we are not going to increase the youth’s trauma • Grounding example: When grounding a youth for a behavior, the act of being grounded to your room could traumatize the youth and could also not result in decreasing the occurrence of that behavior because it does not address the function. The youth may have been acting out to escape a non preferred tasks and may enjoy going to their room, away from others. By infusing both of these techniques we are meeting the youth’s needs, positively changing behavior, while ensuring we don’t increase the trauma.

22. Benefits of Integration for youth • Increased quality of life • Appropriately function in the least restrictive environment • Increased access community activities • Improved family relationships • Allows youth to be served in the least restrictive environment • Increased relationship building skills • Less confusion of expectations • It will help them to transition to reunification or adoptive placement • Maintain placement stability • Creation of an environment that promotes growth • Teaches youth that their behavior has an impact on their life • Increased repertoire and use of coping skills because of the multidisciplinary team approach. • Fewer emotional and behavioral incidents

23. Benefits of integration for Staff • Ensured understanding and implementation of company and best practices • Increased ability to communicate effectively with clients • Empowers staff by giving them the confidence and tools they need to handle any situation • Increased ability to de-escalate in an effective manner that will not re-traumatize youth and decrease the occurrence of the behavior • Increased Job Satisfaction • Gives staff the ability to recognize signs (triggers/antecedents) so they can intervene earlier and prevent situations from escalating • Ensures they know What to do- from PBS training, and How to do it- TIC training, when a youth exhibits problem behavior. • Fewer storms

24. Benefits of integration on the entire system • Promoting an atmosphere where staff understand the importance of take care of themselves reduces turn over. Reducing turn over increases stability for clients. • Secondary trauma, compassion fatigue, and burn out, are very common in this field; implementing mental health services and positive behavior supports services for staff can help take care of your staff. • Helping them to better prep for the storm.

25. Benefits of integration on the entire system • It comes from the top down, how we treat our staff is how are staff will treat our kids • As leadership or administrators it is important to model the same practices we wish for our caregivers and parents to use • This integrated approach will help set expectations and tone for program. • This setting of expectations lets kids will know what is expected of them and what they can expect from the adults in their home, helping them feel safe. This in turn helps avoid the storms. • Setting the expectations for staff, it helps them become empowered to know what intervention to use intervene when needed and feel confident in how they intervene.

26. Benefits of integration: • We are able to improve children’s lives and change their life story • By working together as a multidisciplinary team and integrating our clinical and behavioral practices to improve progress

27. Objective 3: • Essential pieces for successful implementation and maintenance of the integrated system.

28. Training is an essential piece of implementation • To select the training that best suits your needs we can ask: • How do you want caregivers to interact with youth? • What intervention do you want them to use when a youth engages in problem behavior? • Have caregivers been trained on: • The effects of trauma • How trauma effects them as a caregiver • The behaviors that come from trauma • How to respond to the behaviors that are a result of trauma

29. What to do next? • You can use these questions to select the curriculum you wish to use. • It is important to select a Trauma Informed Program and a Positive Behavior Supports Program to use as a foundation, in order to ensure results. • Many such programs also offer training resources

30. Programs • Here are some of the entire system programs that are out there for Trauma Informed Care and Positive Behavior Support implementation: • Sanctuary Model • Whole Systems Change Model • Positive Behavior Interventions and Supports (PBIS)

31. Training curriculum that can be used to train science based behavioral interventions • Behavioral caregiver interventions that are have been researched and found to be science based and found to be effective: • Triple P, Positive Parenting Program • STAR Parenting • Strengthening Parenting Program for Parents and Youth • Systematic Training for Effective Parenting - Collins, C. L., & Fetsch, R. J., (2012). A Review of 16 Major Parenting Education Programs. Journal of Extention, 50(4).

32. Interventions specifically for Child Welfare Services • Behavioral caregiver interventions that have been researched within the Child Welfare System: • SafeCare, home visiting program • For in home visits of parents and children with a history of abuse and neglect. • Is an evidence based service model • For more information you can visit the US Department of Health and Human Services page: https://homvee.acf.hhs.gov/Model/1/SafeCare-In-Brief/18

33. Additional interventions researched within Child Welfare Services in an effort to move towards evidence based practices • Project 12-Ways • STEP • Parent Child Interaction Therapy • Parent Management Training • The Incredible years • Multi Systemic Therapy • Parenting Wisely • Nurturing Parenting • Richard, et al., (2005). Parenting Programs in Child Welfare Services: Planning for a More Evidence-Based Approach to Serving Biological Parents. 15(4). Pp 353-371. DOI: 10.1177/1049731505276321 http://parented.wdfiles.com/local--files/parenting-programs/Parent%20training%20programs%20in%20child%20welfare%20services.pdf

34. Interventions that support the programs • Trauma Informed Care • Trust Based Relational Intervention (TBRI) • Trauma focused CBT

35. We’ve selected techniques and how we will train them,now what? • Once you choose which trainings you will utilize, then it is time to work on creating a team, roll out, buy in, and data. • This is the first place where we can and should pull in our team to be part of the creation process. • Having representation from each caregiver level and as part of the implementation team helps create buy in by using a collaborative approach. • All leadership levels must be on board to support and model practices.

36. Implementing trauma informed care without somehow assessing your agencies trauma informed culture, is likely to reduce the efficacy of the interventions. • Alameda County Behavioral Health Care Services

37. How are we going to measure the changes? • Before conducting a TIC or behavior based training first identify, with your team: • What you want to see come from the training? • Examples: increased praise, expectation setting for youth, increase prevention techniques such as quality time and relationship building • How you are going to measure if the interventions being trained on are being implemented? • How you are going to address maintenance and re-training needs? • All individuals need reinforcement to maintain behavior this will increase the likelihood that those being trained will implement said interventions.

38. Assessment • What should we measure and how should we measure it? • ARTIC – Attitudes Related to Trauma Informed Care • Agency Self Assessment –Traumainformedcareproject.org • List of trauma informed assessments: https://children.wi.gov/PublishingImages/Pages/Integrate/Policy/GRTICN%20Trauma-Informed%20Organizational%20Assessments.pdf • PBIS AET - Agency-wide Evaluation Tool • PBIS FW-TFI – PBIS Facility-Wide Tiered Fidelity Inventory • Triple P offers caregiver and youth data tools • Create your own data tool to monitor occurrences of caregiver or youth behavior that is important to your program • Pre and post assessments can be created to monitor progress before and after training • Role play practice scenarios can be used to measure understanding and ability to implement techniques in the moment

39. Assessment • Would your caregivers pass a scenario survey or roll play test? • What interventions are most important and how are you going to measure those data markers to show across caregivers implementation of trauma informed practices or PBS practices • Data can be taken on anything!

40. How do we move forward? • The assessment tool you select or create will turn into your guide for your next steps and problem solving • Keep it simple, measureable, and focused on Important Aspects that you want to see. • The data should drive the decision making and next steps. • Team planning meetings to review data and problem solve will help maintain forward movement • Examples of self collect data: • Number of Incident Reports • Number of call outs

41. Objective 3: Essential Pieces for Maintenance • Continue to reviewing data on staff performance • Continue to review data on youth performance • Rewarding staff for utilizing correct techniques • Reward youth for behaving appropriately • Keep rewarding and reviewing to keep needle moving forward • Maintaining collaborative team meetings to maintain buy in • Your best friend will be the results, the results will begin to be seen and assist in increasing buy in as well. Remember: you are selecting systems that have been researched, there will be improved results in time!

42. Objective 4: • How to gain more information about Trauma Informed Care and PBIS. • The tools to help get ahead of the storm

43. Objective 4: Links • National child traumatic stress network: https://www.nctsn.org/ - provides free resources on Trauma, trauma informed care implementation, evidenced based practices, behavior management and much more. • NCTSN learning center: https://learn.nctsn.org/ - hundreds of free resources, curriculum, CEU’s including “child welfare trauma training toolkit” • SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach: https://store.samhsa.gov/system/files/sma14-4884.pdf • Trauma Informed Care Implementation Resource Center: https://www.traumainformedcare.chcs.org/ - information specific to TIC implementation with clients and organizationally • Sunshine Health: https://www.sunshinehealth.com/providers/resources/provider-training.html - sunshine provides webinar and in-person trainings for free to in-network providers.

44. Objective 4: Links • PBIS • https://www.pbis.org/ • Florida PBIS • https://flpbis.cbcs.usf.edu/ • https://www.facebook.com/FloridaPBIS/ • ABA • https://www.abainternational.org/ • PBS • https://new.apbs.org/

45. Questions?

46. Thank you for all you do!