Creating Trauma-Informed Child Welfare Systems: Moving towards Safety, Permanency and Well-Being Using a Trauma Lens

1. Creating Trauma-Informed Child Welfare Systems: Moving towards Safety, Permanency and Well-Being Using a Trauma Lens Lisa Conradi Chadwick Center for Children and Families Heather Langan National Center for Child Traumatic Stress – Duke George (Tripp) Ake Center for Child and Family Health - Duke

2. Objectives • Participants will be able to describe the NCTSN and Breakthrough Series (BSC) methodology. • Participants will be able to describe a trauma-informed system, as conceptualized by the NCTSN Child Welfare Committee and CTISP. • Participants will be familiar with several specific improvements developed by teams in the Trauma-Informed Child Welfare BSC to improve their system’s trauma focus and responsiveness.

3. The National Center for Child Traumatic Stress (NCTSN) • Established by Congress in 2000 • Funded by SAMHSA • A unique collaboration of academic and community-based service centers whose mission is to raise the standard of care and increase access to services for traumatized children and their families across the United States.

4. NCTSN Child Welfare Committee • Helping Children in the Child Welfare System Heal from Trauma: A Systems Integration Approach (2005) • Child Welfare Trauma Training Toolkit (2008, currently being revised) • Caring for Children Who Have Experienced Trauma: A Workshop for Resource Parents (2010) • Sponsoring a Breakthrough Series Collaborative focused on foster care placement stability (2010-2012) • Fact sheets on birth parent trauma (2011-2012)

5. Definition of Trauma-Informed Child Welfare System A trauma-informed child welfare system is one in which all parties involved recognize and respond to the varying impact of traumatic stress on children, caregivers and those who have contact with the system.  Programs and organizations within the system infuse this knowledge, awareness and skills into their organizational cultures, policies, and practices.  They act in collaboration, using the best available science, to facilitate and support resiliency and recovery.       - CTISP National Advisory Committee

6. Why is this Important? The research is clear that the experience of abuse or neglect leaves a particular traumatic fingerprint on the development of children that cannot be ignored if the child welfare system is to meaningfully improve the life trajectories of maltreated children, not merely keep them safe from harm. Bryan Samuels, Commissioner for the Administration on Child, Youth and Families Testimony to House Ways and Means Subcommittee on Human Resources, Congress

7. What Makes up a Trauma Informed Child Welfare System? The systems can make it better or make it worse The caregivers play a central role in Recovery Help the child tap their natural resiliency and give them new tools for managing the stress

8. Essential Elements of a Trauma-Informed Child-Serving System

9. What Makes the Essential Elements “Essential”? Artwork courtesy of the International Child Art Foundation (www.icaf.org)

10. Element #1: Maximize Physical and Psychological Safety for the Child, Family and CW Workforce Maximize Physical and Psychological Safety for the Child, Family and CW Workforce Child and Family: • A sense of safety is critical for functioning as well as physical and emotional growth. • Children in the child welfare system AND their families have likely been exposed to numerous events that have threatened both their physical and psychological safety. This exposure can color all of their interactions with people, including those trying to help them. • Traumatic stress overwhelms a child’s sense of psychological safety and can lead to a variety of survival strategies for coping.

11. Element #1: Maximize Physical and Psychological Safety for the Child, Family and CW Workforce, cont. Maximize Physical and Psychological Safety for the Child, Family and CW Workforce System: • The child welfare workforce should understand the potential or perceived threats to safety, including trauma triggers that a child or parent may experience, and provide the caregiver with tools to manage triggers and help the child feel safe. • The child welfare workforce is also exposed to experiences that can feel both physically and psychologically unsafe.

12. Element #2: Identify Trauma-related Needs of Children, Families, and the Workforce Trauma Education: • The child welfare workforce should be educated on trauma and how it affects an individual at any stage of development and intersects with his/her culture Screening: • A universal screening for traumatic history and traumatic stress responses assists the workers in understanding a child’s history, potentially triggers and directs trauma-informed case planning. This may include the need for a referral to mental health for a more comprehensive trauma-focused assessment. Identifying Trauma-related Needs of the Child, Family and the Workforce

13. Element #2: Identify Trauma-related Needs of Children, Families, and the Workforce, cont. Assessment : • A thorough assessment can identify a child’s reactions and how his or her behaviors are connected to the traumatic experience. • Child welfare workers can use assessment results to determine the need for referral to appropriate trauma-specific mental health care or further comprehensive trauma assessment. Identifying Trauma-related Needs of the Child, Family and the Workforce

14. Element #3: Enhancing Child Well-Being and Resiliency Relationships: • Familiar and positive figures—teachers, neighbors, siblings, relatives—play an important role in supporting children who have been exposed to trauma. • Minimizing disruptions in relationships and placements and establishing permanency are critical for helping children form and maintain positive attachments. • The child welfare workforce should focus on facilitating positive outcomes for children by providing appropriate support to enhance their well-being and resiliency and their ability to form and maintain healthy relationship in the aftermath of trauma. Enhancing Child Well-Being and Resiliency

15. Element #3: Enhancing Child Well-Being and Resiliency, cont. Treatment : • This includes ensuring that children have access to evidence-based trauma treatments and services when appropriate. • Trauma treatments, when indicated, should focus on addressing the impact of the child’s trauma, and subsequent changes in child’s behavior, development, and relationships. • Treatment, when indicated, also helps the child reduce overwhelming emotion related to the trauma, cope with trauma triggers, and make new meaning of his/her trauma history and its impact on his/her current and future life events. Enhancing Child Well-Being and Resiliency

16. Element #4:Enhancing Family Well-Being and Resiliency Enhancing Family Well-being and Resiliency Working with Birth Parents and Resource Parents: • Recognize that many of the child’s adult caregivers may be trauma victims as well (recent and childhood trauma). • Providing trauma-informed services to birth parents and resource parents enhances their protective capacities, thereby increasing the resiliency, safety, permanency, and well-being of the child. • Relatives serving as resource families may themselves be dealing with trauma related to the crisis that precipitated child welfare involvement and placement.

17. Element #5 - Enhancing the Well-being and Resiliency of Those Working in the System Enhancing the Well-Being and Resiliency of those Working in the System Primary and Secondary Trauma: • Working with the child welfare system is a risky business and the workforce may be confronted with danger, threats, or violence in their daily work. • Many workers can experience Secondary Traumatic Stress, which are physical and emotional stress responses to working with a highly traumatized population. • When working with children who have experienced maltreatment and parents who have acted in abusive or neglectful ways, feelings of helplessness, anger, and fear are common.

18. Element #5 - Enhancing the Well-being and Resiliency of Those Working in the System, cont. Enhancing the Well-Being and Resiliency of those Working in the System System Trauma: • The system itself can be a highly reactive, traumatizing system without enough services and supports to effectively assist the workforce in effectively responding. • Promoting system resiliency means implementing strategies and practices designed to assist those working within the child welfare system in managing professional and personal stress and addressing the impact of secondary traumatic stress in a systematic way.

19. Element #6: Partnering with Youth and Families • Youth and family members who have experienced traumatic events often feel like powerless “pawns” in the system. • Providing youth and families with a voice in their care plays a pivotal role in helping them reclaim the power that was taken away from them and assisting them towards their own resilience. • Youth and family members who have been in the system have a unique perspective and can provide valuable feedback on how to improve the system response. • These partnerships should occur at all levels of the organization, from policy to practice. Partnering with Youth and Families

20. Element #7: Partnering with System Agencies Partnering with System Agencies • Children and families who have experienced trauma are often involved with multiple service systems. Child welfare workers are uniquely able to promote cross-system collaboration. • Collaboration enables all helping professionals to view the child as a whole person, thus preventing potentially competing priorities.

21. Element #7: Partnering with System Agencies, cont. Partnering with System Agencies • Child Welfare agencies need to establish strong partnerships with other child and family-serving systems to create a continuum of trauma-informed care. These partnerships should occur at all levels of the organization, from policy to practice. • Service providers should try to develop common protocols and frameworks for documenting trauma history, exchanging information, coordinating assessments, and planning and delivering care.

22. “Every system is perfectly designed to achieve the results it gets”

23. The Breakthrough Series Collaborative Methodology • Based on the Model for Improvement, a quality improvement model developed by IHI in the 1990s. • A method for addressing the need for system-wide change and improvement in any area of concern or focus; facilitated by “expert” faculty and planning team, • Teams from multiple agencies come together to collaborate, accelerating the improvement process • Approx. one year+ in length, involving 3+ face-to-face meetings and dynamic “Action Periods” between, in which conference calls, assignments and activities are conducted (many online, using the NCTSN Learning Center site just shown)

24. BSC Model for Improvement Team Priority Framework Element Strategies Measures Act Plan Study Do What are we trying to accomplish? What changes can we make that will result in improvement? How will we know that a change is an improvement? Adapted from 2001 Institute for Healthcare Improvement

25. Plan-Do-Study-Act (PDSA) Cycles: Small Tests of Change • A tool to tackle challenges on several levels • Individual • Team • Organization (including community connections)

26. The NCTSN Trauma Informed Child Welfare BSC • 2010 – 2012 (extended for 1 year) • 9 Teams from 8 states across the country, consisting of Child Welfare + Mental Health agencies working together • Team make-up: CW administrators (“Senior Leader”), supervisors and line workers, MH admin., clinicians, consumers.

27. Goal of the Child Welfare BSC To develop and promote trauma-informed policies and practices related to foster care placement, thereby increasing placement stability and promoting a sense of permanency among children in care.

28. Collaborative Change Framework: The “Blueprint” for the BSC The Collaborative Change Framework (CCF) has two sections: * The Collaborative Charter, which sets the foundation for the Breakthrough Series Collaborative, and * The Key Objectives, which serve as the roadmap for participating teams as they test, implement, and strive to sustain their improvements.

29. TICWP-BSC Collaborative Change Framework: The Five Themes 1. Knowledge Building and Developing Practice 2. Trauma-Informed Mental Health Assessment 3. Case Planning and Management 4. Externally Delivered Trauma-Informed Services 5. Child Welfare Systems, Cross-System Partnerships and System Collaboration

30. Examples of Key Objectives I. A. Child welfare systems’ staff, caregivers, birth parents, and youth as appropriate receive training to increase their knowledge on the impact of trauma exposure and its effects on children. II. D. Birth families and caregivers are involved in the complete trauma-informed assessment process that includes a collection of the birth family’s trauma exposure history and any issues that may compromise the stability of a child's placement or delay permanency. III. E. Visitation between children, birth families, and caregivers is supported in ways that includes dialogue about the impact of trauma exposure on the child, how to identify and manage traumatic stress reactions, and how to prevent future trauma exposure.

31. BSC Practice Changes:What Have We Seen So Far on Dashboards? Strategy Tested-Ready for Spread Strategy Being Tested Strategy in Planning Stage Needs Attention. Not Yet Planning

32. BSC Practice Changes: What Have We Seen So Far on Dashboards?

33. BSC Practice Changes: What Have We Seen So Far on Dashboards?

34. BSC Practice Changes: What Have We Seen So Far on Dashboards?

35. BSC Practice Changes: What Have We Seen So Far on Dashboards?

36. Initiating and Maintaining Strong Partnerships with State Child Welfare North Carolina Lighthouses

37. NC Team and Target Population • NC Division of Social Services • Wilson County Department of Social Services • Center for Child and Family Health • Birth Parent • Foster Youth • Target Population: Youth 13+ • In care or entering care during BSC • Subject to physical abuse or sexual abuse investigative assessment during BSC

38. Relationship with NC DSS • Built on years of collaboration • NCDSS leadership was visionary • Examples of previous collaboration • NC Child Treatment Program • Strong Father’s Curriculum Development • Domestic violence shelter work • Example of current and ongoing collaboration related to involvement with BSC • Joint project with Administration of Children and Families funding • Postadoption Support Services

39. Placement Stability Rates

40. BSC Improvement Goals • Knowledge Building and Developing Practice • Trauma-Informed Assessment • Case Planning and Management • Externally Delivered Trauma-Informed Services • Child Welfare Systems, Cross Systems Partnerships, and System Collaboration

41. Knowledge Building and Developing PracticePDSA: Increase sensitivity and awareness among foster care workers and child welfare staff about impact of trauma on children

42. Trauma-Informed AssessmentPDSA: Increase use of trauma-informed screening/assessment in child welfare setting

43. Case Planning and ManagementPDSA: Identify and use information needed by foster parent to facilitate a collaborative and trauma-informed placement

44. Barriers • Thinking ahead to spread of ideas…county administered child welfare system • Availability of trauma-informed clinicians in remote counties • At times…limited time to creatively think about how to address system barriers including policy change

45. Lessons Learned for Mental Health-Child Welfare Collaboration • Identify and map trauma-informed practices with child welfare system’s priorities (e.g., implementation of practice models, Signs of Safety, permanency efforts, etc.). Trauma will almost inevitably impact/intersect with them in some way; • Actively partner with families and youth throughout the process. They provide a critical perspective and have creative ideas to assist in informing and improving the system; • Focus on creating a system where child welfare workers conduct trauma screenings. This includes training on how to conduct the screenings and how to manage secondary trauma that may emerge in workers while they are conducting the screenings; • Think about and address trauma experienced by different system stakeholders (children, parents, caseworkers, foster parents);

46. Lessons Learned for Mental Health-Child Welfare Collaboration • Think beyond linking children with mental health treatment – address other stakeholders/services within child welfare system (foster parents, mentors, parenting classes, visitation, etc.); • Share trauma-informed resources across systems. This includes tools, trainings, and other products; • Change should be made from both the top-down AND bottom-up perspectives. If the hierarchy is flattened, there is more room for innovation, buy-in and, ultimately, system change; and, • Replace existing practices rather than add new practices because the current child welfare workload is already overwhelming.

47. Next Steps • Growing interest at SAMHSA on trauma within the child welfare system • Extension of BSC for an additional year, additional focus on secondary traumatic stress among staff and foster parents • Recent RFA included focus on youth within child welfare and juvenile justice systems • Collaboration with the Administration for Children and Families on trauma-informed system change grants

48. Next Steps, cont. • Upcoming Learning Session – focus on spread and sustainability • Involvement of local cross-system partner leadership • Invitation to national child welfare and trauma stakeholders • Focus on successes, remaining systemic barriers

49. Resources • Chadwick Trauma-Informed Systems Project – www.ctisp.org • California Evidence-Based Clearinghouse for Child Welfare - www.cebc4cw.org • National Child Traumatic Stress Network - www.nctsn.org and http://learn.nctsn.org • Chadwick Center for Children and Families – www.ChadwickCenter.org • Child Welfare Trauma Training Toolkit - http://www.nctsn.org/nccts/nav.do?pid=ctr_cwtool • Caring for Children who Have Experienced Trauma: A Guide for Resource Parents - www.nctsn.org/rpc