creating trauma-informed child welfare systems: moving towards safety, permanency and well-being...

Creating Trauma-Informed Child Welfare Systems: Moving towards

Safety, Permanency and Well-Being Using a Trauma Lens

Lisa ConradiChadwick Center for Children and Families

Heather LanganNational Center for Child Traumatic Stress – Duke

George (Tripp) AkeCenter for Child and Family Health - Duke

Objectives1. Participants will be able to

describe the NCTSN and Breakthrough Series (BSC) methodology.

2. Participants will be able to describe a trauma-informed system, as conceptualized by the NCTSN Child Welfare Committee and CTISP.

3. 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.

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.

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)

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

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

What Makes up a Trauma Informed Child Welfare System?

Broader Child-Serving System

Factors

Child Welfare System Factors

Family Factors

Individual Factors

The systems can make it better or make it worse

The caregivers play a central role in RecoveryHelp the child tap their

natural resiliency and givethem new tools for managing the stress

Essential Elements of a Trauma-Informed Child-Serving System

Maximize Physical and Psychological Safety for the Child, Family and CW Workforce

Identifying Trauma-related

Needs of the Child, Family

and the Workforce

Enhancing Child Well-Being and Resiliency

Enhancing Family

Well-being and

Resiliency

Enhancing the Well-Being and

Resiliency of those

Working in the System

Partnering with Youth

and Families

Partnering with System Agencies

What Makes the Essential Elements “Essential”?

Artwork courtesy of the International Child Art Foundation (www.icaf.org)

Element #1: 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.

Maximize Physical and Psychological Safety for the Child, Family

and CW Workforce

Element #1: Maximize Physical and Psychological Safety for

the Child, Family and CW Workforce, cont.

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.

Maximize Physical and Psychological Safety for the Child, Family

and CW Workforce

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.



and the Workforce

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.



and the Workforce

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.


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.


Element #4: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.

Enhancing Family Well-

being and Resiliency

Element #5 - Enhancing the Well-being and Resiliency of

Those Working in the SystemPrimary 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.


Resiliency of those


Element #5 - Enhancing the Well-being and Resiliency of

Those Working in the System, cont.

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.


Resiliency of those


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

Element #7: 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.

Partnering with

System Agencies

Element #7: Partnering with System Agencies,

cont. • 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.

Partnering with

System Agencies

“Every system is perfectly designed

to achieve the results it gets”

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)

BSC Model for Improvement

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in improvement?

Plan

DoStudy

Act

Team PriorityFramework Element

Measures

Strategies

Adapted from 2001 Institute for Healthcare Improvement

Plan-Do-Study-Act (PDSA) Cycles:

Small Tests of Change• A tool to tackle

challenges on several levels– Individual– Team– Organization

(including community connections)

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.

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.

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.

TICWP-BSC Collaborative Change Framework: The Five

Themes1. Knowledge Building and Developing

Practice2. Trauma-Informed Mental Health

Assessment3. Case Planning and Management4. Externally Delivered Trauma-Informed

Services5. Child Welfare Systems, Cross-System

Partnerships and System Collaboration

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.

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

Trauma-Informed Child Welfare Breakthrough Series 2011

June 2011 Organizational Assessment

OBJECTIVES Headlines from Change Framework

Self-Assessment: October 2010 Self-Assessment: January 2011 Self-Assessment: June 2011

Key Practice Area 1: Knowledge Building and Developing Practice

A.

Increased knowledge on the impact of trauma exposure and its effects

B.

Increased knowledge of secondary traumatic stress, impacts, and opportunities to mitigate impacts

BSC Practice Changes: What Have We Seen So Far on

Dashboards?Trauma-Informed Child Welfare Breakthrough Series 2011




Key Practice Area 2: Trauma-Informed Mental Health Assessment

A.

Early and continuous information gathering

B.

Integration and documentation of information collected into screening

C.

Integrated and comprehensive mental health assessment focused explicitly on trauma






Key Practice Area 3: Case Planning and Management

A.

Clear information provided early and ongoing to the child and family about placement, with a focus on stability and permanency

B.

Identification of caregiver meets child's specific trauma-related needs

C.

Information provided to caregivers regarding child’s trauma issues and needs






Key Practice Area 4: Externally Delivered Trauma-Informed Services

A.

Delivery of effective trauma-informed services guided by trauma-informed assessment

B.

Preparation and support for birth parents and caregivers for them to engage in effective trauma-informed mental health services

C.

Delivery of effective trauma-informed services for birth parents






Key Practice Area 5: Child Welfare Systems, Cross-System Partnerships and System Collaboration

A.

Policies and practices reviewed and revised to be trauma-informed

B.

Trauma-informed child welfare systems act as facilitators of change in their communities

C.

Cross-system partners receive ongoing training about trauma

Initiating and Maintaining Strong Partnerships with State

Child WelfareNorth CarolinaLighthouses

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

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

Placement Stability Rates

North Carolina 2009-2010 Cohort

Type Frequency Total Percent

No countable placements 126 4571 2.76

1 placement 1962 4571 42.92

2 placements 1157 4571 25.31

3 placements 585 4571 12.80

4 or more placements 741 4571 16.21

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

Knowledge Building and Developing Practice

PDSA: Increase sensitivity and awareness among foster care workers and child welfare staff about

impact of trauma on childrenPlan: 3 hour training provided to select staff on 3 modules of the Resource Parenting Curriculum including information about a foster child’s invisible suitcase

Do: Held training for 25 workers

Study: Workers engaged in focus group discussion and revealed that this information was helpful re: talking with foster parents about tolerating child behaviors

Act: Additional trainings planned for workers and resource parents

Trauma-Informed AssessmentPDSA: Increase use of trauma-informed

screening/assessment in child welfare settingPlan: Four youth were screened for exposure to trauma using four questions from UCLA PTSD RI screener

Do: Foster care worker asked screening questions of four youth on her caseload

Study: 3 of the 4 youth who had been in care for over a year disclosed new traumas/child welfare worker negatively impacted

Act: Trained additional foster care workers on use of screener plus self care module

Case Planning and ManagementPDSA: Identify and use information needed by foster

parent to facilitate a collaborative and trauma-informed placement

Plan: Youth and bio parent team member developed questions to be asked of birth parent before placement with foster parent

Do: Selected foster parents surveyed to determine how useful the information would be generated by these questions

Study: Foster parents were interested in knowing what comforts children, information about routine and schedule, and food preferences

Act: Refined the survey and would have a birth parent involved with DSS to provide feedback

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

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);

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.

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

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

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

http://www.ctisp.org/

http://learn.nctsn.org/

http://www.nctsn.org/nccts/nav.do?pid=ctr_cwtool

http://www.nctsn.org/rpc

creating trauma-informed child welfare systems: moving towards safety, permanency and well-being...

Documents

traumainformed system

systems trauma

nctsn child welfare

broader child

experienced trauma

definition of trauma

child traumatic stress

birth parent trauma