Community Based Community Based Interventions In Two Interventions In Two

Parts: Parts: Systems Of Care AndSystems Of Care And

Approaches To Recovery Approaches To Recovery From Psychological From Psychological

TraumaTraumaLenore B. Behar, PhD, Director

Child & Family Program Strategies

Durham, North Carolina

Presentation forPresentation forMississippi Institute on Mississippi Institute on School HealthSchool Health, Wellness Wellness

and Safetyand Safety

The Super ConferenceThe Super ConferenceSeptember 27-29, 2006September 27-29, 2006

Philadelphia, MississippiPhiladelphia, Mississippi

For Bibliography & SlidesFor Bibliography & Slides

Go to: www.lenorebehar.com

See: Presentations

Community Based Interventions In Two Parts: Systems Of Care And Approaches To Recovery From Psychological Trauma

Mississippi Super Conference,September

2006

DefinitionsDefinitions

Children:

The term “children” includes all people eligible for System of Care services, as defined by the State.

Two Paths for Children Two Paths for Children Exposed to TraumaExposed to Trauma

•System of Care as a Mode of Service Delivery for Children with Serious Emotional Problems

•Trauma Focused Interventions,• usually Individual or Family

Therapies

Converging Paths for Converging Paths for Children Exposed to Children Exposed to

TraumaTrauma Since 1985, System of Care

has been federal policy for children with serious emotional disturbances, and their families

Since 1993, System of Care has been state policy in Mississippi

The Focus of System of CareThe Focus of System of Carein Mississippiin Mississippi

To provide community based care and decrease the use of inappropriate out-of-home placements by using pooled resources from mental health, education, child welfare, and Medicaid for children with SED

How Mississippi SOC How Mississippi SOC EvolvedEvolved

• legislatively mandated services—one of the first in the country

• mechanisms to review service quality• policy guidance from the State • state and community level interagency

teams for children who are difficult to serve—multi-agency assessment and planning teams (MAP)

• teams include agencies and parents

Support from the Family Support from the Family OrganizationOrganization

• Mississippi Families as Allies for Children's Mental Health (MSFAA) established in 1990

• one of the first family-run, family focused organizations in the country

• provided ongoing support to System of Care development

System of Care System of Care PrinciplesPrinciples

• Child centered, individualized• Family focused• Community based• Comprehensive• Culturally competent• Accountable/evidence based• Coordinated across agencies• Requires care management

Why Do We Need SOC?Why Do We Need SOC?

•Need collective expertise•Need unified approach to child and family

•Need to use all the resources available to child and family

It Is Rocket Science!!It Is Rocket Science!!

What is the Population What is the Population for the System of Care?for the System of Care?

The definition is clear:• Children with serious/severe

emotional disturbances and their families

• Children and families who need the services of multiple agencies, or who need multiple services

What is SED?What is SED?

An emotional/behavioral disorder diagnosed by a qualified professional that:

•Requires services of several agencies

•Significantly impairs functioning

• Is anticipated to continue for a significant amount of time

Role of AgenciesRole of Agencies

• Identify children needing services• Identify services needed by the

child and family•Coordinate services within

agency•Coordinate services across

agencies•Use a case manager, if needed

How to Access SOC/MAPHow to Access SOC/MAP

•Refer through your agency representative to the MAP Team

•Refer directly to the MAP Team leader

•Refer through community mental health center

Demonstration SitesDemonstration Sites

• 1999-2006, Children of Mississippi and their Parents Accessing Strength Based Services (COMPASS) in Hinds County

• 2006-2012, the Pinebelt System of Care in Forrest, Lamar and Marion Counties

Acceptance of System of Acceptance of System of CareCare

• Surgeon General’s Report, 2000• Report of the President’s New

Freedom Commission, 2003• Over $100 million annual funding by

Congress through the Center for Mental Health Services, SAMHSA

• Lawsuit settlements in several states

• State statutes and policies

Relevance to Children Relevance to Children Exposed to TraumaExposed to Trauma

• 20 years of study of system of care issues has clarified the value of context of services

• Studies of clinical effectiveness of services for children exposed to trauma have evolved separately

• These two paths are merging for improved services to children and families

Definitions Definitions Trauma

• Physical Abuse and Neglect • Sexual Abuse • Traumatic Grief • Domestic Violence • Community and School Violence

National Child Traumatic Stress Network, 2006

DefinitionsDefinitions

Trauma

• Complex Trauma (multiple trauma)

• Medical Trauma • Refugee and War Zone Trauma • Natural Disasters • Terrorism

Two Groups of ChildrenTwo Groups of Children

•Group 1: Children exposed to trauma who exhibit symptoms requiring treatment; show the potential for PTSD (about 20%)

•Group 2: Children exposed to trauma who will recover without treatment (about 80%)

Description of the GroupsDescription of the Groups

Both may show the same symptoms initially

•Group 1: Symptoms increase; children do not recover with initial intervention

•Group 2: Shows resilience, recovery

System of Care for Group System of Care for Group 11

They meet the definition of serious or severe disturbance:

•The disorder interferes with daily functioning (sleep, school, interactions, thinking)

• It is projected to be long term, without treatment

•Long-term effects without treatment can be damaging

SOC Principles Should SOC Principles Should ApplyApply

• Child centered, individualized• Strengths based• Family focused• Community based• Comprehensive; formal and informal• Culturally competent• Accountable/evidence based• Coordinated across agencies• Requires care management

Evidence Based Services Evidence Based Services for Group 1for Group 1

• Include:–Cognitive Behavioral Therapy–Eye Movement Desensitization and Reprocessing (EMDR)

–Trauma Focused Individual, Family and Group Treatment

Online Course in Online Course in Trauma Focused CBTTrauma Focused CBT

www.musc.edu/tfcbtwww.musc.edu/tfcbt

Importance ofImportance of T Trauma rauma Practices in Systems of Practices in Systems of

CareCareChildren exposed to trauma

•Had higher service costs•Used more high-end services, including: psychiatric hospitalization, residential treatment,and crisis intervention services at higher cost

Yoe, Burns et al, 2004

Importance of Trauma Importance of Trauma Practices in Systems of Practices in Systems of

CareCare•Used more Case Management services at higher cost; and

•Used more outpatient-clinical and medication management services at higher cost

Importance of Trauma Importance of Trauma Practices in Systems of Practices in Systems of

CareCareGroups were the same in service use and costs in•Substance Abuse Tx•Home-Based Family Services•Day Treatment•Community Support Services•Behavioral Health Pharmacy•In-Home Services

Group 2, Why Intervene?Group 2, Why Intervene?

•To alleviate traumatic stress reactions

•To provide comfort•To (possibly) prevent longer-term, more serious reactions

•To identify those who need more intensive interventions

SOC Principles for Group SOC Principles for Group 22

• Not child centered, not individualized

• Strengths based• Family involved• Community based• Comprehensive, only informal

services• Culturally competent• Accountable/evidence based• Coordinated across agencies• Does not require care management

Community BasedCommunity Based

•Interventions delivered in the child’s “community”–With peers– In school or other group setting– Involves child’s helpers-parents, teachers, shelter aides

–Uses indigenous assistants

Strengths BasedStrengths Based•Focuses on stabilization•Corrects misperceptions•Emphasizes maintaining psychological control--coping

•Emphasizes support systems•Focuses on health and self-care

Family FocusedFamily Focused

•Parents involved in planning

•Parents involved in learning how to cope

•Parents involved in ongoing support of children

Impact of Trauma on Impact of Trauma on SchoolsSchools

Events of past 16 years:• Desert Storm—the first war

fought on television• Oklahoma City bombing—news

coverage• School shootings• September 11, 2001• Hurricane Katrina

Marlene Wong, 2006

Crisis & Emergency Crisis & Emergency PlanPlan

for Schoolsfor Schools

Mental Health Mental Health ComponentComponent

www.ed.gov/emergencyplan

Mitigation and Mitigation and PreventionPrevention

•Identify possible disasters•Identify potential hazards/ barriers to a good response

transportation routesfactories/other highly

populated areas

Preparation Preparation

Develop an emergency response plan; consider emotional responses

• Establish relationships with mental health professionals

• Develop protocols for response• Train staff in psychological first aid• Establish back-up systems• Practice, practice, practice

ResponseResponse

•Assess level of exposure• Identify those most at risk•Provide support/first aid•Provide timely

information/media messages• Identify those who need

longer-term intervention and arrange it

RecoveryRecovery

• Address long-term needs through interventions using coping strategies

• Address long-term needs through referral to community or in-school specialists

• Plan for anniversaries

Actions forActions for Schools Schools

• Recognize children are vulnerable to many kinds of trauma through direct or indirect exposure

• Central point for community—50% of people involved with school

Ensure Internal Ensure Internal CoordinationCoordination

• Establish who is in charge• Establish roles for each entity

school safety personnelresource officersschool counselors/psych./swschool healthteachers

Group 2: Evidence Based Group 2: Evidence Based Services/Promising Services/Promising

Practices Practices •Psychological First-Aid•Post Trauma Stress Management

•Classroom-Based Interventions

or Group Interventions National Center for PTSD, 2005, Macy, Behar, et al 2005, Macy, 2006

Trauma Response TeamsTrauma Response Teams

Examples of Effective Programs•Center for Trauma Psychology

–Community

–Classroom•Community Policing Project

(Yale)•Community Stress Prevention

Centre (Israel)

Center for Trauma Center for Trauma Psychology-CommunityPsychology-Community

• Intensively trained volunteers• Follow a clear protocol• Establish contacts in

communities• Provide Psychological First

Aid/Post Traumatic Stress Management

Informal evidence of effectiveness

Center for Trauma Center for Trauma Psychology--ClassroomPsychology--Classroom

• Uses classroom based coping groups

• Trains teachers • Involves parents• Used also by Save the ChildrenMost evidence of effectiveness

Community Policing Community Policing ProjectProject

•Highly trained staff•Train police to handle child cases•Ride along with police•Provide team interventions—

psychologists & police togetherInformal evidence of effectiveness

Community Stress Community Stress Prevention Centre Prevention Centre

(Israel)(Israel)•Trains child caregivers, parents,

teachers, first responders•Provides back-up•Experienced in international

reliefInformal evidence of

effectiveness—theory based

Resources at Resources at www.nctsnet.orgwww.nctsnet.org

For• Educators • General Public • Juvenile Justice Professionals • Media • Mental Health/Medical Professionals • Parents and Caregivers • Policy Makers