Closing the gap between knowledge and practice in trauma-informed care: Analyzing trainings for children’s service pro

1. Closing the gap between knowledge and practice in trauma-informed care: Analyzing trainings for children’s service providers Sophia Hwang, MSEd Leslie Lieberman, MSW Stephen Paesani, MA, MTS One Child, Many Hands June 8, 2011

2. Overview 2

3. Introductions Behavioral Health Training & Education Network The Health Federation of Philadelphia

4. Introductions

5. Objectives Articulate the importance of trauma-informed trainings across various systems Define the mapping process Recognize that the mapping process is a tool used to gather a baseline assessment of curriculum content Recognize that the mapping process is a tool used to identify strengths and opportunities for enhancement in curriculum content Apply this mapping process to your own training activities

6. Purpose and research question Problem: Gap between what we know about trauma and how we deliver services Solution: To close that gap, the workforce needs to be trauma-informed Research question: What trauma-informed content exists in trainings? What is the qualityof the trauma-informed content in the trainings? Method: Use our Core Competencies to map existing curricula to discover best practices and make recommendations

7. What is trauma? • A “traumatic event” is an instance when a person experiences actual or threatened death, serious injury, or threat to the physical integrity of oneself or others. American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV), 2000

8. What does it mean to be trauma-informed? • Trauma-informed services are designed todeliver [services]… in a way that acknowledges the role that violence and abuse play in the lives of many children and families. Harris and Fallot, 2001 Example: “What happened to this child?” versus “What’s wrong with this child?”

9. Why is it important to be trauma-informed? Death Early Death Disease, Disability Adoption of Health-risk Behaviors Social, Emotional, & Cognitive Impairment Adverse Childhood Experiences Birth The Influence of Adverse Childhood Experiences Throughout Life ACE’s Major Determinant of Health & Well Being, Felitti, 2003

10. What is Multiplying Connections? • A cross system collaborative • Prevent/reduce the impact of trauma on young children • Build capacity for trauma informed children’s service system • Use training as a tool for system change • Existing trainings • Develop new trainings

11. What are Core Competencies? • The knowledge, attitude and skills that adults who work with young children need to have to be able to provide care and create a system that is trauma-informed and developmentally appropriate for children and their families Trauma Informed & Developmentally Sensitive Services for Children, Health Federation of Philadelphia, 2008

12. Early 2007 Literature Review Process of developing our Core Competencies Mid 2007 Create Cross Systems Training Institute 2009 Pilot mapping project with written curricula Mid 2008 Draft and refine Core Competencies Mid 2010 Formally begin mapping project

13. Multiplying Connections’ Trauma-Informed Core Competencies Knowledge Communities Trauma Informed & Developmentally Sensitive Services for Children: Core Competencies for Effective Practice Attitudes/ Values Practice Communication Organizations and Systems

14. Example of Multiplying Connections’ Trauma-Informed Core Competencies K1. Identify/describe key signs, symptoms, impact and manifestations of trauma, disrupted attachment, and childhood adversity in children and in adults Source: Trauma Informed & Developmentally Sensitive Service for Children, Health Federation of Philadelphia, 2008

15. The utility of Core Competencies Framework to quantify and classify training content Guide the curriculum mapping process No single training may address all 31 competencies Certain competencies may be prioritized

16. What is curriculum mapping? • Procedure to review and assess curriculum • Initially developed to evaluate K-12 education • Systematic process that generates evidence and data • Examine degree of alignment in content to desired outcome • Adaptable: concept of core competencies and curriculum mapping may be applied in any field http://www.curriculummapping101.com/curriculum-mapping-general

17. Mapping procedure 1. Attend training as a note-taking observer 2. View training as a collection of kernels of information 3. Gather specific data and concrete evidence Powerpoint Handouts Recorded observations 4. Produce mapping document with summary of findings

18. Mapping procedure • Mapping process takes place after the training • Classify each piece of data under a Core Competency • Alignment • Uncover which core competencies were addressed, to what degree, and with what frequency • Example: • Evidence from training: • Title: Trauma Informed Practice: Support for Recovery • Citation: Powerpoint slide 16-21: Described how trauma shapes the brain over time. Positive, tolerable, and toxic stress are defined and compared. • Mapping: K3- Describe the domains and stages of normal childhood development and how they can be affected by trauma

19. Development of a rubric Content lies on a spectrum Evaluation rubric: 3= The core competency is explicitly addressed 2= The core competency is partially addressed 1= The material referencing the core competency has opportunity for enhancement N/A or blank= Core Competency was not addressed or the content was outside the scope of the Core Competency

20. Rubric example K1. Identify/describe key signs, symptoms, impact and manifestations of trauma 3= The core competency is explicitly addressed: “A traumatic incident may act as a trigger and some may turn to substances and develop addictions to self-medicate and cope with the trauma.” 2= The core competency is partially addressed: “Some people may have addictions due to negative life experiences.” 1= Opportunity for enhancement: “Regardless of why someone has an addition, their condition must be treated.” N/A= Outside the scope of the core competencies: “This is how you complete the paperwork to enroll in a drug and alcohol treatment program.”

21. Recommendations • Concrete, quick-fix • Example: “On slide 23, mention that a client-centered approach is also a trauma-informed value/attitude.” • Complex, re-framing • Example: “Include PTSD as a childhood disorder. Discussing the cause of the behavior/diagnosis (i.e. traumatic event) can increase trauma sensitivity.”

22. Structure of the mapping document Introduction Summary Observations of trauma-informed training techniques Recommendations Mapping of content with rubric score 3 K4. Describe local resources for trauma specific treatment and trauma informed services for children and their families

23. Case study: our partner • Behavioral Health Training and Education Network (BHTEN) • How did this partnership begin? • Reasons to engage in this project

24. Case study: overview Mapped 22 trainings at BHTEN BHTEN Voluntary trauma-related trainings offered by the Cycles of Violence series Participants may serve children, adults, and/or families Mandatory 8 week orientation for new children’s case managers in DBH/CBH (Fall and Spring) Participants serve children Exploratory nature of study with organic outcomes

25. Case study: outcomes After observing the 8 week orientation in the Fall: 1. Mapping overview chart Training synopsis Compares trainings Shows addressed competencies and frequency

26. Sample mapping overview chart Shows which competencies are addressed and with what frequency Color reflects the rubric scores Shows the gaps Compares trainings

27. Full mapping overview chart

28. Case study: outcomes Winter meeting with partners 2. Conversation guide for feedback meetings Recommendations for future trainings Quality improvement Brainstorm, action plan

29. Case study: outcomes 3. Pre-test: survey and data collection tool Behavioral health children’s case managers took the pre-orientation survey during week 1 of the 8 week series Self-assessment of familiarity and knowledge “I want to learn more about all of the Core Competencies. I am coming in with very little knowledge.” “I want to learn about how to not create more trauma for my patients.”

30. Case study: outcomes 4. Post-test: survey and data collection tool • Behavioral Health children’s case managers took the post-orientation survey at the end of the 8 week series • Observed changes in self-reported knowledge over time

31. Results

32. Additional post-survey information “Do you believe you have enough knowledge (at the end of the 8 week orientation) to provide trauma-informed services?” • Half of the respondents said yes, the others said no. • “When does one ever have enough knowledge?” • “I don’t think I could provide trauma treatment, but I can assist by referring the client to a specialist in trauma.”

33. Case study: outcomes 5. Specific action plans for each partner • Customized next steps • Recommendations for curricula changes for those with red or yellow rubric scores • Create new content to include unaddressed Core Competencies • Capture changes in training content over time • Direct participants to other trainings

34. Case study: evaluation Via qualitative interviews with our partners we learned that this benefited the: • Training center • Clients of the participants • Professional careers of the participants • Multiplying Connections • “I was always conscious of your presence, but you were not intrusive.” • “For good quality improvement to occur you have to stop and really focus on making change and spend the time and energy necessary.” • Appreciated that “not everything is going to have all the competencies and allowed lots of room for improvement.”

35. Project limitations • We cannot directly implement the training recommendations • Analyzing and improving training content does not guarantee a change in the participant’s practice • Proxy: self-reported change in knowledge across 8 weeks. • Longitudinal component gives more insight than a same day pre/post survey • Survey may prime the participants and act as an intervention

36. Success and impact System Program Individual

37. Future steps • Develop sustainability and new trauma-informed champions • “Train the trainer” • User-friendly guide to mapping • Calendar of trauma-informed trainings • Track individual’s accumulation of core competencies/trainings • Increase awareness about the core competencies. • Individuals: share them with trainers and participants • Systems: sponsorship of core competencies by various organizations and agencies

38. Discussion Think, Pair, Share: How are core competencies or curriculum mapping applicable to your work? How feasible are the suggested future steps? Additional comments or questions?

39. Conclusion: importance and significance The core competencies and mapping project… • created bridges • highlighted a common theme and provided a unified vocabulary • generated a baseline assessment and cross-systems snapshot of trauma-informed training • served as a reference tool • contributed to quality improvement efforts • collected data, created surveys, and monitored changes over time • are generalizable and applicable

40. Thank you! Behavioral Health Training & Education Network The Health Federation of Philadelphia

41. For more information Contact: • Sophia Hwang sophia.hj.hwang@gmail.com • Leslie Lieberman llieberman@healthfederation.org • Stephen Paesanispaesani@pmhcc.org

42. Internet resources Trauma The Trauma Center at Justice Resource Institute, www.traumacenter.org/ Bruce Perry, MD, Child Trauma Academy, www.childtrauma.org David Baldwin’s Trauma Pages, www.trauma-pages.com/ Anna Foundation, www.annafoundation.org/MDT.PDF Sandra L. Bloom, MD, Community Works, www.sanctuaryweb.com Sidran Foundation for Traumatic Stress, www.sidran.org PTSD Alliance, www.ptsdalliance.org Adverse Childhood Experience Study, www.acestudy.org International Society of Traumatic Stress, http://www.istss.org/

43. Internet resources Trauma Informed Care Multiplying Connections Initiative, http://multiplyingconnections.org National Center for Trauma Informed Care, http://mentalhealth.samhsa.gov/nctic/ Community Connections – Roger Fallot, PhD, http://www.communityconnectionsdc.org Community Works – Sandra Bloom, MD, http://www.sanctuaryweb.com/ National Child Traumatic Stress Network, http://www.nctsnet.org

44. Internet resources Child Development The American Academy of Pediatrics, http://www.aap.org/ The National Association for Childhood Development, http://www.nacd.org/ The National Black Child Development Institute, http://www.ncbcdi.org/04/ The National Institute of Child Health and Human Development, http://www.nichd.nih.gov/ Zero to Three, http://www.zerotothree.org