Developing a Trauma-Informed Child Welfare System WHAT WOULD IT TAKE?

1. Developing a Trauma-Informed Child Welfare SystemWHAT WOULD IT TAKE? Bryan Samuels, CommissionerAdministration on Children, Youth and Families

2. Most States Have the Capacity to Get Smaller Data Source: Adoption and Foster Care Reporting and Analysis System (2002-2010). Children’s Bureau, Administration on Children, Youth, and Families (USDHHS, ACF) Neuroscience & Child Maltreatment

3. Smaller Is Not Always Better Bellamy, J. (2008). Behavioral problems following reunification of children in long-term foster care. Children and Youth Services Review. 30:216. Fechter-Leggett, MO & O’Brien, K. (2010). The effects of kinship care on adult mental heath outcomes of alumni of foster care. Children and Youth Services Review. 32(2):206. Simmel, C.; et al. (2007). Adopted youths psychosocial functioning: A longitudinal perspective. Child and Family Social Work. 12(4):336. BPI: Behavior Problems Index Neuroscience & Child Maltreatment

4. Typical Programs for Youth Yield Poor Outcomes Koball, Heather, et al. (2011). Synthesis of Research and Resources to Support At-Risk Youth, OPRE Report # OPRE 2011-22, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. Neuroscience & Child Maltreatment

5. “Simply removing a child from a dangerous environment will not by itself undo the serious consequences or reverse the negative impacts of early fear learning. There is no doubt that children in harm’s way should be removed from a dangerous situation. However, simply moving a child out of immediate danger does not in itself reverse or eliminate the way that he or she has learned to be fearful. The child’s memory retains those learned links, and such thoughts and memories are sufficient to elicit ongoing fear and make a child anxious.” National Scientific Council on the Developing Child (2010). Persistent Fear and Anxiety Can Affect Young Children’s Learning and Development: Working Paper No. 9. Retrieved fromwww.developingchild.harvard.edu FFTA

6. Challenges Associated with Trauma • BIOLOGY • Sensorimotor developmental problems • Analgesia • Problems with coordination, balance, body tone • Somatization • Increased medical problems across a wide span (e.g., pelvic pain, asthma, skin problems, autoimmune disorders, pseudoseizures) • ATTACHMENT • Problems with boundaries • Distrust and suspiciousness • Social isolation • Interpersonal difficulties • Difficulty attuning to other people’s • emotional states • Difficulty with perspective taking • COGNITION • Difficulties in attention regulation and executive functioning • Lack of sustained curiosity • Problems with processing novel information • Problems focusing on and completing tasks • Problems with object constancy • Difficulty planning and anticipating • Problems understanding responsibility • Learning difficulties • Problems with orientation in time and space • SELF CONCEPT • Lack of continuous, predictable sense of self • Poor sense of separateness • Disturbances of body image • Low self-esteem • Shame and guilt • BEHAVIORAL CONTROL • Poor modulation of impulses • Self-destructive behavior • Aggression toward others • Pathological self-soothing behaviors • Sleep disturbances • Eating disorders • Substance abuse • Excessive compliance • Oppositional behavior • Reenactment of trauma in behavior or play ( e.g., sexual, aggressive) • DISSOCIATION • Distinct alterations in states of consciousness • Amnesia • Depersonalization and derealization • Two or more distinct states of consciousness • Impaired memory for state-based events • AFFECT REGULATION • Difficulty w/ emotional self-regulation • Difficulty labeling & expressing feelings • Problems knowing and describing internal states • Difficulty communicating wishes, needs Cook, et. al., 2005 FFTA

7. Path of Maltreatment’s Impact on Relationships throughout Life Neuroscience & Child Maltreatment

8. http://www.acf.hhs.gov/programs/cb/laws_policies/policy/im/2012/im1204.pdfhttp://www.acf.hhs.gov/programs/cb/laws_policies/policy/im/2012/im1204.pdf FFTA

9. Taking a Different Approach • “Acute care” forms of child and adolescent mental health services are poorly matched to the service needs of a disadvantaged child population presenting with complex attachment- and trauma-related psychopathology, and unstable living arrangements. • Promoting well-being for children who have experienced maltreatment requires evidence-based screening and interventions that address their unique behavioral and mental health needs, as well as: • Help them understand their experiences • Support the development of new coping strategies • Address developmental stages and delays • Strengthen environmental buffers • For children who have experienced complex interpersonal trauma, attention must be paid to their capacity to establish and maintain healthy relationships • Resilience is not seen as good fortune arising from chance encounters with a supportive friend, peer or partner, but rather as an ongoing process of developing the competencies necessary to form, maintain and benefit from supportive interpersonal relationships. Leslie, LK; Kelleher, KJ; Burns, BJ; Landsverk, J & Rolls, JA. (2003). Foster care and Medicaid managed care. Child Welfare. 82(3):367. Neuroscience & Child Maltreatment

10. Framework for Well-being Cognitive Functioning Physical Health and Development Emotional/ Behavioral Functioning Social Functioning The framework identifies four basic domains of well being: (a) cognitive functioning, (b) physical health and development, (c) behavioral/emotional functioning, and (d) social functioning. Within each domain, the characteristics of healthy functioning relate directly to how children and youth navigate their daily lives: how they engage in relationships, cope with challenges, and handle responsibilities. Environmental Supports Personal Characteristics Developmental Stage (e.g., early childhood, latency) Neuroscience & Child Maltreatment

11. Elements of Social & Emotional Well-being Self-management—Impulse control, stress management, persistence, goal setting, and motivation. Self-awareness—Identification and recognition of one’s own emotions, recognition of strengths in self and others, sense of self-efficacy, and self-confidence. Social awareness—Empathy, respect for others, and perspective taking. Responsible decision making—Evaluation and reflection, and personal and ethical responsibility. Relationship skills—Cooperation, help seeking and providing, and communication. Neuroscience & Child Maltreatment

12. Measure Outcomes, Not Services “It is common for child welfare systems to gauge their success based on whether or not services are being delivered. One way to focus attention on well-being is to measure how young people are doing behaviorally, socially, and emotionally and track whether or not they are improving in these areas as they receive services” (ACYF-CB-IM-12-04). Stop Measuring Services How many children received…? How many hours of training were delivered? What percent of children got…? Start Measuring Outcomes Are trauma symptoms reduced? Did services increase relationship skills? Do children have healthier coping strategies? Neuroscience & Child Maltreatment

13. Trauma Screening, Functional Assessment & Progress Monitoring • “Functional assessment—assessment of multiple aspects of a child’s social-emotional functioning (Bracken, Keith, & Walker, 1998)—involves sets of measures that account for the major domains of well-being.” • “Child welfare systems often use assessment as a point-in-time diagnostic activity to determine if a child has a particular set of symptoms or requires a specific intervention. Functional assessment, however, can be used to measure improvementin skill and competencies that contribute to well-being and allows for on-going monitoring of children’s progress towards functional outcomes.” • “Rather than using a “one size fits all” assessment for children and youth in foster care, systems serving children receiving child welfare services should have an array of assessment tools available. This allows systems to appropriately evaluate functioning across the domains of social-emotional well-being for children across age groups (O’Brien, 2011) and accounting for the trauma- and mental health-related challenges faced by children and youth who have experienced abuse or neglect.” Valid and reliablemental and behavioral health and developmental screening and assessment tools should be used to understand the impact of maltreatment on vulnerable children and youth. • TRAUMA SCREENING • Child and Adolescent Needs and Strengths (CANS) Trauma Version • Childhood Trauma Questionnaire (CTQ) • Pediatric Emotional Distress Scale (PEDS) • FUNCTIONAL ASSESSMENT • Strengths and Difficulties Questionnaire (SDQ) • Child Behavior Checklist (CBCL), the Social Skills Rating Scale (SSRS) • Emotional Quotient Inventory Youth Version (EQ-i:YV) FFTA

14. Shifting Resources to Support What Works De-scaling what doesn’t work Investing in what does INEFFECTIVE APPROACHES RESEARCH-BASED APPROACHES Neuroscience & Child Maltreatment

15. EBPs for Social & Emotional Well-being Neuroscience & Child Maltreatment

16. EBPs for Social & Emotional Well-being Neuroscience & Child Maltreatment

17. Making Meaningful and Measurable Improvements in Outcomes Neuroscience & Child Maltreatment

18. Final Thoughts: Where We Are Going • IMPLICATIONS FOR CASE-LEVEL WORK WITH YOUTH • Caseworkers are more aware of trauma, mental health needs, and evidence-based practices to get youth the right services at the right time. • Caseworkers better understand the trauma-related relational challenges that youth bring with them when they enter care and screen for social-emotional problems. • Transition planning and promotion of social/emotional skills for adulthood begin well in advance of exit from care. • Service plans include activities to promote relational competencies and efforts to find/engage siblings, relatives, etc. The child welfare performance proposal incentivizes the development of a child welfare workforce marked by: • Focus on child & family level outcomes • Progress monitor for improved child/youth functioning • Proactive approach to social and emotional needs • Developmentally specific approach • Promotion of healthy relationships Neuroscience & Child Maltreatment

19. Final Thoughts: Where We Are Going • IMPLICATIONS FOR SYSTEM’S WORK WITH YOUTH • Data describing trauma and social and emotional well-being of youth are collected and analyzed regularly • Research and data are used to drive decision-making, policies, program design, and contracting services. • Evidence-based services that promote healing and recovery from truama and build key skills and capacities in youth are available. The goal of the proposal is to propel the child welfare system towards greater: • Organization around positive outcomes • Emphasis on continuous quality improvement to include review of child functioning indicators • Allocation of existing resources from ineffective, generic practice to an array of specific, evidence-based interventions • Workforce is prepared to support installation and implementation of evidence-based practices that promote social-emotional well-being Neuroscience & Child Maltreatment

20. Vehicles for Promoting Social and Emotional Well-Being • Flexible Funding Waivers • Discretionary Funding: • Trauma and Mental Health Screening, Assessment, and Treatment • Educational Stability • Early Childhood-Child Welfare Linkages • Youth Services • Child Welfare-Supportive Housing • Regional Partnership Grants • High Priority Goal on Trauma • Psychotropic Medication Oversight and Monitoring • President’s Budget Proposal - $2.5 billion/10 years Neuroscience & Child Maltreatment