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Creating Policies to Support Trauma-informed Perspectives and Practices. Janice L. Cooper, PhD Interim Director. 3 rd Annual Symposium, Bridging the Gap Fort Worth, Texas | November 3, 2009. Who We Are.

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Creating policies to support trauma informed perspectives and practices l.jpg

Creating Policies to Support Trauma-informed Perspectives and Practices

Janice L. Cooper, PhD

Interim Director

3rd Annual Symposium, Bridging the Gap

Fort Worth, Texas | November 3, 2009

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Who We Are

  • NCCP is the nation’s leading research and policy center dedicated to the economic security, health, and well-being of America’s low-income children and families.

  • Part of Columbia University’s Mailman School of Public Health, NCCP promotes family-oriented solutions at the state and national levels.

  • Our ultimate goal: Improved outcomes for the next generation.

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  • Background

  • Trauma and Its Effects

  • Special Populations

  • Current Services and Policy Challenges

  • Best Practices

  • Specific Policy Interventions

  • Policy Recommendations

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  • 1982 Jane Knitzer’s seminalstudy, Unclaimed Children: The Failure of Public Responsibility to Children and Adolescents in Need of Mental Health Services

  • 2005 work began for “Unclaimed Children Revisited: The Status of Children’s Mental Health in the United States 25 Years Later ”

  • 2007 released Trauma Report

  • 2008 released national report

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Throughout her remarkable life and its many diverse experiences and achievements, Dr. Jane Knitzer embodied one consistent theme:

that every child and every family is sacred, and that it is every

person’s duty to reach out to the

most marginalized and vulnerable

among us.

Her life’s work reflects these values at every stage.

Most recently on the IOM Committee on Depression, Parenting Practices, and the Healthy Development of Children

NCCP Director


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Unclaimed Children Revisited: Interests & Aims experiences and achievements, Dr. Jane Knitzer

  • Identify effective state fiscal, infrastructure, training and related policies

    • Research-informed

    • Developmentally appropriate

    • Family/youth driven

    • Culturally competent

  • Promote research informed dialogue to move policy

  • Complement President’s New Freedom Commission’s initiatives by disseminating information on specific policy options

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Understanding Trauma and its Effects experiences and achievements, Dr. Jane Knitzer

  • Trauma is pervasive.

  • Trauma refers to the severe distress, harm or suffering that results from overwhelming mental or emotional pain or physical injury.

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Understanding Trauma and its Effects experiences and achievements, Dr. Jane Knitzer

  • A core feature of the impact of the trauma is the long and short term loss experienced by those exposed to traumatic events.

  • Critical elements of child development undermined by trauma (Cloitre, Cohen and Koenen, 2006):

    • healthy attachment,

    • social and emotional competency,

    • self-assurance, confidence,

    • independence

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Lessons from ACES Study experiences and achievements, Dr. Jane Knitzer (Dube et al., 2001, Felitti et al., 1998)

  • Strong relationship between adverse childhood experiences (5+)

    • Suicide and Suicidal Attempts

    • Chronic Illness (Obesity, Heart Disease, Liver Disease)

    • Addictions

    • Mental Health Problems

    • Premature Death

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What We Mean By Trauma-informed experiences and achievements, Dr. Jane Knitzer

  • Trauma-informed strategies ultimately seek to (Harris & Fallot, 2001):

    • do no further harm;

    • create and sustain zones of safety for children, youth and families who may have experienced trauma;

    • promote understanding, coping, resilience, strengths-based programming, growth, and healing

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Children & Youth Disproportionately At-risk experiences and achievements, Dr. Jane Knitzer

  • Children from Military Families

  • Survivors of Abuse, Neglect & Sexual Violence

  • Children & Youth with Disabilities

  • Youth in Juvenile Justice

  • Children who Experienced Natural and Man-Made Disasters

  • Youth with Substance Use Disorders

  • Homeless & Runaway Youth

  • Children & Youth at Risk of Suicide

  • Youth of Color

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Children from Military Families experiences and achievements, Dr. Jane Knitzer

  • Over 1.2 million children live in military families

  • Approximately 700K have at least one parent deployed (Johnson et al., 2007)

  • Deployment predictive of:

    • 2X increase risk of child maltreatment (Gibbs et al., 2007)

    • Increased risk of child trauma across developmental span from infancy through adolescence (Lincoln, Swift, Shorteno-Fraser, 2008)

    • 32% child psychological morbidity; 42% high parental stress (5-12 yo) (Flake et al., 2009)*

    • High parental stress put children at more than 7X increase risk for poor child psychological functioning*

    • Among young children (U 5yo) those 3-5 higher levels of externalizing behaviors independent of parental distress (Chartrand,et al., 2008)

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Children and Youth from Military Families experiences and achievements, Dr. Jane Knitzer

  • Prevalence of Mental Health Problems among Military Personnel

    • Post deployment 20% of active duty and 42% of reservists needed mental health treatment (not identify prior to deployment) (Lamberg, 2008)*

    • Reservists, National Guard and younger active duty service members with combat related exposure increased risk for new onset of heavy drinking, binge drinking and alcohol-related problems (Jacobson et al., 2009)

    • Lack of confidentiality may deter soldiers from accessing SUD related treatment (Milliken, Auchterlonie & Hoge 2007)*

    • Referrals to SUD treatment dramatically lower compared to MH treatment*

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Child/Youth Survivors of Abuse, Neglect & Sexual Violence experiences and achievements, Dr. Jane Knitzer

  • Maine: 33% females and 67% males: a trauma related diagnosis or were involved in child welfare due to traumatic event (Yoe, Russell, Ryder, Perez and Boustead 2005)

  • 50% female & 70 male rape survivors raped prior to age 18 (Tjaden, P and Thoennes 2006)

    • 20% Females

    • 50% Males

    • Raped by age 12

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Children Who Experienced Abuse, experiences and achievements, Dr. Jane Knitzer Neglect or Sexual Violence

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Disabled Children & Youth at Higher Risk experiences and achievements, Dr. Jane Knitzer

  • More likely to be abused (Sullivan & Knutson, 1998)

    • physically (1.5 times)

    • sexually (2.2 times)

  • Deaf children & youth higher risks (Sullivan & Knutson, 1998)

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High Prevalence of Trauma Exposure in Juvenile Justice experiences and achievements, Dr. Jane Knitzer

  • Over 90 % in juvenile detention in a large urban county have been exposed to at least one traumatic event & nearly 60% have experienced 6 or more traumatic events. (Abram et al, 2004)

  • 11 % of youth in JJ were diagnosed with PTSD upon clinical assessment. (Abram et al, 2004)

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What the Data Shows School-age Youth in Juvenile Detention experiences and achievements, Dr. Jane Knitzer

Prevalence Behavioral Health Disorders of Youth in Detention by Gender (%)

NB: Approx. 90% of youth in JJ are males.

Source: Teplin, L., Abram, K., McClelland, G. M., Dulcan, M., & Washburn, J. J. (2006). Psychiatric Disorders of Youth in Detention. Juvenile Justice Bulletin (April 2006), 1-16.

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What Data Shows: School-age Youth Who Experience Cumulative Trauma

  • Overall cumulative exposure to childhood trauma = 82.5

  • Males were:

    • 3.3 x more likely than females to experience intentional or “assaultive” violence (e.g. being raped, mugged, held up or threatened with weapon)

    • 2.2 x more likely than females to experience other injury or trauma

Source: Breslau, N., Wilcox, H. C., Storr, C. L., Lucia, V. C., & James, A. (2004). Trauma Exposure and Post-Traumatic Stress Disorder: A Study of Youths in Urban America. Journal of Urban Health, 81(4), 531-544.

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Children who experienced trauma from natural and man-made disasters

  • Of Katrina survivors who were parents: (Abramson & Garfield, 2006)

    • Nearly 50% reported their children had new emotional/behavioral problems

    • Nearly 50% reported that they “never or only sometimes felt safe”

  • Of all returning vets from Afghanistan & Iraq, those of transition-age (18-25), were the most likely to develop PTSD (Seal, Miner, Sen, & Marmar, 2007)*

  • Overall PTSD rates among veterans of OEF/OIF 4X higher than community samples*

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3-4 times higher risk for PTSD (1) disasters

Multiple exposures to trauma predicted developing SUD (2)

Youth with co-occurring PTSD & SUD lower levels of functioning (1)

SUD associated with community violence, interpersonal violence, child maltreatment and self harm (3)

SUD can serve as mechanism for self addressing trauma (3)

SUD impedes effective trauma treatment (4)

Youth with Substance Use Disorders at High Risk

1) Giaconia et al., 2000; 2) Giaconia et al., 1995; 3) Kilpatrick et al., 2003; 4) Jaycox, Ebener, Damesek, & Becker, 2004; Riggs, 2003.

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Children of Homeless Families & Runaway Youth disasters

  • Two-fifths of the homeless population in the United States is made up of families (Bassuk et al, 2005). Their homelessness puts them at increased risk for other trauma, including physical and sexual violence, emotional abuse and intense anxiety and uncertainty.

  • Almost two-thirds of homeless and runaway youth living on the street have witnessed violence and between 15-51 percent have been physically or sexually assaulted (Kipke et al, 1997).

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Children at Risk of Suicide disasters

  • Three groups with a greater risk:

    • American Indian/Alaska Native children and youth

    • due to the historical trauma and current deprivation and trauma

    • 64 % of all the completed suicide are committed by this group nationally, 17.6/100,000 versus 10.4/100,000 (Middlebrook et al, 2005)

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Children at Risk of Suicide disasters

  • Adolescent Latinas

    • A higher risk for suicide than Latino boys (15 % versus 7.8%) and non-Latino boys and girls (Keaton et al, 2006).

    • Among girls, Latinas attempted suicide 50-60% more than African-American and white female adolescents (The NHSDA report, 2003).

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Children at Risk of Suicide disasters

  • Gay, Lesbian, Bisexual, Transgendered and Questioning Youth (GLBTQ)

    • Between 1.7 and 2 times more likely than their non-gay and lesbian peers to have suicidal thought (Russell & Joyner, 2001)

    • More than 2.5 times more likely to attempt suicide than their non-gay peers (Russell & Joyner, 2001)

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Secondary/Vicarious Trauma among Providers disasters

  • Impacts their ability as caregivers (Bober et al., 2005)

  • Leads to higher rates of turnover (Van Hook, 2008)

  • Provider with self care strategies included these in tx, led to lower levels secondary trauma & reduced turnover (Gordon, 2005)

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Strategies to Reduce Vicarious Trauma disasters(Osofsky, Putnam & Lederman, 2008)

  • Smaller Caseloads

  • Self-care

  • Improve supervision of front-line workers

  • Access to mh services

  • Impart information on secondary trauma

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Long-term Effects of Trauma disasters

  • Negative Impact on Brain Development

  • Academic and Social Problems

  • Chronic Illness, Morbidity and Mortality

  • Intergenerational Impact

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Current Policy and Service Responses Characterized by: disasters

  • Failure to routinely screen and treat for trauma

  • Lack of traction to use proven effective treatment strategies

  • Use treatment practices and environments that re-traumatize

    • Seclusion & Restraint

    • Boot Camp

    • Peer or Staff Abuse

  • Insufficient Attention to Vicarious/Secondary Trauma

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Failure to Routinely Screen and Treat disasters

  • Information on child trauma rarely received according to some studies (Taylor et al., 2005; Hansen, Hasselbrock & Tworkowski, 2002)

    • 84% of agencies reported in one study no/or extremely limited information on child/youth trauma history

  • Much of emerging knowledge on trauma fails to make it into daily practice (Taylor et al., 2005)

    • 33% of agencies report did not train staff to assess trauma

    • Less than 50% reported training their staff on EBP for children and youth with exposure to trauma

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GAO (2007) report on Abuse in State-sponsored institutions: RTFs, boot-camps, wilderness camps

  • 33 states with over 1600 staff involved in incidences of abuse of children and youth in 2005

  • 10 investigated deaths within RTFs (one case in Texas) revealed common threads

    • Untrained and inexperienced staff

    • Lack of adequate nourishment in pursuit of “tough love” philosophy/strategies

    • Reckless/negligent operating procedures

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SAMHSA Policy on Seclusion and Restraint RTFs, boot-camps, wilderness camps

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Immigration Reform RTFs, boot-camps, wilderness camps

Restrictive Housing Policies

Disaster Response Plans

Other Public Policies Can Serve to Expose Children/Youth to Trauma or Re-traumatize

Photo: P. Pereira, The Standard Times

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Immigration Policies and Trauma RTFs, boot-camps, wilderness camps

  • 12 million undocumented workers in the US

  • Estimates 5 million children have at least one parent undocumented

  • 60% of these children are US-born citizens

  • Over 1.6 million immigration related arrests

  • Impact on children: Urban Institute/La Raza study

    • 506 children; impact on attending school, accessing resources, getting different caring arrangements (Capps, et al. 2007)

    • Children whose parents deported, arrested or detain in MN, CO, TX, NE,IA (NCCP analysis, 2006)

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Source: http:// RTFs, boot-camps, wilderness

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Unaddressed Challenges RTFs, boot-camps, wilderness camps

  • Funding Restrictions that Impeded Care and Sustainable Treatment

  • Limited Support for Prevention & Early Intervention

  • Workforce problems: Inadequacy in Supply and Quality

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Services RTFs, boot-camps, wilderness camps

Standardized Screening and Assessments

Evidence-Based Interventions

Culturally-Based Strategies

Family and Youth Engagement and Support



Policies to Eliminate/ Reduce Seclusion & Restraint

Financial Strategies

Culturally Competent Policies

State Disaster-Related Plans for MH services

Identifying Best Practices: Key Elements

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Best Practices: Selected Screening & Assessment Tools RTFs, boot-camps, wilderness camps

Children’s Sexual Behavior Inventory

Clinician Administered PTSD Scale

DISC (PTSD Module)

Lifetime Incidence Traumatic Events

Los Angeles Symptoms Checklist

Trauma Symptom Checklist (Young Children/Children)

When Bad Things Happen

  • Acute Stress Checklist

  • Child Dissociative Checklist

  • Child Post-traumatic Stress Reaction Index

  • Child PTSD Symptom Scale

  • Child Stress Disorder Checklist

  • Child’s Reaction to Trauma Event Scale

  • Children’s Impact of Traumatic Event Scale

  • Children’s PTSD Inventory

  • Children’s PTSD Interview

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Selected Evidence-based Interventions RTFs, boot-camps, wilderness camps

  • Parent Child Interaction Therapy aka Honoring Children, Making Relations (Bigfoot)

  • Trauma-Focused CBT aka Honoring Children, Mending the Circle (Bigfoot)

  • Cognitive Behavioral Interventions for Trauma in Schools

  • Dialectical Behavior Therapy

  • Trauma Recovery and Empowerment for Adolescents

  • Seeking Safety for Adolescents

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Case Studies (NY, ND, ME) RTFs, boot-camps, wilderness camps

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North County Children’s Clinic (NCCC): New York RTFs, boot-camps, wilderness camps

  • Watertown, NY

  • 10th Mtn Division avg deployment OEF/OEF 5x

  • Target Population- Families (Children) of Military Personnel

  • 27,000 residents (16,000 active duty military – 60% deployed)

  • 4 school-based health centers provide over 2000 mental health visits per year to children and families

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Strengths RTFs, boot-camps, wilderness camps

Positive School Relations

Clinically sound programming

Collaboration with the Military HMO


Military reimbursement for psy. health care inadequate

Sustainable program funding

Magnitude of needs exceed capacity

Gaps in the continuum of care

TriCare two-tier system; disallows some PCTs for e.g. family conflict and child maltx; no coverage intensive commty tx

North Country Children’s Clinic, New York

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Quote from Family Member RTFs, boot-camps, wilderness camps

We receive our medical care at the -- Ambulatory Health Clinic. We took our son there in June and expressed our concerns for his mental health. The Doctor wrote a referral for a child psychologist in our town. That doctor had a 3 month waiting list to get on the waiting list for an appointment. By now school had started and we were having nights where he stayed up all night crying, wanting his father to come home. If I did get him to sleep, he woke up crying. It became a struggle even to get him to go to school, he saw no use in going to school if that meant growing up without his father. He had also started losing interest in church, and cub scouts, two things that he usually loves. He did not want to leave the house at all……

With the help of the school-based clinic I was able to start helping my son cope with the deployment……

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Medicine Moon Initiative-North Dakota RTFs, boot-camps, wilderness camps

  • State-Tribal Initiative with 6 tribes

  • Built upon System of Care Sacred Child Project

  • Strong training component draws on cultural strengths and lessons learned from historical trauma

“Ours is a way of teaching parents that children are sacred”

Courtesy: Deb Painte, MMI

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Strengths RTFs, boot-camps, wilderness camps

Culturally competent


Agreement with the state to bill directly for Medicaid

Focus on both current and historical trauma


Lack of sufficient psychiatric or behavioral resources to meet the most acute needs

Lack of funding

Medicine Moon Initiative-ND

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Care delivery through trauma-lens RTFs, boot-camps, wilderness camps

Age 0-12

Service philosophy: “What has happened to this family” not, “What is wrong with this family”

Thrive: Trauma-informed System of Care, Maine

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Strengths RTFs, boot-camps, wilderness camps

System of care focused on strength, engaging whole family

Universal screening

Promotion of effective trauma specific treatments

Staff Training

Use of trauma sensitive assessments

Quality assurance


On-going provider buy-in, territorial issues pose obstacles to collaboration

Medicaid managed care curve-out

Struggles with substantive inclusion of all relevant agencies

Sustainable financial and programmatic efficacy

Thrive: Trauma-informed System of Care, Maine

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Literature Review & Analysis of publicly available data: RTFs, boot-camps, wilderness campsMain Data Sources

  • Jennings, Ann. (2004). Blueprint for Action. Building Trauma-Informed Mental Health Service Systems: State Accomplishments, Activities and Resources. September 2004.

  • State block grant applications. 2004-2007

  • SAMHSA Grant Awards - State Summaries FY 2005/2006

  • Personal Interviews with selected state officials

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Services: Standardized Screening and Assessments RTFs, boot-camps, wilderness camps

  • Most states offer some form of screening and assessment.

  • In nearly 60 percent of states and territories (data available on 46 states) universal or selective screenings and assessments are being conducted. In many cases the scope is limited.

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Services: Evidence-Based Interventions RTFs, boot-camps, wilderness camps

  • In less than 20 percent of states which provide screenings and assessments, the screening and assessment tools are evidence-based.

  • More than 50 percent of states provide evidence-based treatment/services; however, the scope is mostly limited.

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Services: Culturally-Based Strategies RTFs, boot-camps, wilderness camps

  • About 30 % of states have culturally competent, trauma informed or focused treatment/services.

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Infrastructure: Training RTFs, boot-camps, wilderness camps

  • Many states have developed training strategies of varying depth to increase the clinical and support capacity of those who deliver services to children, youth and their families who have been exposed to trauma.

    • Nearly 40 percent of states (data available for 38 states) report training on trauma-informed/specific evidence-based practices.

    • A small proportion of this training focuses on cultural groups, gender or families.

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Infrastructure: Training (cont’d) RTFs, boot-camps, wilderness camps

  • While not widespread some best practices in training in states include:

    • Strategies those aimed at developing trauma specialists as in Oklahoma

    • System-wide or discipline-wide training like in Connecticut, Maine, Nevada, New York, Oklahoma, Illinois and Washington

    • Trauma-related training that meet the conditions for state clinician certification as in Wyoming

    • Embedding a trauma focus in statewide evidence-based training dissemination center in New York

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Infrastructure: Policies to Eliminate/Reduce Seclusion & Restraint

  • At least twenty states have implemented laws, regulations or policies designed to reduce and ultimately eliminate the use of seclusion and restraint. Five of these states have implemented strategies with far-reaching impact.

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Infrastructure: Financial Strategies Restraint

  • A number of state legislatures have also appropriated funding for specific trauma-related initiatives.

  • Other state leaders have expanded the Medicaid benefit set to reimburse evidence-based trauma treatments, to facilitate trauma-specific treatments through billing and to fund specific clinicians.

  • Generally absent are any state specific strategies to use the focus on information technology to create a more trauma-informed system.

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Infrastructure: Culturally Competent Policies Restraint

  • 8 states reported have culturally competent, trauma-focused policies.

    • Alaska

    • Connecticut

    • Illinois

    • New York

    • Oklahoma

    • South Carolina

    • Vermont

    • Washington

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Illinois Restraint

Legislation requiring trauma informed services

State plan for child welfare includes public health framework

Workforce development

Use of Effective Treatment Strategies


Trauma strategies heavily workforce development centered

Promotes cross systems collaboration

Full-time state level trauma coordinator

Evaluates and provides TA to contractors based on Jennings checklist of administrative practices and services

Highlights of State Responses: Illinois & Oklahoma

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Key Elements of Success Restraint

Leadership Support



Child Trauma Counseling


Co-occurring Initiative

Cross Training Initiative

Transformation Initiative

National Child Traumatic Stress Initiative

Full time coordinator


Lessons Learned

Standards for Trauma Informed Care

Standards/Core Competencies for Trauma Informed Care

Communication is essential

Develop a common language for trauma.

Transformation takes time.

Courtesy: Julie Young, OK

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What did NCCP Survey Questions Restraint

on Trauma Add?

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Systematic Screening or Intervention for Trauma or Suicide Risk (Children and/or their Parents)

  • 40 states report systematic screening or treatment for trauma or suicide risk

  • 13 states did not respond or systematic screen/treat

  • Common state efforts

    • 12 reported screening for trauma/suicide risk (4 reported using Columbia Teen Screen)

    • 10 states reported providing training on validated tools such as on TF-CBT; Applied Suicide Intervention Skills Training (ASIST); Question, Persuade & Refer (QPR); and, crisis/suicide prevention and intervention

    • 7 states report using funds like Garrett Smith funds for prevention

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Plan to Deliver Mental Health Services and Supports in Times of Disaster or Emergency

  • 34 states reported that they had a specific plan

  • 17 states reported that they did not have a plan

  • 2 states did not respond

    Designated Individual in CMH charged with service coordination in the case of disaster/emergency

  • 24 states reported they had a designated individual

  • 8 states reported that they did not (in case of 3 for MH not specifically child mh)

  • 17 missing/NA

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Types of Responses from States on MH Services for Children in State Emergency Plan

  • Each regional coordinator has a designated emergency satellite phone

  • Regional (10) disaster management teams

  • A system of trained and coordinated crisis counseling staff and networks

  • A network ready to respond of volunteers and professionals

  • “All hazards” leadership team

  • A MOU with community behavioral health centers to coordinate, organize and mobilize during any crisis

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Policy Recommendations in State Emergency Plan

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All federal, tribal, state and local policies should reflect a trauma-informed perspective

  • Important factors:

    • Developmentally appropriate

    • Culturally & Linguistically Competent

    • Encompass public health framework

    • Engage children, youth and their families in healing.

    • Fiscally-responsive

    • Collaborative

    • Accountable

    • Support infrastructural development

    • Competency-based training

    • Address vicarious trauma

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Policies should support/reinforce: a trauma-informed perspective

  • Delivery systems that identify and implement strategies to prevent trauma, increase capacity for early intervention and intervention and provide comprehensive treatment

  • Strategies designed to prevent and eliminate practices that cause trauma or re-traumatize

  • Core components of best practices in trauma-informed care: prevention, developmentally appropriate, empirically supported strategies, cultural and linguistic competence and family and youth engagement

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Trauma-informed related policies must include/ensure: a trauma-informed perspective

  • Funding that is supportive of care and that adequately reimburses for effective strategies

  • Funding is contingent upon elimination harmful practices that re-traumatize

  • Investment in strategies to ensure workforce competency in effective strategies

  • Provision of incentives for care delivered in community-based settings like schools and child care settings in addition to health care settings

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For More Information, Contact: a trauma-informed perspective

Dr. Janice Cooper

Or Visit NCCP web site