Advancing Trauma-Informed Care in Child Welfare Practice

Today’s Presenters: Jennifer Marple, MSSA, LISW –Lorain County Children Services –Continuous Quality Improvement Manager Mark R. Groner, MSSA, LISW-S –Beech Brook –Vice President of Clinical Services & Clinical Director Kathryn Biddle, MSSA, LISW-S –Beech Brook –Assistant Vice President of Clinical Services –Program Leader for Center of Excellence for Trauma-Informed Care

Lorain County Children Services Mission Statement: In partnership with the community, the staff, foster parents and volunteers of Lorain County Children Services are committed to the safety and well- being of abused, neglected, and dependent children and will provide the highest quality protection, permanency, and prevention services for children and families.

Mission Statement: To advance the emotional well-being and self-sufficiency of children, youth, and families by providing effective, innovative behavioral health, permanency, educational and related services, and by serving as a strong voice for children, youth and families.

Other Key Stakeholders Lorain County Mental Health Board Lorain County Child Advocacy Center Other Provider Agencies Consumers Nord Family Foundation

History of the Project Unfunded Federal Grant co-authored by Lorain County Integrated Partnership, Lorain County Children Services, Lorain County Mental Health Board and Beech Brook Successful Application for a Local Grant of a scaled- down project awarded in March, 2012, with implementation planning started immediately Expansion to other child- and family-serving systems envisioned

Community Context

National Council of Community Behavioral Healthcare’s Trauma-Informed Care Learning Community Lorain County Children Services is a current participant in this year’s learning community Beech Brook participated last year –Shared vision for trauma informed care –Shared strategies for Continuous Performance Improvement –Shared language

Consideration: This is a change process! Change often starts with denial Resistance typically follows Aim is to achieve adaptation, meaning employees develop an understanding of the change and reflect a positive perception about it –Process involves mourning that which is lost from the past, bringing only the best of the past forward, all the while fully embracing the “new”

Goal of the Nord-Funded Initiative Promotion of trauma-informed child welfare service delivery for: Enhanced child safety Permanency, Child well-being (i.e., CFSR outcomes) Through trauma-informed care principles, practices, and approach.

What is trauma-informed care child welfare practice? Child welfare professionals are educated about: –The impact of trauma on the development and behavior of children –When and how to intervene directly in a trauma-sensitive manner and to make strategic referrals to trauma-informed mental health practices, when indicated –The importance of access to timely, quality, and effective trauma-focused interventions and case planning process that supports resilience in long-term healing and recovery Aim is to improve upon Child and Family Services Review goals of: child safety, permanency, and child well-being

Key Principles 1.Trauma awareness: This includes establishing a philosophical shift, with the overall system taking a different perspective on the meaning of symptoms and behaviors. Staff training, consultation and supervision are important aspects of organizational change to incorporate trauma awareness. Practices should include changes, such as screening for trauma history, facilitating access to trauma specific services, and promotion of staff self care. 2.Emphasis on Safety: Because trauma survivors are often sensitized to potential danger, trauma informed services work towards building physical and emotional safety for consumers and providers. The system should be aware of potential triggers and strive to avoid retraumatization. Emphasis on appropriate boundaries, Privacy, confidentiality and mutual respect are important in developing emotional safe environment. Diversity is accepted and respected.

Key Principles 3.Opportunities to rebuild control and empower: Because control is often taken away in traumatic situations, trauma-informed service settings emphasize the importance of choice and empowerment of consumers. Predictable environments that allow consumers a sense of efficacy and personal control over their lives are essential. Consumers are involved actively in the design and evaluation of services. 4. Strengths based-approach: Trauma-informed care is strength based as opposed to punitive. Consumers are assisted in identifying their own strengths and developing coping skills. Trauma-informed systems are future-focused, and utilize skill building to advance resiliency.

Major Project Components Training on Trauma Development of a System to Screen for Trauma on Child Welfare Cases and a Referral Process Case Consultation on Concerning Cases Support to Staff Exposed to Secondary Trauma

Component 1: Trauma Training Half-Day ACE and Complex Trauma Workshop for All Lorain County Children Services staff Two-Day Child Welfare Trauma Toolkit Training for Direct Care Staff and their Supervisors

ACE and Complex Trauma Exercises

NCTSN Trauma Toolkit Exercises

Program Component 2: Screening and Referral Installation of screening system using the Child Events Trust Survey to identify children and adolescents adversely impacted by trauma Use of results to: Inform case planning Improve making appropriate referrals to community-based mental health services Targeting with the best trauma-informed evidence-based practices

Childhood Trust Events Survey (CTES) 26-Item survey for assessing exposure to traumatic events Children age 8 and older complete the Child and Adolescent Version The Caregiver Version is completed for children younger than age 8 English and Spanish versions

Referrals for Trauma-Informed Care Evidence-Based Model Agency Provider(s) Caring for Children Who Have Experienced Trauma Beech Brook, Bellefaire JCB Parent-Child Interaction Therapy (PCIT) Firelands Trauma-Focused CBT ‘(TF- CBT) Applewood, Beech Brook, Bellefaire JCB, Firelands, Guidestone, Nord Center Alternatives for Families CBT (AF-CBT) Beech Brook Trauma-Grief Component Therapy for Adolescents Beech Brook Child-Parent Psychotherapy (CPP) Guidestone

Program Component 3: Case Consultation on Youth with Trauma Scheduled every week for an hour independent of other meetings Scheduled as part of routine unit meetings Case Example: Karla

Program Component 4: Attention to Secondary (Vicarious) Trauma Training on importance of reaching out for support Availability of outside help upon request Use of UIR system to identify employees exposed to vicarious trauma and reaching out to them Advancing the existing organizational climate of mutual support

Desired Outcomes LCCS staff members will deepen their knowledge of trauma-informed child welfare practice LCCS’s ability to indentify trauma in children will increase LCC’s traumatized children will be referred to trauma-informed mental health treatments in the community LCCS staff members impacted by vicarious trauma will be supported Long-term, the percentage of children experiencing safety, permanency, and well- being will improve

Results to Date: Achievements Training on trauma, complex trauma, and trauma-informed child welfare and mental health practices has been provided and received favorably A screening process and protocol have been created, and staff members have been trained on them, including use of the Child Trust Events Survey Case consultations have occurred and used to facilitate appropriate case planning and referrals Attention to vicarious trauma has begun Baseline data has been collected on the Professional Quality of Life Scale, a tool that measures compassion satisfaction and compassion fatigue (i.e., burnout and secondary traumatic stress) Project activities have been supported by several teams (i.e., an Advisory Team, a Screening Team, and a Training Team) not envisioned in the original grant.

Results to Date: Key Challenges Because of the pace, not all child welfare workers have had the opportunity to participate in the NCTSN Trauma Toolkit Training State-mandated requirements make it hard for child welfare workers to find time to screen for trauma and attend case consultations Self-referral for attention to secondary trauma is slow to occur

Lessons Learned Staff from all levels of agency need to be included in introducing this model ~ Need finger on the pulse of staff concerns with agenda like introducing more assessments or training Vicarious trauma: a) will be present from before, b) needs to be taken into consideration at the start, and c) needs to be openly addressed Must recognize context and pressures with which staff members are coping in order to elicit genuine engagement ~ Case gone bad with media coverage