John R. Kasich, Governor Tracy J. Plouck, Director John L. Martin, Director 1 Developmental Disabilities Mental Health and Addiction Services

What is Trauma ? Individual trauma results from an event, series of events, or a set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well- being (SAMHSA) 2

What is Trauma? The individual’s experience of these events or circumstances helps to determine whether it is a traumatic event. The long-lasting adverse effects on an individual are the result of the individual’s experience of the event or circumstance. 3

Prevalence of Trauma Exposure to trauma is widespread Trauma can occur at any age Trauma can affect individuals from all walks of life 4

Prevalence of Trauma Exposure to trauma is especially common among individuals with mental illness, substance use disorders and developmental disabilities 5

Trauma Affects… Over one out of three females with mental health disorder; and About one out of five males with mental health disorder in Ohio Source: Client Self-Reported Experiences of Trauma, SFY13, Ohio Behavioral Health Module

Trauma Affects… Over one out of four females with a substance use disorder; and About one out of ten males with a substance use disorder in Ohio Source: Client Self-Reported Experiences of Trauma, SFY13, Ohio Behavioral Health Module

Trauma Affects… Over one out of three females with co-occurring mental health and substance use disorders; and Over one out of ten males with co-occurring mental health and substance use disorders in Ohio Source: Client Self-Reported Experiences of Trauma, SFY13, Ohio Behavioral Health Module

Trauma Affects Ohioans with Developmental Disabilities… Neglect Physical Abuse 310 Verbal Abuse 83 Sexual Abuse CRN Validation Cube. Ohio Department of Developmental Disabilities 2013.

Ohioans with Developmental Disabilities…  Increased risk for abuse as compared to the general population (Gil, 1970; Mahoney & Camilo, a998; Ryan, 1994)  Over four times as likely to be victims of crime (Sobsey, 1996)  Two – ten times more likely to sexually abused than those without disabilities (Westat Ind., 1993)  Often experience rejection and loneliness (Pitonyak)

Trauma Affects Ohio’s Children… Neglect Physical Abuse Foster care Multiple Allegations Sexual Abuse 1800 Emotional Abuse PCSAO Fact Book: 11 th Edition, , Public Children Services Association of Ohio

In 2013, 15,000 Ohio children of a substance-abusing guardian entered the county child-welfare system At least half of these children remained in the county’s custody for more than 300 days compared with the average 70-day stay Child abuse and neglect reports in which heroin was listed as a factor increased from 4.9% of total reports in 2010 to 8.9% 2013 Trauma Affects Ohio’s Children… Ohio Department of Job and Family Services, Office of Families and Children

Trauma Affects Ohioans with Domestic Violence… Domestic Violence Calls (68,000) Victims (56,000) Arrests (41,000) Barbara Warner Committee on Workplace Domestic Violence Report, Ohio Department of Health Ohio Domestic Violence Statistics, 2012, Ohio Domestic Violence Network HealthDay, Copyright © 2013

Trauma Affects Ohioans with Domestic Violence… Of families who experience intimate partner violence: Four out of five adult children commit violence against partners Three out of four adult children become victims of domestic violence Barbara Warner Committee on Workplace Domestic Violence Report, Ohio Department of Health Ohio Domestic Violence Statistics, 2012, Ohio Domestic Violence Network HealthDay, Copyright © 2013

Ohio ranks fifth among all US states in human trafficking 1000 Ohio children are estimated to become victims of human trafficking each year NOT FOR SALE Trauma Affects Ohioans Who Are Victims of Human Trafficking…

Trauma Affects Women... Interpersonal violence is a major source of trauma in the United States, particularly for women While men are most likely to experience violence from strangers, women and girls are most likely to be hurt by people they know. For women in the military, the greatest risk of harm is from fellow soldiers; for adolescent girls, it is from the people they love.

Adverse Childhood Experiences Study Collaboration between Kaiser Permanente and CDC 17,000 patients undergoing physical exam provided detailed information about childhood experiences of abuse, neglect and family dysfunction ( ) 17

ACE Categories Abuse Emotional Physical Sexual Neglect Emotional Physical Household Dysfunction Mother Treated Violently Household Substance Abuse Household Mental Illness Parental Separation or Divorce Incarcerated Household Member 18

Number of ACE Categories 19 ACE SCOREWOMEN (%) MEN (%) TOTAL (%) or more

ACE Score and Health Risk As the ACE score increases, risk for these health problems increases in a strong and graded fashion: Alcoholism and alcohol abuse Chronic obstructive pulmonary disease (COPD) Depression Hallucinations Fetal death Health-related quality of life Illicit drug use Ischemic heart disease (IHD) Liver disease Risk for intimate partner violence Multiple sexual partners Sexually transmitted diseases (STDs) Smoking Suicide attempts Unintended pregnancies Early initiation of smoking Early initiation of sexual activity Adolescent pregnancy HIV 20

ACE Pyramid 21

Cost of Trauma Trauma is a major driver of medical illness, including cardiac disease and cancer Addressing trauma can positively impact the physical, behavioral, social and economic health of Ohio and Ohioans 22

Effects of Trauma on Neurocognitive Development 23

What is “Trauma Informed”? A program, organization or system that is trauma- informed: Realizes the widespread prevalence and impact of trauma Understands potential paths for healing Recognizes the signs and symptoms of trauma and how trauma affects all people in the organization, including: Patients Staff Others involved with the system Responds by fully integrating knowledge about trauma into practices, policies, procedures, and environment. 24

Key Principles of Trauma-Informed Care Safety Trustworthiness and transparency Collaboration and mutuality Empowerment Voice and choice Peer support and mutual self-help Resilience and strength-based Inclusiveness and shared purpose Cultural, historical and gender issues Change process 25

Outcomes with TIC Improved quality of care and impact of care Improved safety for patients and staff Decreased utilization of seclusion and restraint Fewer no-shows Improved patient engagement Improved patient satisfaction Improved staff satisfaction Decreased “burnout” and staff turnover 26

Six Core Strategies for Reduction of Seclusion and Restraint 1.Leadership toward organizational change 2.Use of data to inform practice 3.Workforce development 4.Use of S/R prevention tools 5.Consumer roles in inpatient settings 6.Debriefing techniques (NASMHPD, 2005) 27

Ohio’s Trauma Informed-Care (TIC) Initiative Many mental health and addiction treatment agencies, inpatient facilities, child-serving agencies and other community partners, have already provided training and consultation in trauma informed practice Many clinicians are trained in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Eye Movement Desensitization training (EMDR); Dialectical Behavioral Therapy (DBT) and other treatment modalities ODYS has embarked on the development of a universal trauma screening tool for youth in detention centers Trauma Informed Care is not the same as PTSD treatment 28

Ohio’s Trauma-Informed Care (TIC) Initiative There continues to be a need for training for staff/facilities and community system partners The ability of all communities and providers to organize trauma trainings internally is often beyond their finances, time and capabilities, yet the need of persons served has not changed The initiative will seek to provide additional resources for agencies and programs in Ohio who may need this support 29

Ohio’s Trauma-Informed Care (TIC) Initiative Since Summer of 2013, an interagency workgroup comprised of leaders from Ohio MHAS and Ohio Department of Developmental Disabilities (DODD) has been meeting to formulate plans to expand TIC across the state A portion of the “Strong Families, Safe Communities” funds from the Governor’s Office have been earmarked for this purpose The National Center for Trauma-Informed Care (NCTIC)/SAMHSA and Ohio Center for Innovative Practices (CIP) have also consulted formally Additional conversations and advice from Ohio Hospital Association, OACBHA, Ohio Council, PCSAO, and many others (thanks!) 30

Ohio’s Trauma-Informed Care (TIC) Initiative Vision: To advance Trauma-Informed Care in Ohio Mission: To expand opportunities for Ohioans to receive trauma- informed interventions by enhancing efforts for practitioners, facilities, and agencies to become competent in trauma- informed practices 31

Ohio’s TIC Initiative Trauma-Informed Care The TIC model assesses a service delivery system and makes modifications based on the basic understanding of how trauma affects the life of an individual seeking services TIC means that every part of an organization or program understands the impact of trauma on the individuals they serve and promotes cultural and organization change in responding to the consumers/clients served This is not a service; rather it is an approach to interpersonal interactions that takes into account the potential scars of a person’s past experience The TIC Initiative is not about endorsing particular trauma-informed practices, treatment models, screening or assessment instruments or processes and takes an across-the lifespan approach 32

Trauma-Informed Care (TIC) Promotes Cultural Change 33 “What’s wrong with you?” “What has happened to you?”

TIC Planning Framework Interdepartmental Team (OhioMHAS and DODD) Statewide Trauma Informed (TIC) Propagation Plan For MH, DD and AoD TIC Training/Summit for Clinical and Administrative Leaders Regional TIC Collaboratives Community Agencies CO Partners, Specialty Groups (Children, older adult s, DD) Internal Departmental Implementation (Hospitals/community support network, developmental centers, therapeutic communities) Collaboration with other departments and agencies Technical Support Organization(s) Advisory Committee TIC Project Coordinator OhioMHAS and DODD Leadership Ongoing communications/Training for Regions, Boards, Agencies and Providers

TIC Planning Framework Interdepartmental Team (OhioMHAS and DODD) Statewide Trauma Informed (TIC) Propagation Plan For MH, DD and AoD TIC Training/Summit for Clinical and Administrative Leaders Regional TIC Collaboratives Community Agencies CO Partners, Specialty Groups (Children, older adult s, DD) Internal Departmental Implementation (Hospitals/community support network, developmental centers, therapeutic communities) Collaboration with other departments and agencies Technical Support Organization(s) Advisory Committee TIC Project Coordinator OhioMHAS and DODD Leadership Ongoing communications/Training for Regions, Boards, Agencies and Providers

Interdepartmental Leadership Team 36 Dr. Mark Hurst, OhioMHAS, Co-Chair Kathy Coate-Ortiz, OhioMHAS Jody Lynch, OhioMHAS Angie Bergefurd, OhioMHAS Trudy Sharp, OhioMHAS Dr. Lisa Gordish, Twin Valley RPH Dr. Kraig Knudsen, OhioMHAS Latonya White, OhioMHAS Pam Berry, DODD, Co-Chair Sarah Lawson, DODD Angela Sausser-Short, Ohio MHAS Patrick Kanary, CIP, Case Western Reserve University Joyce Starr, OhioMHAS Dr. Tammy Collins, OhioMHAS Jackie Doodley, OhioMHAS Dr. Afet Kilinc, OhioMHAS Rob Robbins, DODD Kim Kehl, OhioMHAS

Framework for Ohio’s TIC Initiative Progress so far—Hospital Services: June 2013: Initial training of ODMH/MHAS Central Office and Regional Psychiatric Hospital (RPH) leadership in TIC On site training of clinical and support staff at all RPHs, with participation of DODD Developmental Centers, as available Consultation from NCTIC on next steps in Hospital Service Each RPH has identified specific TIC project(s) Establishment of staff and patient safety initiative in RPHs Plans for subsequent visits and consultation from NCTIC Launch of TIC research study in collaboration with OSU College of Social Work 2014 Spring Conference – “Why The Need For Trauma- Informed Care?” 37

Framework for Ohio’s TIC Initiative Progress: Statewide TIC Project Coordinator Statewide Advisory Committee Meets monthly Endorsed “Fundamentals of TIC” approach Serve as “ambassadors” of TIC Partnership with National Center for Trauma-Informed Care NCTIC Train-the-trainers model System infrastructure and infiltration Updated TIC Website (in progress): 38

TIC Advisory Committee: Survivors of Trauma DODD Ohio Hospital Association Medicaid PCSAO OACBHA Ohio Council OACCA ODH Hamilton County Board of DD ODE ODJFS Wright State University: MI/DD CCOE Depart of Aging Human Trafficking Commission CIP ODYS Ohio Women’s Network Board of Regents Center for the Treatment and Study of Traumatic Stress Ohio Provider Resources Association (DD) 39

Framework for Ohio’s TIC Initiative TIC Summit - June 26, 2014 Creating Environments of Resiliency and Hope Thematic fundamental training for clinical and administrative leaders AM session: Didactic by leaders from NCTIC PM session: Regional breakouts to advance TIC locally Identify strengths, weaknesses, needs, champions Identify initial plan to proceed, with support from departments for communication, facilitation, etc. Sustainability 40

Framework for Ohio’s TIC Initiative Regional Collaboratives Progressively transmit TIC and increase expertise within regions Facilitate cultural change within organizations, addressing gaps and barriers and taking effective steps based on the science of implementation Topical workgroups (prevention, DD, child, older adult, etc.) Department(s) continue to support, facilitate, communicate 41

Framework for Ohio’s TIC Initiative Sustainability: Based on the passion of those involved in the initiative This can be launched and maintained with fairly little infusion of resources Encourage use and repurposing of existing resources Technical support: NCTIC and deliverables of CCOEs Encourage regions and states to develop internal expertise and learning communities to transmit, maintain and advance our ability to respond to those with trauma needs 42

TIC: Why is this important? 43

TIC: Why is this important? “What Happened to You?” 44

45 Ohio Department of Developmental Disabilities National Center for Trauma-Informed Care OhioMHAS Office of Research Public Children’s Services Association of Ohio Ohio Human Trafficking Commission Ohio Department of Health Ohio Domestic Violence Network SAMHSA Ohio MHAS Trauma Website:

ACE Categories Abuse Emotional Physical Sexual Neglect Emotional Physical Household Dysfunction Mother Treated Violently Household Substance Abuse Household Mental Illness Parental Separation or Divorce Incarcerated Household Member 47

ACE Pyramid 48

Mark Hurst, M.D., FAPA Medical Director Ohio Dept. of Mental Health and Addiction Services 30 East Broad Street, Floor 36 Columbus, Ohio (614) Kim Kehl Trauma Program Manager Office of the Medical Director Ohio Dept. of Mental Health & Addiction Services 30 East Broad Street, Floor 36 Columbus, Ohio (614)