1. Creating Trauma-Informed Child Welfare Systems: Moving towards Safety, Permanency and Well-Being Using a Trauma Lens
Lisa Conradi
Chadwick Center for Children and Families
Heather Langan
National Center for Child Traumatic Stress – Duke
George (Tripp) Ake
Center for Child and Family Health - Duke

2. Objectives
Participants will be able to describe the NCTSN and Breakthrough Series (BSC) methodology.
Participants will be able to describe a trauma-informed system, as conceptualized by the NCTSN Child Welfare Committee and CTISP.
Participants will be familiar with several specific improvements developed by teams in the Trauma-Informed Child Welfare BSC to improve their system’s trauma focus and responsiveness.

3. The National Center for Child Traumatic Stress (NCTSN)
Established by Congress in 2000
Funded by SAMHSA
A unique collaboration of academic and community-based service centers whose mission is to raise the standard of care and increase access to services for traumatized children and their families across the United States.
Mention Cat 1,2, 3 sites and how they collaborate; work groups/committees, training and implementation team and LCs/BSCs.
*** Share screen and show NCTSN website: Home page, Learning Center, Special Topics/Child Welfare Trauma Training Toolkit

4. NCTSN Child Welfare Committee
Helping Children in the Child Welfare System Heal from Trauma: A Systems Integration Approach (2005)
Child Welfare Trauma Training Toolkit (2008, currently being revised)
Caring for Children Who Have Experienced Trauma: A Workshop for Resource Parents (2010)
Sponsoring a Breakthrough Series Collaborative focused on foster care placement stability ( )
Fact sheets on birth parent trauma ( )

5. Definition of Trauma-Informed Child Welfare System
A trauma-informed child welfare system is one in which all parties involved recognize and respond to the varying impact of traumatic stress on children, caregivers and those who have contact with the system.  Programs and organizations within the system infuse this knowledge, awareness and skills into their organizational cultures, policies, and practices.  They act in collaboration, using the best available science, to facilitate and support resiliency and recovery.      
- CTISP National Advisory Committee
Lisa

6. Why is this Important?
The research is clear that the experience of abuse or neglect leaves a particular traumatic fingerprint on the development of children that cannot be ignored if the child welfare system is to meaningfully improve the life trajectories of maltreated children, not merely keep them safe from harm.
Bryan Samuels, Commissioner for the Administration on Child, Youth and Families
Testimony to House Ways and Means Subcommittee on Human Resources, Congress
The realization that what may be the underlying force that has shaped and driven the experiences children in the child welfare is not the physical at of abuse or neglect it is the toll that those experiences have on the children’s brain, biochemical systems, world view, and ability to regulate their emotions and connect with other human beings. That thing is called “traumatic stress.”

7. What Makes up a Trauma Informed Child Welfare System?
The systems can make it better or make it worse
Broader Child-Serving System Factors
Child Welfare System Factors
Family Factors
Individual Factors
The caregivers play a central role in Recovery
Help the child tap their
natural resiliency and give
them new tools for
managing the stress

8. Essential Elements of a Trauma-Informed Child-Serving System
Maximize Physical and Psychological Safety for the Child, Family and CW Workforce
Identifying Trauma-related Needs of the Child, Family and the Workforce
Enhancing Child Well-Being and Resiliency
Enhancing Family Well-being and Resiliency
Enhancing the Well-Being and Resiliency of those Working in the System
Partnering with Youth and Families
Partnering with System Agencies

9. What Makes the Essential Elements “Essential”?
Artwork courtesy of the International Child Art Foundation (

10. Element #1: Maximize Physical and Psychological Safety for the Child, Family and CW Workforce
Child and Family:
A sense of safety is critical for functioning as well as physical and emotional growth.
Children in the child welfare system AND their families have likely been exposed to numerous events that have threatened both their physical and psychological safety. This exposure can color all of their interactions with people, including those trying to help them.
Traumatic stress overwhelms a child’s sense of psychological safety and can lead to a variety of survival strategies for coping.

11. Element #1: Maximize Physical and Psychological Safety for the Child, Family and CW Workforce, cont.
System:
The child welfare workforce should understand the potential or perceived threats to safety, including trauma triggers that a child or parent may experience, and provide the caregiver with tools to manage triggers and help the child feel safe.
The child welfare workforce is also exposed to experiences that can feel both physically and psychologically unsafe.
Examples
CAC vs CWS or cops or field interview
Enveironment
How the receptionist treats the parent

12. Identifying Trauma-related Needs of the Child, Family and the Workforce
Element #2: Identify Trauma-related Needs of Children, Families, and the Workforce
Trauma Education:
The child welfare workforce should be educated on trauma and how it affects an individual at any stage of development and intersects with his/her culture
Screening:
A universal screening for traumatic history and traumatic stress responses assists the workers in understanding a child’s history, potentially triggers and directs trauma-informed case planning. This may include the need for a referral to mental health for a more comprehensive trauma-focused assessment.

13. Identifying Trauma-related Needs of the Child, Family and the Workforce
Element #2: Identify Trauma-related Needs of Children, Families, and the Workforce, cont.
Assessment :
A thorough assessment can identify a child’s reactions and how his or her behaviors are connected to the traumatic experience.
Child welfare workers can use assessment results to determine the need for referral to appropriate trauma-specific mental health care or further comprehensive trauma assessment.

14. Element #3: Enhancing Child Well-Being and Resiliency
Relationships:
Familiar and positive figures—teachers, neighbors, siblings, relatives—play an important role in supporting children who have been exposed to trauma.
Minimizing disruptions in relationships and placements and establishing permanency are critical for helping children form and maintain positive attachments.
The child welfare workforce should focus on facilitating positive outcomes for children by providing appropriate support to enhance their well-being and resiliency and their ability to form and maintain healthy relationship in the aftermath of trauma.

15. Element #3: Enhancing Child Well-Being and Resiliency, cont.
Treatment :
This includes ensuring that children have access to evidence-based trauma treatments and services when appropriate.
Trauma treatments, when indicated, should focus on addressing the impact of the child’s trauma, and subsequent changes in child’s behavior, development, and relationships.
Treatment, when indicated, also helps the child reduce overwhelming emotion related to the trauma, cope with trauma triggers, and make new meaning of his/her trauma history and its impact on his/her current and future life events.

16. Element #4:Enhancing Family Well-Being and Resiliency
Working with Birth Parents and Resource Parents:
Recognize that many of the child’s adult caregivers may be trauma victims as well (recent and childhood trauma).
Providing trauma-informed services to birth parents and resource parents enhances their protective capacities, thereby increasing the resiliency, safety, permanency, and well-being of the child.
Relatives serving as resource families may themselves be dealing with trauma related to the crisis that precipitated child welfare involvement and placement.

17. Enhancing the Well-Being and Resiliency of those Working in the System
Element #5 - Enhancing the Well-being and Resiliency of Those Working in the System
Primary and Secondary Trauma:
Working with the child welfare system is a risky business and the workforce may be confronted with danger, threats, or violence in their daily work.
Many workers can experience Secondary Traumatic Stress, which are physical and emotional stress responses to working with a highly traumatized population.
When working with children who have experienced maltreatment and parents who have acted in abusive or neglectful ways, feelings of helplessness, anger, and fear are common.

18. Enhancing the Well-Being and Resiliency of those Working in the System
Element #5 - Enhancing the Well-being and Resiliency of Those Working in the System, cont.
System Trauma:
The system itself can be a highly reactive, traumatizing system without enough services and supports to effectively assist the workforce in effectively responding.
Promoting system resiliency means implementing strategies and practices designed to assist those working within the child welfare system in managing professional and personal stress and addressing the impact of secondary traumatic stress in a systematic way.

19. Element #6: Partnering with Youth and Families
Youth and family members who have experienced traumatic events often feel like powerless “pawns” in the system.
Providing youth and families with a voice in their care plays a pivotal role in helping them reclaim the power that was taken away from them and assisting them towards their own resilience.
Youth and family members who have been in the system have a unique perspective and can provide valuable feedback on how to improve the system response.
These partnerships should occur at all levels of the organization, from policy to practice.

20. Element #7: Partnering with System Agencies
Children and families who have experienced trauma are often involved with multiple service systems. Child welfare workers are uniquely able to promote cross-system collaboration.
Collaboration enables all helping professionals to view the child as a whole person, thus preventing potentially competing priorities.

21. Element #7: Partnering with System Agencies, cont.
Child Welfare agencies need to establish strong partnerships with other child and family-serving systems to create a continuum of trauma-informed care. These partnerships should occur at all levels of the organization, from policy to practice.
Service providers should try to develop common protocols and frameworks for documenting trauma history, exchanging information, coordinating assessments, and planning and delivering care.

22. “Every system is perfectly designed to achieve the results it gets”3 3 3 22

23. The Breakthrough Series Collaborative Methodology
Based on the Model for Improvement, a quality improvement model developed by IHI in the 1990s.
A method for addressing the need for system-wide change and improvement in any area of concern or focus; facilitated by “expert” faculty and planning team,
Teams from multiple agencies come together to collaborate, accelerating the improvement process
Approx. one year+ in length, involving 3+ face-to-face meetings and dynamic “Action Periods” between, in which conference calls, assignments and activities are conducted (many online, using the NCTSN Learning Center site just shown)
The BSC approach focuses on adapting, spreading, and adopting best practices across multiple settings and on creating changes within organizations to promote the delivery of effective practices

24. BSC Model for Improvement
What are we trying to accomplish?
Team Priority
Framework Element
Strategies
What changes can we make that will result in improvement?
How will we know that a change is an improvement?
Measures
Plan Do
Study
Act
The 3 big questions
Adapted from 2001 Institute for Healthcare Improvement

25. Plan-Do-Study-Act (PDSA) Cycles: Small Tests of Change
A tool to tackle challenges on several levels
Individual
Team
Organization (including community connections)
Heather
Everyone can use this tool at all levels: Individual, team, organizational.

26. The NCTSN Trauma Informed Child Welfare BSC
2010 – 2012 (extended for 1 year)
9 Teams from 8 states across the country, consisting of Child Welfare + Mental Health agencies working together
Team make-up: CW administrators (“Senior Leader”), supervisors and line workers, MH admin., clinicians, consumers.

27. Goal of the Child Welfare BSC
To develop and promote trauma-informed policies and practices related to foster care placement, thereby increasing placement stability and promoting a sense of permanency among children in care.
Overview
This is the gap we were trying to address in our BSC. 27

28. Collaborative Change Framework: The “Blueprint” for the BSC
The Collaborative Change Framework (CCF) has two sections: * The Collaborative Charter, which sets the foundation for the Breakthrough Series Collaborative, and * The Key Objectives, which serve as the roadmap for participating teams as they test, implement, and strive to sustain their improvements.
Note: a document developed by faculty/planning + experts in the planning phase of the project and used thereafter.

29. TICWP-BSC Collaborative Change Framework: The Five Themes
1. Knowledge Building and Developing Practice 2. Trauma-Informed Mental Health Assessment 3. Case Planning and Management 4. Externally Delivered Trauma-Informed Services 5. Child Welfare Systems, Cross-System Partnerships and System Collaboration

30. Examples of Key Objectives
I. A. Child welfare systems’ staff, caregivers, birth parents, and youth as appropriate receive training to increase their knowledge on the impact of trauma exposure and its effects on children.
II. D. Birth families and caregivers are involved in the complete trauma-informed assessment process that includes a collection of the birth family’s trauma exposure history and any issues that may compromise the stability of a child's placement or delay permanency.
III. E. Visitation between children, birth families, and caregivers is supported in ways that includes dialogue about the impact of trauma exposure on the child, how to identify and manage traumatic stress reactions, and how to prevent future trauma exposure.

31. BSC Practice Changes: What Have We Seen So Far on Dashboards?
Trauma-Informed Child Welfare Breakthrough Series 2011
June 2011 Organizational Assessment
OBJECTIVES Headlines from Change Framework
Self-Assessment: October 2010
Self-Assessment: January 2011
Self-Assessment: June 2011
Key Practice Area 1: Knowledge Building and Developing Practice A.
Increased knowledge on the impact of trauma exposure and its effects B.
Increased knowledge of secondary traumatic stress, impacts, and opportunities to mitigate impacts
Lisa
Strategy Tested-Ready for Spread
Strategy Being Tested
Strategy in Planning Stage
Needs Attention. Not Yet Planning

32. BSC Practice Changes: What Have We Seen So Far on Dashboards?
Trauma-Informed Child Welfare Breakthrough Series 2011
June 2011 Organizational Assessment
OBJECTIVES Headlines from Change Framework
Self-Assessment: October 2010
Self-Assessment: January 2011
Self-Assessment: June 2011
Key Practice Area 2: Trauma-Informed Mental Health Assessment A.
Early and continuous information gathering B.
Integration and documentation of information collected into screening C.
Integrated and comprehensive mental health assessment focused explicitly on trauma
Lisa

33. BSC Practice Changes: What Have We Seen So Far on Dashboards?
Trauma-Informed Child Welfare Breakthrough Series 2011
June 2011 Organizational Assessment
OBJECTIVES Headlines from Change Framework
Self-Assessment: October 2010
Self-Assessment: January 2011
Self-Assessment: June 2011
Key Practice Area 3: Case Planning and Management A.
Clear information provided early and ongoing to the child and family about placement, with a focus on stability and permanency B.
Identification of caregiver meets child's specific trauma-related needs C.
Information provided to caregivers regarding child’s trauma issues and needs
Lisa

34. BSC Practice Changes: What Have We Seen So Far on Dashboards?
Trauma-Informed Child Welfare Breakthrough Series 2011
June 2011 Organizational Assessment
OBJECTIVES Headlines from Change Framework
Self-Assessment: October 2010
Self-Assessment: January 2011
Self-Assessment: June 2011
Key Practice Area 4: Externally Delivered Trauma-Informed Services A.
Delivery of effective trauma-informed services guided by trauma-informed assessment B.
Preparation and support for birth parents and caregivers for them to engage in effective trauma-informed mental health services C.
Delivery of effective trauma-informed services for birth parents
Lisa

35. BSC Practice Changes: What Have We Seen So Far on Dashboards?
Trauma-Informed Child Welfare Breakthrough Series 2011
June 2011 Organizational Assessment
OBJECTIVES Headlines from Change Framework
Self-Assessment: October 2010
Self-Assessment: January 2011
Self-Assessment: June 2011
Key Practice Area 5: Child Welfare Systems, Cross-System Partnerships and System Collaboration A.
Policies and practices reviewed and revised to be trauma-informed B.
Trauma-informed child welfare systems act as facilitators of change in their communities C.
Cross-system partners receive ongoing training about trauma
Lisa

36. North Carolina Lighthouses
Initiating and Maintaining Strong Partnerships with State Child Welfare
North Carolina
Lighthouses
Tripp

37. NC Team and Target Population
NC Division of Social Services
Wilson County Department of Social Services
Center for Child and Family Health
Birth Parent
Foster Youth
Target Population: Youth 13+
In care or entering care during BSC
Subject to physical abuse or sexual abuse investigative assessment during BSC
Tripp

38. Relationship with NC DSS
Built on years of collaboration
NCDSS leadership was visionary
Examples of previous collaboration
NC Child Treatment Program
Strong Father’s Curriculum Development
Domestic violence shelter work
Example of current and ongoing collaboration related to involvement with BSC
Joint project with Administration of Children and Families funding
Postadoption Support Services
Tripp

39. Placement Stability Rates
North Carolina Cohort
Type
Frequency
Total
Percent
No countable placements
126
4571
2.76
1 placement
1962
42.92
2 placements
1157
25.31
3 placements
585
12.80
4 or more placements
741
16.21
Tripp

40. BSC Improvement Goals Knowledge Building and Developing Practice
Trauma-Informed Assessment
Case Planning and Management
Externally Delivered Trauma-Informed Services
Child Welfare Systems, Cross Systems Partnerships, and System Collaboration
Tripp

41. Knowledge Building and Developing Practice PDSA: Increase sensitivity and awareness among foster care workers and child welfare staff about impact of trauma on children
Plan: 3 hour training provided to select staff on 3 modules of the Resource Parenting Curriculum including information about a foster child’s invisible suitcase
Do: Held training for 25 workers
Study: Workers engaged in focus group discussion and revealed that this information was helpful re: talking with foster parents about tolerating child behaviors
Act: Additional trainings planned for workers and resource parents
Tripp

42. Trauma-Informed Assessment PDSA: Increase use of trauma-informed screening/assessment in child welfare setting
Plan: Four youth were screened for exposure to trauma using four questions from UCLA PTSD RI screener
Do: Foster care worker asked screening questions of four youth on her caseload
Study: 3 of the 4 youth who had been in care for over a year disclosed new traumas/child welfare worker negatively impacted
Act: Trained additional foster care workers on use of screener plus self care module
Tripp

43. Case Planning and Management PDSA: Identify and use information needed by foster parent to facilitate a collaborative and trauma-informed placement
Plan: Youth and bio parent team member developed questions to be asked of birth parent before placement with foster parent
Do: Selected foster parents surveyed to determine how useful the information would be generated by these questions
Study: Foster parents were interested in knowing what comforts children, information about routine and schedule, and food preferences
Act: Refined the survey and would have a birth parent involved with DSS to provide feedback
Tripp

44. Barriers
Thinking ahead to spread of ideas…county administered child welfare system
Availability of trauma-informed clinicians in remote counties
At times…limited time to creatively think about how to address system barriers including policy change
Tripp

45. Lessons Learned for Mental Health- Child Welfare Collaboration
Identify and map trauma-informed practices with child welfare system’s priorities (e.g., implementation of practice models, Signs of Safety, permanency efforts, etc.). Trauma will almost inevitably impact/intersect with them in some way;
Actively partner with families and youth throughout the process. They provide a critical perspective and have creative ideas to assist in informing and improving the system;
Focus on creating a system where child welfare workers conduct trauma screenings. This includes training on how to conduct the screenings and how to manage secondary trauma that may emerge in workers while they are conducting the screenings;
Think about and address trauma experienced by different system stakeholders (children, parents, caseworkers, foster parents);
Lisa
Barriers to successful CW MH partnership
Dialogue to overcome barriers-Points of alignment between CW and MH goals to build on
Action plan to walk away with

46. Lessons Learned for Mental Health- Child Welfare Collaboration
Think beyond linking children with mental health treatment – address other stakeholders/services within child welfare system (foster parents, mentors, parenting classes, visitation, etc.);
Share trauma-informed resources across systems. This includes tools, trainings, and other products;
Change should be made from both the top-down AND bottom-up perspectives. If the hierarchy is flattened, there is more room for innovation, buy-in and, ultimately, system change; and,
Replace existing practices rather than add new practices because the current child welfare workload is already overwhelming.
Lisa
Barriers to successful CW MH partnership
Dialogue to overcome barriers-Points of alignment between CW and MH goals to build on
Action plan to walk away with

47. Next Steps
Growing interest at SAMHSA on trauma within the child welfare system
Extension of BSC for an additional year, additional focus on secondary traumatic stress among staff and foster parents
Recent RFA included focus on youth within child welfare and juvenile justice systems
Collaboration with the Administration for Children and Families on trauma- informed system change grants
Erika

48. Next Steps, cont.
Upcoming Learning Session – focus on spread and sustainability
Involvement of local cross-system partner leadership
Invitation to national child welfare and trauma stakeholders
Focus on successes, remaining systemic barriers
Erika

49. Resources Chadwick Trauma-Informed Systems Project – www.ctisp.org
California Evidence-Based Clearinghouse for Child Welfare -
National Child Traumatic Stress Network - and
Chadwick Center for Children and Families –
Child Welfare Trauma Training Toolkit -
Caring for Children who Have Experienced Trauma: A Guide for Resource Parents -