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Kay Jankowski, Ph.D.

and Judge Susan Ashley The 26th Annual San Diego International Conference on Child and Family Maltreatment January 23, 2012

Purpose: To familiarize you with work in NH that interfaces the issue of child trauma with the work of child serving systems in the state, including the work of the family courts, DCYF and DJJS By practical extension, this includes first responders, RTFs, ISOs, family resource centers and CMHCs

Hope: To stimulate conversation about how to improve services for children and families and to improve outcomes for traumatized children and youth

To understand the goals of the NH Bridge Project To learn about the successes and barriers of creating an integrated trauma-informed system of care

To learn about implementation of traumainformed child service systems

Who we are Background/rationale of project Description of NH Bridge Project

Lessons Learned including Successes and Challenges

Overview of Project Juvenile Justice Change Child Welfare Change

Departments of Psychiatry and Community and Family Medicine, Dartmouth Medical School
Stan Rosenberg, Ph.D., Director

A major goal of DTIRC is to translate evidence-based practices into a range of trauma-related interventions for underserved populations

Over the past 6 years, DTIRC has received considerable funding used for implementing projects to improve mental health services to children and adolescents receiving services in the public sector
Category III NCTSN site since 2005

Stan Rosenberg, Project Director Kay Jankowski Harriet Rosenberg Eric Vance Erin Barnett Martha Robb Robert Racusin Judges Ashley, Sadler, Yazinski and Gordon the NH Breakthrough Series Collaborative Child Welfare Team

The National Child Traumatic Stress Network


The National Child Traumatic Stress Network is supported through funding from the Donald J. Cohen National Child Traumatic Stress Initiative, administered by the Department of Health and Human Services (DHHS), Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration (SAMHSA).

National Child Traumatic Stress Network Mission Statement


The mission of the National Child Traumatic Stress Network (NCTSN) is to raise the standard of care and improve access to services for traumatized children, their families and communities throughout the United States.

NH

PATT NH Telemedicine Project Project Prevent

The goal of The New Hampshire Project for Adolescent Trauma Treatment was to implement, evaluate and disseminate best practices for severely emotionally disturbed adolescents who have experienced trauma and who are served by the community mental health system in New Hampshire

PATT educated, trained and supervised community mental health child and family providers to:
screen for and assess the emotional sequelae of trauma exposure

increase outreach to traumatized adolescents and their families implement best practices for trauma treatment across the NH mental health system

Brought Trauma Focused CBT to all 10 lead community mental health centers in NH Screened 3000+ youth 12 and older in trauma exposure, posttraumatic symptoms, depressive symptoms and substance abuse

The primary goal of this program was to assess the feasibility, value and sustainability of a child mental health videoconferencing network across NH.

The New Hampshire Child/Adolescent Trauma Telehealth Project Phase II: A Videoconferencing Demonstration Program Contd
This Telehealth network now connects the Dartmouth Trauma Interventions Research Center (DTIRC) with child providers in the states 10 lead community mental health centers, the NH State Hospital, DCYF and expert clinicians across the country. The network provides a mechanism for reducing geographical barriers, for improving training, provider capacity and consultation, and optimizing the use of scarce resources (particularly child psychiatrists).

Project Prevent is an ongoing demonstration program, funded by the NH Endowment for Health with supplementary funds from the NH Bridge Project

Begun in 2009 and continuing through 2013, the project goal is to evaluate the feasibility of disseminating and implementing Child-Parent Psychotherapy in rural public mental health and family resource agencies in New Hampshire

NH statistics show that children under 5 comprise 37% of all victims of child maltreatment; 40% of all victims of physical abuse; 44% of all victims of neglect and 13% of all victims of sexual abuse.

Project Prevent: The New Hampshire Program to Improve Outcomes for Young Children at Risk for Neglect and Abuse Contd
To

date, over 20 therapists have been trained in three counties across six settings.
Each

of our trainees continues to take part in ongoing consultation groups.


Aside

from those most recently trained, each therapist has begun at least two CPP cases
Over

50 families have begun treatment with CPP

The goal of the Bridge Project is to integrate trauma treatment services across several state systems that serve NH youth and families who have been exposed to abuse, neglect, violence, or trauma. The Bridge Project targets 3 care systems of key importance to abused and at risk children:
Child

protective services (NH Division for Children, Youth & Families)

Juvenile Judicial

justice (also part of NH Division for Children, Youth & Families)


branch (NH Family Court Division).

Prioritize service coordination and follow case disposition and treatment progress, as these children often move back and forth multiple times between divisions, residential placements and treatment providers Continuity of care will be emphasized by the development of a coherent, portable evidence-based treatment plan that can guide the recovery of the children and families

Emphasis will be on collaboration between service providers, divisions, families and communities, and on strength-based, resiliency oriented interventions
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To provide screening, assessment and appropriate referral for children and youth entering the three identified child serving systems
To provide training of non-clinical personnel at all levels of the organization in principles of trauma informed services. To provide training of key clinical personnel who serve these youth and families in evidence-based practices

Systems Change

Child Welfare

DJJS (juvenile justice)

Family Courts

Foster Care Parent Care

Screening

Screening

Pilot Program

Learning Collaborative

Trauma Informed Training

5 Courts

CPP

TF-CBT
HNC

Practice Change

CMHCS

ISOs

RTFs

Private Practice

CPP TFCBT AFCBT

TFCBT AFCBT CPP TFCBT Trauma informed training TFCBT

Trauma Informed Training

Anchored project around 5 family courts; 4 judges Started with Juvenile Justice; child welfare began approximately 6 months later Judges have been community conveners set the expectation; provide leadership

Launched a kick-off meeting in June, 2010 where Charles Wilson, Judge Michael Howard of Ohio, and Monique Marrow presented Breakout workgroups for child welfare, juvenile justice and the Judges to identify priorities, goals for each of the divisions Identified a timeline and workplan for each of the divisions to accomplish goals

Training Trauma 101 training for residential treatment facilities approximately 15 months ago and again in Dec. 2011 Monique Marrow returned to provide training to all JPPOs and Youth Detention Center (Sununu Center) staff in principles of trauma-informed practice

Screening JPPOs trained in administering our web-based trauma screen to youth Screening initiated in 5 family courts, originally by JPPOs at adjudication

Upsetting

exposure) UCLA PTSD Reaction Index (posttraumatic problems) Mood and Feelings Questionnaire (affective problems) CRAFFT (substance abuse issues)

Events Survey (trauma

The Resiliency Checklist (protective factors) Each of these screening components targets factors that can impact decision-making about what might be the best approach to helping the youth you are evaluating.

Resilience

is the ability to rise above risk factors, to cope well with stress, and avoid bad life outcomes factors are characteristics of the individual, supportive relationships, or positive life experiences that counter-act the damaging effects of risk, and therefore give resilience

Protective

Resilience and protective factors Contd


Life outcome can be anticipated, in part, by the balance of risk and protective factors

Screened 200 youth thus far across 5 courts


93% screened positive for trauma exposure Average number of traumas:5.7 48% screened positive for PTSD 51% screened positive for depression 61% screened positive for substance abuse 22% have 2 disorders; 26% have 3 disorders

Switched to screening at arraignment in 4 of the courts; social work intern doing screening in 2 courts

Trained about 10 residential providers Continued to train community based providers in TF-CBT specifically for JJ involved youth Provide initial live training and ongoing weekly consultation with our team of expert consultants Of 48% of youth screening positive for PTSD, approximately 10% are enrolled in TF-CBT

Screening of JJ involved youth in the Courts is not only possible but beneficial Screening at arraignment widens the net and seems to work best Social work intern was very helpful to move screening forward, to coordinate referral for youth who screen positive Judge who is champion of screening and evidence-based trauma treatment is key

Where to screen: In Court v. Out-ofCourt Physical space to screen at court? Someone consistently at court to administer the screening survey? Internet access? Portability of survey?

Community mental health centers

In Court? (+) Larger jurisdictionsnumbers may allow for CMHCs to provide court liaison for screenings (-) Small jurisdictionsunlikely to have liaison from CMHC At CMHC? (+) Ideal environment for assessment (-) Timing difficultunlikely to get immediate appointments to conform to judicial schedule (-) Reliant on parents to get juvenile to appointment

Who will administer screening survey Contd


JPPO
In Court? (+) consistently available at court hearings (-) court docket may not allow JPPOs to spend time just before/after hearing to do screen At JPPO office? (+) Can choose time (+) Can complete other paperwork (-) Reliant on parents to get juvenile to JPPO office soon after court hearing (-) Juveniles may not be comfortable disclosing trauma with JPPO present, even though screening tool is computerized

Who will administer screening survey Contd


Other local resources Graduate studentsnearby colleges may have masters-level students looking for internships (+) available for court hearings (+) less intimidating than JPPO (+) Have more dedicated time than JPPOs (-) Trauma education necessary (-) Regular turnover, requiring coordination Diversion programs Schools

Delinquency Petition

Arraignment

Adjudicatory

Pre-dispositional report

Disposition

Review Hearing Case closure

Delinquency Petition Plea at Arraignment and summary disposition (Entering dispo orders without reports, assessments, evaluations)

Review Hearing Case closure

At arraignment

Post-arraignment

(+) Earliest court hearing (+) Results can help parties formulate best disposition (-) usually no attorney present to help explain (+) attorney now present (-) many cases resolve by plea at arraignment, and dont return for review hearingwould lose opportunity to assess need for trauma treatment

Inform prosecutor and defense attorney whether screen is positive or negative, but no need to share narrative answers. Parties should recommend referral for individual counseling, with TF-CBT focus Counselor ultimately determines whether TF-CBT is appropriate BUT, beware counselors reluctance to delve into trauma treatment Cannot wait for ideal time in courtinvolved casestime is of the essence.

Although many youth screened positive for PTSD, Depression and Substance Abuse, very few have been engaged and maintained successfully in traumafocused treatment

Why not? Extent of chaos in family that prevents prioritization of treatment; logistical barriers, psychological barriers Unwillingness of mental health providers Misconceptions of TF-CBT and its appropriateness for complex trauma, adolescents, co-morbidity, lack of stability in family, too many crises, waiting for chaos to subside, but to no avail Administrative barriers youth are difficult to engage limited to office-based settings, strict no-show policies.

Juvenile not interested in treatment, refuse to participate Parental apathy Changes in placementshome to residential, then back home Changes in providers/counselors Waiting list for counseling Past poor experiences with counseling Payment/insurance coverage JPPOs reluctance to advocate for new treatment options Attorneys aim to minimize requirements of dispositional orders

NH Division for Children, Youth and Families was undergoing CFSR review at launch of the Bridge Project, slower start than JJ In October, 2010, DCYF trainers were trained on the Trauma Informed Child Welfare Toolkit (NCTSN). Over the next 6 months (through Spring, 2011) staff within the 4 district offices for the Bridge Project courts were trained in the toolkit

Also in October, 2010, DTIRC staff collaborated with Granite State College to revise the Resource Parent trauma training curriculum; trainings for resource parents launched soon after and continue to be offered presently Over Summer/Fall 2011, DTIRC staff worked with DCYF to revise their standard mental health screening tools to more effectively address trauma and its effects

October, 2011, DTIRC trainers provided training on a new mental health referral tool to be completed by CPWs in the 4 NH Bridge Project district offices Currently in trial period to test and revise this screening tool; goal is to screen all children in founded cases, and when indicated make referral for trauma-focused treatment

A Breakthrough Series Collaborative


May 2010 September 2012
The goal of the Child Welfare BSC is to develop and promote trauma-informed policies and practices related to foster care placement stability and promoting a sense of permanency among children in care.

Core

Team 4 DCYF staff -State and Local level (Claremont) Local Community Mental Health Center Child Director 2 DTIRC staff Birth Parent and Foster Parent Youth Extended Team

Child welfare, mental health and consumer voice working together to streamline working collaboratively Created new intake process/forms for child welfare and mental health that take into account more effectively birth parent, foster parent and youth needs Created new forms for mental health providers that better meet the needs of child welfare workers (e.g., for purposes of going to court, etc)

Created materials and executed multiple trainings for mental health and related staff re: trauma informed care (e.g., Early Supports and Services workers, mental health case managers, etc) Raising awareness of trauma related issues among foster and resource parents demand for more offerings of the NCTSN Resource Parent curriculum trainings across the State

Continued training of both community based and residential providers treating DCYF involved children and families Increased awareness of importance of involving birth parents in treatment when possible and when case plan is reunification (thus far in BSC pilot site)

Many competing initiatives within NH DCYF. Interest is there, Division Head is very supportive, but resources (human and fiscal) are limited. Goal is to integrate the various initiatives (they are mostly complementary); has proven challenging Gaining support through the Breakthrough Series Collaborative has been key

First, some percentage of local mental health providers must be trained in evidence-based trauma treatment, and a screening tool identified

Identify small core of judges Educate them on trauma and its side effects Show how those side effects can lead to repeated delinquent conduct or truancy Describe for them evidence-based treatment options

Identify necessary stakeholders DHHS (CPSWs, JPPOs) Prosecutors and defense attorneys School District representatives Local mental health providers

Educate DHHS, prosecutors and school team members, similar to judges

Who will be screened? Who will screen? When will screening occur? Who gets the screening results?

Local community mental health centers In-home service providers Residential treatment facilities

Secondary screening after completion of trauma treatment For DJJS cases, statistics on recidivismwhat to measure Post-treatment delinquency petitions Post-treatment CHINS/truancy petitions

Lots of system level changes over the course of the project including division for child welfare subsuming juvenile justice. Division Head of DCYF Maggie Bishop now oversees child welfare and juvenile justice. Constant pressures and requirements to respond to real and threatened budget cuts; staff layoffs; making due with less

Overall Lessons Learned


Budget cuts resulted in a new CHINS definition (Children in Need of Services), essentially eliminating truancy petitions and restricting services to a small percentage of children previously eligible Clear need for child serving systems to work collaboratively, but priorities and constraints of each system can conflict.

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