Trauma-Informed Care
FINAL REPORT
July26,2017
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Contents
ListofTables..........................................................................................................................iii
ExecutiveSummary................................................................................................................1
Purpose..................................................................................................................................4
OrganizationoftheReport.....................................................................................................4
BriefOverviewofTrauma-InformedCareLiteratureandResearch.........................................5
Introduction...............................................................................................................................5
WhatIsTrauma-InformedCare?................................................................................................5
TheHistoryofTrauma-InformedCare.......................................................................................6
HowIs“Trauma-InformedCare”Defined?................................................................................6
Evidence-BasedTrauma-InformedPractices.............................................................................9
Trauma-FocusedTraining.......................................................................................................9
Trauma-SpecificInterventionsinMentalHealth.................................................................10
Trauma-SpecificInterventionsinJuvenileJustice................................................................11
Trauma-SpecificInterventionsinChildWelfare..................................................................12
Trauma-SpecificInterventionsinSchools............................................................................14
Trauma-Informed,Cross-SystemCollaborationModels......................................................15
ALookatStateConsortiumsandCouncils...............................................................................16
StateResolutions..................................................................................................................18
WhatDoesTrauma-InformedCareLookLikeinTexas?..........................................................20
HowManyChildreninTexasHaveBeenAffectedbyTrauma?...............................................20
MethodologyforEstimatingPrevalence..............................................................................21
Trauma-InformedCareLegislationinTexas.............................................................................25
Trauma-InformedTraininginTexas.........................................................................................27
Trauma-InformedApproachesinTexas...................................................................................28
ChildTraumaAcademy–NeurosequentialModelofTherapeutics(NMT)andNeurosequentialModelofEducation(NME).......................................................................28
FosteringResilience–ReachingTeens©–Dr.KennethGinsburg........................................30
KarynPurvisInstituteofChildDevelopment–Trust-BasedRelationalIntervention(TBRI®)–Dr.KarynPurvisandDr.DavidCross....................................................................................32
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SummaryofKeyInformantInterviews....................................................................................34
HowTexasDefinesTrauma-InformedCare(TIC).................................................................34
HowTrauma-InformedCareIsOperationalized..................................................................37
WhatAretheBenefitsofTIC?..............................................................................................40
BarrierstoImplementation..................................................................................................40
SuccessfulCommunity-BasedCross-SystemEfforts.............................................................42
LocalMentalHealthAuthorities(LMHAs)TICEfforts..........................................................47
FundingTIC...............................................................................................................................50
Findings.................................................................................................................................55
AppendixOne:NationalEvidence-BasedPracticesRepositories............................................60
AppendixTwo:Trauma-InformedCareTraining....................................................................63
AppendixThree:KeyInformants...........................................................................................69
AppendixFour:Trauma-FocusedApproachesUtilizedbyKeyInformants..............................74
AppendixFive:Trauma-focusedApproachesUtilizedbyKeyInformants...............................78
AppendixSix:TravisCountyCollaborativeforChildren:DefiningaTrauma-InformedOrganization,Program,orSystem.........................................................................................80
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List of Tables Table1:ChildrenandYouthWhoHaveExperiencedThreeorMoreAdverseChildhoodExperiences..................................................................................................................................21Table2:ChildrenandYouthAnnualExposuretoViolence..........................................................22Table3:CharacteristicsofYouthAdmittedtotheTexasDepartmentofJuvenileJusticeinFY2015.............................................................................................................................................24Table4:ChildandYouthTraumaExposureAssessedThroughCANSFY2016............................25Table5:Trauma-InformedCareLegislationinTexas...................................................................26
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Executive Summary Thephilosophicalfoundation,keyassumptions,andprinciplesthatcomprisetheSubstanceAbuseandMentalHealthServicesAdministration’s(SAMHSA)trauma-informedcareapproachalignswiththoseofotherleadingbehavioralhealthandhealthcareorganizations.However,thereisnoconsensusonasingledefinitionof“trauma-informedcare.”Thisambiguityhasresultedinvariationsinhowtrauma-informedcareisoperationalizednationallyandstatewideandrisksthisdesignationhavinglittleornomeaning.TheMeadowsMentalHealthPolicyInstitute(MMHPI)examinedprevalenceestimates,reviewedliteratureandnationalbestpractices,andtalkedwithkeyinformantsinTexastodescribehowthestate’smajorchildservingagencieshaveoperationalizedtrauma-informedcareforchildrenandyouthinvolvedwiththechildwelfaresystem.PrevalenceestimatesofAdverseChildhoodExperiences(ACE)amongchildrenandyouthinthemajorchild-servingsystemsinTexasunderscoretheneedforthesesystemstobeadeptatidentifying,understanding,andtreatingtrauma.
• Statewide,approximately730,000childrenandyouth,or1in10children/youthoverall,haveexperiencedthreeormoreACEs.
• Forchildrenandyouthage0–17,nearly90,000havebeenexposedto10ormoreepisodesofviolence.
• AmongyouthinvolvedwithinthejuvenilejusticesysteminTexas,5,900haveexperiencedfourormoreACEs.
• AmongallchildrenandyouthlivinginfostercareinthestateofTexas,approximately24,300haveexperiencedoneormoreACEs.
• AmongchildrenandyouthenrolledinserviceswiththeLMHA,7,700(or19%)childrenandyouthhaveexperiencedatraumaticlifeevent;nearlyhalfoftheseindividualsshowedevidencethatthetraumaticexperiencewasimpactingoneormorelifedomains.
Inrecognitionofthisneed,Texaslawmakersandmajorchild-servingagencieshavetakeninitialstepstowardstransformingthestate’ssystems.Legislativemandatesrequirechildwelfare,juvenilejustice,andstatehospitalstafftotrainprofessionals,staff,andcaregiversinunderstandingtheeffectsoftrauma.Childwelfareandjuvenilejusticehavedevelopedandareimplementingsystem-widetraining.Additionallegislationrequiresthatallchildrenandyouthenteringthechildwelfaresystemarescreenedfortrauma.Likewise,effortsinmentalhealthhavekeptpacewiththoseinjuvenilejusticeandchildwelfare,ensuringchildrenandyoutharescreenedandagencystaffaretrainedtorecognize,understand,andtreattrauma.Inadditiontotrainingandscreening,mostorganizationsservingchildrenandyouthprovideatleastsometrauma-focused,evidence-basedtherapeuticapproaches.
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Areviewofthetrauma-informedlandscapeinTexasrevealedgrassrootsandformaleffortstoshapetrauma-informedcareatagencyandcommunitylevels.Theseefforts,tovaryingdegrees,useSAMHSA’ssixguidingprinciplesandimplementationdomainstodriveorganizationalandsystematicchange.Thetwocommunityeffortswiththelargestreachusetrauma-focused,evidence-informedapproachestopromotecommonlanguage.Keystakeholdersattributetheirsuccesstowide-spreadcross-systemtrainingontraumaandtrauma-informedcareapproaches,supportfromleadership,anidentifiedtrauma-champion,andexternalresourcesandphilanthropicsupport.Thesesameindividualsidentifiedlimitedresources,regulatorystandards,andstafftraumaasbeingmajorbarrierstodevelopingatrauma-informedsystem.Keyinformantsstressedthatprovidingtrauma-informedcarerequiresorganizationalchangeatmultiplelevelsandfundingstructuresthatsupporttheprinciplesunderlyingthisapproach.Traditionalstatefundingstructuresallowfortheprovisionofevidence-basedtraumascreening,assessment,treatment,andrecoverysupports.However,theydonotsupportthedevelopmentofappropriateandsafefacilities;theprovisionofpeersupportforprofessionals,staff,andcaregivers;thedevelopmentandimplementationoforganization-widetraumatraining;thetrainingandimplementationoftrauma-informedcommunicationstrategiesandcaregivermodels;thedevelopmentofcross-agencycollaborations;andtheevaluationoftrauma-informedprogramsandservices.Thefollowingisasummaryofthefindingsthatresultedfromthislookattrauma-informedcareforchildren,youth,andfamiliesinthechildwelfare,juvenilejustice,andmentalhealthsystems.
• Child-servingsystemsaretrainingstaffontrauma-informedcare.• Despitetheavailabilityoftrainingthataddressesunderstandingandtreatingtrauma,
thereisstillanexpressedneedtotrainchildwelfarestaffandfosterparents.• Themainchild-servingsystemsinthestateofTexashavetakensomestepstowards
becomingtrauma-informed.• Theprimarycross-systemtrauma-informedapproachesbeingimplementedinTexasare
basedonthe“AdverseChildhoodExperience”researchandaregroundedinthesametrauma-informedframework.
• ReachingTeensãandTrust-BasedRelationalIntervention(TBRIâ)provideaphilosophicalframework,sharedlanguage,andcommonsetofapproachesthatallowprovidersinacommunitytooperationalizetheconceptoftrauma-informedcare.Thesetwoapproachesareeasytounderstandandcanbeimplementedbyalargecross-sectionofprofessionals,parents,andfosterparents.
• Inadditiontoasharedapproach,successfultrauma-informedcross-systemeffortsinTexasallhaveanexternalfunderandacommunitychampion.
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• Thelocalmentalhealthauthorities(LMHAs)areconstrainedtoacoresetoftrauma-focusedinterventionsthatlimitLMHAabilitytoselectaninterventionbasedonthechild’soryouth’straumahistory,needs,orbraindevelopment.
• Medicaid(StarHealth)paysfortraditionaloffice-basedtrauma-informedservicesandsupports,andSTARHealthprovidestraininginTrauma-FocusedCognitiveBehavioralTherapy(TF-CBT)andParentChildInteractionTherapy(PCIT).However,providersstillidentifiedfundingasabarriertoexpandingTrauma-FocusedEvidence-BasedTreatment(TF-EBT)capacity.
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Purpose Mostchildrenandyouthinthechildwelfaresystemareimpactedbytrauma.Formany,theseexperiencesleadtobehaviorsthataremisunderstoodandmisdiagnosed,resultingindisruptionsincare,suspensionorexpulsionfromschool,orjuvenilejusticeinvolvement.Tobettersupportthesechildrenandyouth,itisnecessarytounderstandtrauma,itsmanifestations,andhowtodelivercareinawaythatbuildsrelationships,fostershope,andpromotesresilienceandsuccess.Asasteptowardthisgoal,theMeadowsMentalHealthPolicyInstitute(MMHPI)partneredwiththeSupremeCourtofTexasChildren’sCommissiontosupporttheChildWelfareTraumaConsortiuminunderstandingandaddressingtheneedsofchildreninfostercarewithmentalhealthconditions,particularlyinrelationtoexposuretotraumaandinunderstandingtrauma-informedcare(TIC).Organization of the Report Inthefirstsectionsofthisreport,weexaminethenationalTIClandscapetoprovidecontextforunderstandingTICeffortsinTexas.WereviewcommonlyciteddefinitionsofTICandhighlightsharedcorecomponents.Weprovideanoverviewofnationaltrauma-informedbestpracticesforavarietyofindividualswhointeractwithchildrenandyouthinthechildwelfaresystem.Inaddition,weprovideareviewofseveralsuccessfulstatewidesystem-levelTICinitiatives.Thelatersectionsofthisreportdescribetrauma-informedinitiativesandeffortsinthestateofTexas.First,weidentifykeytrauma-informedplayersinTexasanddiscusstheirapproaches,reach,andimplementationefforts.Ourresearchutilizedinformationgainedfrom75keyinformantinterviewstounderstandhowprovidersdefineandoperationalizeTICinTexasandtodiscussthebarrierstheyhaveencountered.Wealsofocusonthelocalmentalhealthauthorities(LMHAs)andtheirroleinservingchildrenandyouthwhohaveexperiencedtrauma.Finally,weprovideanoverviewofTexasMedicaidanddiscussfundingbarriersrelatedtothedeliveryofTIC.Inthefinalsectionofthisreport,wesummarizeourfindingsandhighlightareasfortheChildren’sCommissionPlanningWorkGrouptoconsiderwhensupportingTICeffortsinTexas.
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Brief Overview of Trauma-Informed Care Literature and Research Introduction
UnderstandingandrecognizingtheprevalenceofAdverseChildhoodExperiences(ACE)shelpstorecognizeandtreattrauma.ACEsaretraumaticorstressfuleventsthattakeplaceinchildhoodandcanpotentiallyhaveenduringanddamagingeffectsonachild’shealthandwell-being.Theycanaffectchildrenandyouthofallbackgrounds,economicclasses,andgeographiclocations.1Furthermore,ACEscomeinmanyforms,includingeconomichardship,abuseandneglect,neighborhoodviolenceordomesticviolence,growingupwithaparentwhohasamentalillnessorasubstanceusedisorder,incarcerationofaparent,orparentaldivorce.Nationally,economichardshipisthemostcommonlyreportedACE.2AchildwhohasexperiencedACEsismorelikelytoexperiencelearningorbehavioralissuesandtodevelopawiderangeofhealthproblemsincludingobesity,alcoholism,anddruguse.TheoriginalstudyonACEswasconductedbyKaiserPermanenteandtheCentersforDiseaseControlandPrevention(CDC)from1995to1997.Over17,000healthmaintenanceorganization(HMO)memberscompletedsurveysontheirchildhoodexperiencesandcurrenthealthstatusandbehaviors.ThestudyfoundthatACEsarecommon,anditidentifiedanassociationbetweenthenumberofACEsanindividualsexperiencedandsocialandhealthproblemstheyreportedhavinglaterinlife.3What Is Trauma-Informed Care?
Atrauma-informedapproachacknowledgestheprevalenceandimpactoftraumaandattemptstocreateasenseofsafetyforallpersons,whetherornottheyhaveexperiencedtrauma.Becomingtrauma-informedrequiresare-examinationofpoliciesandproceduresthatmayresultinparticipantsfeelingalossofcontrol,trainingstafftobewelcomingandnon-judgmental,andmodifyingphysicalenvironments.Becomingtrauma-informedalsoinvolvesminimizingperceivedthreats,avoidingre-traumatization,andsupportingrecovery.
1AmericanAcademyofPediatrics(2014).Adversechildhoodexperiencesandthelifelongconsequencesoftrauma.https://www.aap.org/en-us/Documents/ttb_aces_consequences.pdf2Sacks,V.,Murphy,D.,&Moore,K.(2014).ResearchBrief-Adversechildhoodexperiences:Nationalandstatelevelprevalence.ChildTrends.Publication#2014-283CentersforDiseaseControlandPrevention.(2016,March).Adversechildhoodexperiences(ACEs).Retrievedfromhttps://www.cdc.gov/violenceprevention/acestudy/.
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The History of Trauma-Informed Care
TheNationalAssociationofSocialWorkers(NASW)providesanoverviewoftheeventsthatformedthefoundationforandinfluencedtheframeworkofwhatisnowknownastrauma-informedcare(TIC).4Theseeventsincludethefollowing:
• Thedomesticviolenceandrapecrisismovementofthe1970sandchildadvocacycentersandmultidisciplinaryteamresponsetochildabuseinthe1980sgaveavoicetovictimsofinterpersonalviolence.
• TheformationoftheInternationalSocietyofTraumaticStressStudies(ISTSS)in1985servedasaresourceforprofessionalstreatinghighlytraumatizedpopulations.
• Theinvestigationofthehighprevalenceofphysicalandsexualabuseamongwomenservedbythepublicmentalhealthsystemhighlightedthevictimizationmanywomenexperiencedwhenseekingmentalhealthservices.
• The1998WomenandCo-OccurringDisordersandViolenceStudyencouragedproviderstodeliverservicesinamannerthatdidnotaddtrauma,unnecessarilytriggermemoriesofpasttraumaticevents,orplaceawomaninaphysicallyorpsychologicallydangeroussituation.
• TheNationalChildTraumaticStressNetwork(NCTSN)wasestablishedbyCongressin2000aspartoftheChildren’sHealthActtoidentifyandpromotetheuseofevidence-based,trauma-specificmentalhealthinterventionswithchildrenandtheirfamilies.
• TheNCTSNcreatedtheSystemIntegrationCommitteein2005inrecognitionofthefactthatsystemissuesunderminetheeffectivenessoftrauma-specificinterventions.
How Is “Trauma-Informed Care” Defined?
“Trauma”isdefinedsomewhatdifferentlyacrossdisciplines.However,themostcommonlyreferenceddefinitioncomesfromtheSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA):
Individualtraumaresultsfromanevent,seriesofevents,orsetofcircumstancesthatisexperiencedbyanindividualasphysicallyoremotionallyharmfulorlifethreateningandthathaslastingadverseeffectsontheindividual’sfunctioningandmental,physical,social,emotional,orspiritualwell-being.(p.7)5
4NationalAssociationofSocialWorkersandOxfordUniversityPress(2013).EncyclopediaofSocialWork:TraumaInformedCare.Retrievedfromhttp://socialwork.oxfordre.com/view/10.1093/acrefore/9780199975839.001.0001/acrefore-9780199975839-e-10635SubstanceAbuseandMentalHealthServicesAdministration.(2014,July).SAMHSA’sconceptoftraumaandguidanceforatrauma-informedapproach.HHSPublicationNo.(SMA)14-4884.Rockville,MD:SubstanceAbuseandMentalHealthServicesAdministration.Retrievedfromhttps://store.samhsa.gov/shin/content//SMA14-4884/SMA14-4884.pdf
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Theterms“trauma-informedcare”,“trauma-informedapproach,”and“trauma-informedsystem”areoftenusedinterchangeablytodescribehowcareisdeliveredatanorganizationalorsystemlevel.TICcanbeimplementedinanyservicesettingororganizationanddiffersfromatrauma-specificinterventionortrauma-focusedtreatmentthatisdesignedspecificallytoaddresstheconsequencesoftrauma.AreviewoftheliteraturerevealsseveraldefinitionsforTICandlittleconsensusonasingleone.Thisambiguityleavesproviders,organizations,andsystemstointerprethowtooperationalizetheconcept.Ingeneral,thereisafairlylowbarforsomethingtobeconsidered“trauma-informed,”anddefinitionscenteronaphilosophicalfoundationthatTICispresentwhentheawarenessthattraumaexistsiscombinedwithanunderstandingoftrauma.Asaresult,thereisoftenlittlemeaningbehindanorganization’sdesignationas“trauma-informed.”Hopper,Bassuk,andOlivet6summarizedthebasicprinciplesofTICdefinitionsandidentifiedfourcross-cuttingthemes:
• Traumaawareness:Stafftraining,consultation,andmodificationsinorganizationalpracticesreflectanunderstandingoftraumaandthevariousbehaviorsandsymptomsthatrepresentadaptationstotrauma.
• Emphasisonsafety:Organizationaloperationsensurethatconsumersarephysicallyandemotionallysafe,potentialtriggersandre-traumatizationareavoided,andclearrolesandboundariesaredefined.
• Opportunitiestorebuildcontrol:Trauma-informedservicesemphasizetheimportanceofchoiceandbuildasenseofefficacyandpersonalcontrol.
• Strength-basedapproach:TICisstrength-basedandfuture-oriented;itutilizesskill-buildingtodevelopresiliency.
Basedonthesecombinedprinciples,Hopperetal.offerthefollowingconsensus-baseddefinitionofTIC:
Trauma-InformedCareisastrengths-basedframeworkthatisgroundedinanunderstandingofresponsivenesstotheimpactoftrauma,thatemphasizesphysical,psychological,andemotionalsafetyforbothprovidersandsurvivors,andthatcreatesopportunitiesforsurvivorstorebuildasenseofcontrolandempowerment.(p.82)7
TheNCTSNdefinesatrauma-informedchildandfamilyservicessystemasfollows:
Atrauma-informedchild-andfamily-servicesystemisoneinwhichallpartiesinvolvedrecognizeandrespondtotheimpactoftraumaticstressonthosewhohavecontact
6Hopper,E.K.,Bassuk,E.L.,&Olivet,J.,(2010).Shelterfromthestorm:Trauma-informedcareinhomelessservicesettings.TheOpenHealthServicesandPolicyJournal,3,80-100.7Hopper,E.K.,Bassuk,E.L.,&Olivet,J.,(2010).Shelterfromthestorm:Trauma-informedcareinhomelessservicesettings.TheOpenHealthServicesandPolicyJournal,3,82.
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withthesystemincludingchildren,caregivers,andserviceproviders.Programsandagencieswithinsuchasysteminfuseandsustaintraumaawareness,knowledge,andskillsintotheirorganizationalcultures,practices,andpolicies.Theyactincollaborationwithallthosewhoareinvolvedwiththechild,usingthebestavailablescience,tomaximizephysicalandpsychologicalsafety,facilitatetherecoveryofthechildandfamily,andsupporttheirabilitytothrive.8
SAMHSAdefinesTICasanapproachtothedeliveryofbehavioralhealthservicesthat
includesanunderstandingoftraumaandanawarenessoftheimpactitcanhaveacrosssettings,services,andpopulations.Itinvolvesviewingtraumathroughanecologicalandculturallensandrecognizingthatcontextplaysasignificantroleinhowindividualsperceiveandprocesstraumaticevents,whetheracuteorchronic.(p.xix)9
SAMHSAutilizesthe“FourRs”todescribethefourelementsthatarenecessaryinatrauma-informedapproach:
Aprogram,organization,orsystemthatistrauma-informed…realizesthewidespreadimpactoftraumaandunderstandspotentialpathsforrecovery;recognizesthesignsandsymptomsoftraumainclients,families,staff,andothersinvolvedwiththesystem;respondsbyfullyintegratingknowledgeabouttraumaintopolicies,procedures,andpractices;andseekstoactivelyresistre-traumatization.(p.33)10
Inaddition,SAMHSAstatesthatatrauma-informedapproachadherestoakeysetofsixprinciplesratherthanasetofpoliciesandprocedures.11TheseprinciplesappeartobuildonHopper,Bassuk,andOlivet’swork:
• Safety• Trustworthinessandtransparency• Peersupport• Collaborationandmutuality• Empowerment,voice,andchoice• Cultural,historical,andgenderissues
8TheNationalChildTraumaticStressNetwork.(n.d.)Creatingtrauma-informedsystems.Retrievedfromhttp://www.nctsn.org/resources/topics/creating-trauma-informed-systems9SubstanceAbuseandMentalHealthServicesAdministration.(2014).Trauma-InformedCareinBehavioralHealthServices.TreatmentImprovementProtocol(TIP)Series57.HHSPublicationNo.(SMA)13-4801.Rockville,MD:SubstanceAbuseandMentalHealthServicesAdministration.Retrievedfromhttps://store.samhsa.gov/shin/content/SMA14-4816/SMA14-4816.pdf10Flatow,R.B.,Blake,M.,&Huang,L.N.,(2015).SAMHSA’sconceptoftraumaandguidanceforatrauma-informedapproachinyouthsettings.FocalPoint:Youth,YoungAdults,&MentalHealth.Trauma-InformedCare,29–35.Retrievedfromhttps://www.pathwaysrtc.pdx.edu/pdf/fpS1510.pdf11SubstanceAbuseandMentalHealthServicesAdministration.(n.d.)Trauma-informedapproachandtrauma-specificinterventions.Retrievedfromhttps://www.samhsa.gov/nctic/trauma-interventions
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TheCenterforHealthCareStrategies(CHCS)statesthatTICmustinvolveorganizationalandclinicalpracticesthatrecognizetheimpactoftraumaonboththeproviderandthepatient.12
CHCSstressesthat,inordertobetrauma-informed,anorganizationmustinitiatewidespreadtrauma-informedorganizationalchangethatincludeschangestocultureandpolicy.Thesechangesformthefoundationforthedeliveryoftrauma-specifictreatment.Evidence-Based Trauma-Informed Practices
DespitethefactthatthereisnosingledefinitionfortraumaorTIC,therearemanyevidence-based,trauma-specificortrauma-focusedapproachesavailabletoworkwithwhenprovidingservicestochildren,youth,andtheirfamiliesinthevariouschild-servingsystems.Severaloftheseapproachesandinterventionsarelistedinthisreport.Thisisnotanexhaustivelist.Furtherinformationontheapproachesmentionedbelowandonadditionalevidence-basedpracticescanbefoundbyaccessingthewebsitesfortheNCTSN,13theNationalRegistryofEvidence-BasedProgramsandPractices(NREPP),14andtheCaliforniaEvidence-BasedClearinghouseforChildWelfare(CEBC).15SeeAppendixOneforanoverviewNREPPandCEBC.Trauma-FocusedTrainingTrauma-focusedinterventionsaremosteffectivewhentheyareimplementedwithinandthroughoutanorganizationsothatapproachesbecomeingrainedinthecultureofanorganizationandthateverypersonwhocomesincontactwithachildoryouthunderstandstheimpactoftraumaandcanrespondtotraumaticstresssymptomsinasupportivemanner.BelowisasampleofcurriculadevelopedbytheNCTSNaswellasadditionalpromisingtraumamodelsandtools.16ChildWelfareCaseworkers
• ChildWelfareTraumaTrainingToolkit(ChildWelfareCollaborativeGroup,NCTSN,andtheCaliforniaSocialWorkEducationCenter,2013)17
12Menschner,C.,&Maul,A.,(2016).Issuebrief:Keyingredientsforsuccessfultrauma-informedcareimplementation.AdvancingTrauma-InformedCare.CenterforHealthCareStrategies,Inc.Retrievedfromwww.chcs.org13NationalChildren’sTraumaticStressNetwork(NCTSN).http://www.nctsn.org/14NationalRegistryofEvidence-basedProgramsandPractices(NREPP).https://www.samhsa.gov/nrepp.15CaliforniaEvidence-BasedClearinghouseforChildWelfare(CEBC).http://www.cebc4cw.org/16Olafson,E.,HalladayGoldman,J.,Gonzalez,C.(2016).Trauma-informedcollaborationsamongjuvenilejusticeandotherchild-servingsystems:Anupdate.OJJDPJournalofJuvenileJustice.(5)1.Retrievedfromhttp://www.journalofjuvjustice.org/JOJJ0501/article01.htm17ChildWelfareCollaborativeGroup,NationalChildTraumaticStressNetwork,CaliforniaSocialWorkEducationCenter.(2013).Childwelfaretraumatrainingtoolkit:Trainer’sguide(2nded.).LosAngeles,CA&Durham,NC:NationalCenterforChildTraumaticStress.
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ResidentialTreatmentStaff,ProbationOfficers,CourtPersonnel
• ThinkTrauma:AFour-ModuleTraumaMilieuTraining(Marrow,Benamati,Decker,Griffing,&Lott,2012)18
• Cops,Kids,andDomesticViolence(NCTSN,2006)19• TenThingsEveryJuvenileCourtJudgeShouldKnowAboutTraumaandDelinquency
(Buffington,Dierkhising,&Marsh,2010)20• NCTSNBenchCardfortheTrauma-InformedJudge(NCTSNJusticeConsortiumand
NationalCouncilofJuvenileandFamilyCourtJudges,2013)21FosterFamilies
• CaringforChildrenWhoHaveExperiencedTrauma:AWorkshopforResourceParents(NCTSN,2010).22Thistrainingwasco-createdbyNCTSNexpertsandexperiencedfosterparents.Itcombinestraumaknowledgeandpeersupportwithopportunitiestoapplythatknowledgetoachildinthecaregiver’shome.
Educators
• ChildTraumaToolkitforEducators(NCTSNSchoolsCommittee,2008)23Trauma-SpecificInterventionsinMentalHealth24,25,26
Thetrauma-specific,evidence-basedorevidence-informedtherapeuticapproachesmostcommonlymentionedintheliteraturefortreatingchildren,youth,andtheirfamiliesarethefollowing:
18Marrow,M.,Benamati,J.,Decker,K.,Griffin,D.,Lott,D.A.(2012).Thinkingtrauma:Atrainingforstaffinjuvenilejusticeresidentialsettings.LosAngeles,CA&Durham,NC:NationalCenterforChildTraumaticStress.19NationalChildTraumaticStressNetwork(2006).Cops,Kids&Domesticviolence:Protectingourfuture(DVD).LosAngeles,CA&Durham,NC:NationalCenterforChildTraumaticStress.20Buffington,K.,Dierkhising,C.B.,Marsh,S.C.(2010).Tenthingseveryjuvenilecourtjudgeshouldknowabouttraumaanddelinquency.Retrievedfromhttp://www.ncjfcj.org/sites/default/files/trauma%20bulletin_1.pdf21NationalChildTraumaticStressNetwork,JusticeConsortium&NationalCouncilforJuvenileandFamilyCourtJudges.(2013).NCTSNbenchcardforthetrauma-informedjudge.Retrievedfromhttp://www.nctsn.org/sites/default/files/assets/pdfs/judge_bench_cards_final.pdf22NationalChildTraumaticStressNetwork.(2010).Caringforchildrenwhohaveexperiencedtrauma:Aworkshopforresourceparents.Retrievedfromhttp://nctsn.org/nctsn_assets/pdfs/rpc/RPCParticipantHandbookFINAL.pdf23NationalChildTraumaticStressNetworkSchoolsCommittee.(2008).Childtraumatoolkitforeducators.LosAngeles,CA&Durham,NC:NationalCenterforChildTraumaticStress.Retrievedfromhttps://wmich.edu/sites/default/files/attachments/u57/2013/child-trauma-toolkit.pdf24DeArellano,M.A.,Ko,S.J.,&Sprague,C.M.(2008).Trauma-informedinterventions:Clinicalandresearchevidenceandculture-specificinformationproject.LosAngeles,CA&Durham,NC:NationalCenterforChildTraumaticStress.25NationalChildTraumaticStressNetwork.TreatmentsthatWork.Retrievedfromhttp://www.nctsn.org/resources/topics/treatments-that-work/promising-practices#q426ChildTraumaAcademy.(n.d.).NMT.Retrievedfromhttp://childtrauma.org/nmt-model/
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• Attachment,Self-Regulation,andCompetency(ARC):AComprehensiveFrameworkforInterventionwithComplexlyTraumatizedYouth
• CognitiveBehavioralTherapyApproaches(CBT)- Trauma-FocusedCognitiveBehavioralTherapy(TF-CBT)- CombinedParentChildCognitiveBehavioralApproachforChildrenandFamiliesAt-
RiskforChildPhysicalAbuse(CPC-CBT)- AlternativesforFamilies-CognitiveBehavioralTherapy(AF-CBT)
• DialecticalBehavioralTherapy(DBT)- AdaptedDialecticalBehavioralTherapyforSpecialPopulations(DBT-SP)
• EyeMovementDesensitizationandReprocessing(EMDR)-ChildandAdolescent• Parent-ChildInteractionTherapy(PCIT)• ProlongedExposureTherapyforAdolescents(PE-A)• NeurosequentialModelofTherapy(NMT)• StructuredPsychotherapyforAdolescentsRespondingtoChronicStress(SPARCS)• TraumaAffectRegulationGuidelineforEducationandTherapyforAdolescents
(TARGET-A)• TraumaandGriefComponentTherapyforAdolescents(TGCT)
Trauma-SpecificInterventionsinJuvenileJusticeProbationofficersandjuvenilejusticestaffarenotmentalhealthprofessionals.Theydonotneedtoknowhowtoimplementtrauma-specifictreatmentapproaches.However,itisimportantthattheyunderstandhowtraumaimpactsbehaviors,aretrainedtodeterminetheneedsofayouth,andidentifytheservicesandsupportsrequiredtomeettheseneeds.Probationofficersandjuvenilejusticestaffmusthaveaccesstoacomprehensivecontinuumofcarethatincludesevidence-based,trauma-specifictreatmentseffectivewithyouthinthejuvenilejusticesystem.27Ford,Kerig,Desai,andFeirmanidentifiedfourevidence-basedpsychosocialinterventionsthathavebeenproventobeeffectivewiththejuvenilejusticepopulation.28
• CognitiveProcessingTherapy(CPT)• TraumaAffectRegulation:GuideforEducationandTherapy(TARGET)• TraumaandGriefComponentsTherapyforAdolescents(TGCTA)• Trauma-AdaptedMultidimensionalTreatmentFosterCare(TA-MTFC)
27NationalCenterforMentalHealthandJuvenileJusticePolicyResearchAssociates.(2015).Strengtheningourfuture:Keyelementstodevelopingatrauma-informedjuvenilejusticediversionprogramforyouthwithbehavioralhealthconditions.Retrievedfromhttps://www.ncmhjj.com/wp-content/uploads/2015/12/Strengthening-Our-Future.pdf28Ford,J.D.,Kerig,P.K.,Desai,N.,&Feierman,J.(2016).Psychosocialinterventionsfortraumatizedyouthinthejuvenilejusticesystem:Research,evidencebase,andclinical/legalchallenges.OJJDPJournalofJuvenileJustices.(5),1.
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Twoadditionalmodelsthatsupportatrauma-informedcareenvironmentinjuvenilejusticediversionandsupervisionpracticesareidentifiedinStrengtheningOurFuture.29T4(TARGET1,2,3,4)isafour-stepshortcuttotheTARGETtraining.Itprovidesconcretetoolsthathelpyouthandstaffachieveoptimalpersonalcontrol.TheSanctuaryModelisawhole-organizationalmodelofserviceandcare.Itwasoriginallydesignedforanacuteinpatientpsychiatricpopulationofadultswhohadbeentraumatizedaschildren.Ithasbeenadaptedtocoveravarietyofpopulations,includingchildrenandyouth.Trauma-SpecificInterventionsinChildWelfare30,31,32,33
Manypeopletouchthelivesofchildrenandyouthwhoareinvolvedinthechildwelfaresystem.Theseincludejudges,lawyers,childprotectiveservice(CPS)workers,CourtAppointedSpecialAdvocates(CASAs),mentalhealthandprimarycareproviders,biologicalparents,relatives,andfosterparents.Theseindividualsneedtounderstandwhattraumais,recognizesignsandsymptoms,knowhowtotreatit,andcreateopportunitiesforchildrenandyouthwhohaveexperiencedtraumatofeelsafeandempowered.Thereareseveralevidence-basedinterventions,evidence-informedapproaches,tools,andsourcesofinformationtohelpindividualswhoprovideservicesandsupportstochildrenandyouthinvolvedinthechildwelfaresystemandtheirfamilies.TherapeuticInterventionsforMentalHealthProfessionals
Thefollowingapproacheswerefoundtobeeffective,specificallywithchildrenandyouthinvolvedinthechildwelfaresystem,andsupplementthetherapeuticapproachesmentionedabove.
• AttachmentandBiobehavioralCatch-Up(ABC)• ChildandFamilyTraumaticStressIntervention• RealLifeHeroes:Resiliency-FocusedTreatmentforChildrenwithTraumaticStress(RLH)• TreatmentFosterCareOregon(TFCO-A)EducationalInterventionforChildreninFoster
Care
29StrengtheningOurFuture.(2015).Strengtheningourfuture:Keyelementstodevelopingatrauma-informedjuvenilejusticediversionprogramforyouthwithbehavioralhealthconditions.Retrievedfromhttps://www.ncmhjj.com/wp-content/uploads/2016/01/traumadoc012216-reduced-003.pdf30NationalChildTraumaticStressNetwork.(n.d.).Treatmentsthatwork.Retrievedfromhttp://www.nctsn.org/resources/topics/treatments-that-work/promising-practices#q431CaliforniaEvidence-BasedClearinghouseforChildWelfare.(n.d.).TreatmentFosterCareOregon.Retrievedfromhttp://www.cebc4cw.org/program/32CircleofSecurityInternational.ForParents.Retrievedfromhttps://www.circleofsecurityinternational.com/for-parents33FosteringResilience:Preparingchildrenandteenstothrivethroughbothgoodandchallengingtimes.(n.d.).Retrievedfromhttp://www.fosteringresilience.com/professionals/
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InterventionsforFoster,Kinship,andBiologicalParents
• Trauma-InformedPSMAPP(TIPS-MAPP)• Trust-basedRelationalIntervention(TBRI®)• KEEP(KeepingFosterandKinParentsSupportedandTrained)• CircleofSecurity-Parents(COS-P)• ReachingTeens©:Strength-BasedCommunicationStrategiestoBuildResilienceand
SupportHealthyAdolescentDevelopmentInterventionforCaseworkers
Thefollowingapproachesareinadditiontotheinterventionslistedforparents.• Child-AdultRelationshipEnhancement(CARE):AdaptationofParentChildInteraction
Therapy(PCIT)• Wraparound
Trauma-InformedResourcesInformationforJudges,Attorneys,andCASAsTherearenospecifictrauma-focusedinterventionsorapproachesforjudges.However,theNCTSNrecommendsthatcourtsbecometrauma-informedatalllevels.Theintentistomakethecourtasafeenvironmentthatdoesnotincreasethetraumaexperiencedbythechild,youth,orparentsandthatdoesprovideopportunitiestolearntoolstocopewithtraumaticstressreactions.Inaddition,courtscanscreenfortrauma,referfornecessarytraumaassessments,andrefertoprovidersthatusetrauma-focusedapproaches.Courtsareencouragedtotakealeadershiproleinincreasingsystem-wideawarenessoftrauma,developingcommunitycapacitytodelivertrauma-focusedapproaches,andfosteringpartnershipsamongyouth,families,professionals,andstakeholders.Thefollowingtoolwasidentifiedaseffectiveinassistingattorneysandothercourt-appointedadvocatesinincorporatingtraumaknowledgeintotheirdailypractices.Itisnotintendedtobeascreeningtool.Itisdesignedtohelpadvocatesidentifytraumaexperiencesandsymptomsoftraumaandidentifybeneficialservices.34
• IdentifyingPolyvictimizationandTraumaAmongCourt-InvolvedChildrenandYouth:AChecklistandResourceGuideforAttorneysandOtherCourt-AppointedAdvocates.35
34Klain,E.J.,&White,A.R.,(2013).Implementingtrauma-informedpracticesinchildwelfare.Retrievedfromhttp://www.centerforchildwelfare.org/kb/TraumaInformedCare/ImplementingTraumaInformedPracticesNov13.pdf35Pilnik,L.,&Kendall,J.R.(2012).Identifyingpolyvictimizationandtraumaamongcourt-involvedchildrenandyouth:Achecklistforattorneysandothercourt-appointedadvocates.NorthBethesda,MD:SafeStartCenter,OfficeofJuvenileJusticeandDelinquencyPrevention,Programs,U.S.DepartmentofJustice.Retrievedfromhttps://www.ojjdp.gov/programs/safestart/IdentifyingPolyvictimization.pdf
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KlainandWhiteidentifyfivetrauma-informedpracticerecommendationsforchildwelfaresystems,courts,advocates,andstaff:36
• Educatestakeholdersabouttheeffectsoftraumaonchildrenandfamiliesaswellaseffectivetrauma-specifictreatments.
• Ensurechildrenenteringthechildwelfaresystemarescreenedandassessedfortrauma.• Referchildrentoappropriateevidence-based,trauma-specifictreatment.• Provideinformationandtrauma-relatedservicestobirthfamiliesandcaregivers.• Encouragestakeholderstocollaboratetoformacohesive,integratedcommunity
approachtoaddressingtrauma.Trauma-SpecificInterventionsinSchools37,38,39
Socialandemotionallearning(SEL)isaprocessthroughwhichastudentacquiresandappliestheknowledgeandskillsnecessarytounderstandandmanageemotions,setandachievegoals,feelandshowempathy,anddeveloppositiverelationships.40TICandSELshareinterrelatedcharacteristicsthat,whenusedintandem,helpchildrenandyouthwhohaveexperiencedtraumasucceedinschool.BlodgettandDoradobelievethatthesocialandemotionalskillsofachildoryouthwhohasexperiencedtraumawilldevelopnaturallywhentrauma-sensitiveeducationalpracticesareutilized.Despitethisalignment,therearenostandardpracticesforintegratingtrauma-informedortrauma-sensitivecareandSELinschools.Thereareseveralevidence-basedandevidenced-informedschool-basedinterventionsidentifiedintheliterature.Theseinterventionsareeffectivewithchildrenandyouthwhohaveexperiencedabuseandneglect,exceptforPsychologicalFirstAid(PFA).PFAforschoolsisdesignedtoassistchildren,youth,andtheirfamiliesintheaftermathofdisasterorterrorism.Structured,MentalHealth-Focused,Student-Centered,andTrauma-Specific
• CognitiveBehavioralInterventionforTraumainSchools(CBITS)isaschool-basedprogramdesignedtoreducethesymptomsofpost-traumaticstressdisorder,depression,andgeneralanxietyamongchildrenexposedtomultipleformsoftrauma
• MultimodalityTraumaTreatment(MMTT),alsoknownasTrauma-FocusedCopinginSchools
36Klain,E.J.,&White,A.R.,(2013).Implementingtrauma-informedpracticesinchildwelfare.Retrievedfromhttp://www.centerforchildwelfare.org/kb/TraumaInformedCare/ImplementingTraumaInformedPracticesNov13.pdf37NationalChildTraumaticStressNetwork.TreatmentsthatWork.38ChildTraumaAcademy.NME.39Blodgett,C.,&Dorado,J.(n.d.).CLEARtrauma-informedschoolswhitepaper:Aselectreviewoftrauma-informedschoolpracticeandalignmentwitheducationalpractices.Retrievedfromhttp://ext100.wsu.edu/cafru/wp-content/uploads/sites/65/2015/02/CLEAR-Trauma-Informed-Schools-White-Paper.pdf40CASEL:EducatingHearts.InspiringMinds.(n.d.).WhatisSEL.Retrievedfromhttp://www.casel.org/what-is-sel/
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Structured,Population-Focused,Trauma-informed,System-Centered
• CollaborativeLearningforEducationalAchievementandResilience(CLEAR)• HealthyEnvironmentsandResponsetoTraumainSchools(HEARTS)• NeurosequentialModelinEducation(NME)• PsychologicalFirstAid(PFA)-Schools
School-Wide,TeacherCentered,Trauma-Informed
• FuelEd:FuelingSchoolswiththePowerofRelationshipsTrauma-Informed,Cross-SystemCollaborationModelsOlafson,HalladayGoldman,andGonzalez41identifiedfourthemesthatareessentialtofosteringtrauma-informedcross-systemcollaborations.Theyare(1)effectivecross-system,multi-levelleadership;(2)formalizedstakeholderengagementthroughmemorandaofunderstanding(MOUs)andmulti-disciplinaryteams;(3)collaborativeidentificationofsharedoutcomesbykeystakeholdersandcommunitymembers;and(4)evaluationoftheimpactinordertoinformfutureplanningandsupportsustainability.Usingthesethemes,theyidentifiedseveralexamplesoftrauma-informedcross-systemcollaboration.
• GeorgetownUniversityCrossoverYouthPracticeModel42ThismodelisacollaborationbetweenCaseyFamilyProgramsandtheCenterforJuvenileJusticeReform(CJJR).Itfocusesonyouthwhoareknowntobeinboththechildwelfareandjuvenilejusticesystems.
• Trauma-SystemsTherapy(TST)43Thisisapromisingcross-systemcomprehensiveapproachforyouthwhohaveexperiencedtrauma.Ithasbeenusedwithvariouspopulationsincludingyouthinvolvedinthechildwelfareandjuvenilejusticesystems.
• PositiveStudentEngagementModelforSchoolPolicing44InitiallyknownastheMulti-IntegratedSystemsApproach,thismodelwasdevelopedinresponsetotheschool-to-prisonpipeline.Itencouragestheuseofrestorativeratherthanpunitivepractices.
41Olafson,E.,HalladayGoldman,J.,&Gonzalez,C.,(2016).Trauma-informedcollaborationsamongjuvenilejusticeandotherchild-servingsystems:Anupdate.OJJDPJournalofJuvenileJustice,(5)1.42GeorgetownUniversityCrossoverYouthPracticeModel.(n.d.).Retrievedfromhttp://cjjr.georgetown.edu/our-work/crossover-youth-practice-model/43Trauma-SystemsTherapy.(n.d.).Retrievedfromhttps://med.nyu.edu/child-adolescent-psychiatry/research/institutes-and-programs/trauma-and-resilience-research-program/trauma-systems-therapy44Multi-IntegratedSystemsApproach.(n.d.).Retrievedfromhttp://www.ncjfcj.org/sites/default/files/Zero%20Tolerance%20Policies%20in%20Schools%20%282%29.pdf
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• ChildDevelopmentCommunityPolicingProgram(CDCP)45DevelopedbytheYaleChildStudyCenterincollaborationwiththeNewHavenPoliceDepartment,CDCPsupportstheworkofmentalhealthprovidersandpoliceofficersattendingtotheneedsofchildrenandyouthexposedtotraumaticevents,respondingimmediatelytocallsinvolvingchildrenoryouthwhoarewitnessesorvictimstoviolentevents,includingdomesticviolence.
• CourtandMentalHealthCollaborations46Olafsonetal.providenumerousexamplesofproactivecollaborationsbetweenthecourtsystemandmentalhealthsystemthathaveshownpromiseintheareasofpreventionandtreatment.
A Look at State Consortiums and Councils
Successfulstateshavecollaboratedacrossservicesystemstodeveloptheirworkforces,screenfortrauma,changepractices,andincreaseaccesstoevidence-basedpractices.Connecticut,Iowa,Ohio,andOregonhavedevelopedstatewideorregionalcross-systemcollaboratives,steeringcommittees,andlearningcommunities.Iowa’ssteeringcommitteehasdevelopedafive-yearvisionandcommonlegislativeagenda.ConnecticutandOregonhaveexpandedtheircollaborativeeffortstoincludetrainingprimaryhealthcareproviders,withConnecticutdevelopingatraumascreeningforphysicians.Ohio’sinitiativeprovidestrainingtoexpandopportunitiesforpractitionerstobecomecompetentintrauma-informedapproaches.Inaddition,Washington,Pennsylvania,andCaliforniahavepassedstatewideresolutionsthatsupporttrauma-informedcare.Thefollowingareexamplesofstates’collaborativeefforts.Thislistisnotexhaustive.ConnecticutTheChildHealthandDevelopmentInstituteofConnecticut,Inc.(CHDI)hasbeenworkingtoimplementatrauma-informedsystemofcareinConnecticutsince2007.CHDIhasworkedwithstateagencies,providerorganizations,andfamiliestoimproveaccessforchildrentoservicesthataddresstrauma.Theirstrategiesincludeworkforcedevelopment,traumascreening,practicechangeandaccesstoevidence-basedpractices,andcross-systemcollaboration.47WithfundingfromtheDepartmentofChildrenandFamiliesandtheFederalAdministrationforChildrenandFamilies,CHDIhasdevelopedandimplementedtrauma-informedpolicies,systems,andpracticesinthechildwelfare,juvenilejustice,andchildren’smentalhealth
45ChildDevelopmentCommunityPolicingProgram(CDCP).https://medicine.yale.edu/childstudycenter/cvtc/programs/cdcp.aspx.46Olafson,E.,HalladayGoldman,J.,&Gonzalez,C.,(2016).Trauma-informedcollaborationsamongjuvenilejusticeandotherchild-servingsystems:Anupdate.OJJDPJournalofJuvenileJustice,(5)1.47Lang,J.,Campbell,K.,&Vanderploeg,J.(2015)Advancingtrauma-informedsystemsforchildren.Farmington,CT:ChildHealthandDevelopmentInstituteofConnecticut.
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systems.Theyhavealsotrainedpediatrichealthproviderstoidentifytraumaandlinkchildrenandfamiliestoservices,developedascreeningtoolforchildhoodtrauma(TheChildTraumaScreen),anddevelopedawebsitetoincreasepublicawarenessforparentsandcaregivers.AnotherstatewideTICconsortiumistheConnecticutWomen’sConsortium,whichexpandedstatewidein1998.TheconsortiumhasworkedwiththeDepartmentofMentalHealthandAddictionServicestotrainprovidersonevidence-basedpracticesandtopromotearecovery-orientedsystemthatistrauma-informedandgender-responsive.Theconsortium’spartnership,theTraumaandGenderInitiative,willbemovingtowardsaregionalcollaborativemodelin2017.IowaCentralIowaAdverseChildhoodExperiencesSteeringCommitteefocusesoncollectivecommunityeffortstopreventorlessentheimpactofACEsandisacoalitionofbusiness,education,non-profit,andphilanthropicentities.48Thestructureofthecoalitionincludesalearningcommunitywithopenmembershipthatconvenesatleasttwiceayeartoshareinformationandopportunitiesforengagement,asteeringcommittee,andactiongroups.TheIowaACEsSteeringCommitteestartedin2011afterlearningabouttheACEsstudyfindings.49Thegroup’spasteffortsincludedevelopingastandardpresentationtoover1,000peopleinthestate,addingchildneglectquestionstotheBehavioralRiskFactorSurveillanceSystem(BRFSS)questionnaire,andhostingasummittoengageeducationandjuvenilejusticesectorsonACEs.IncollaborationwithotherIowagroups,thepolicycommitteehasdevelopedafive-yearvisionalongwithacommonlegislativeagendaregardingACEs.Ohio
Ohio’sTrauma-InformedCareInitiative50isorganizedthroughsixregionalcollaboratives.TheOhioDepartmentofMentalHealthandAddictionServices(OhioMHAS)andDepartmentofDevelopmentalDisabilities(DODD)collaborateonastatewideTrauma-InformedCareInitiative.Theinitiative’sintentistopromoteasenseofsafety,security,andequalityamongclients.Theinitiativeexpandsopportunitiesforpeopletoreceivetrauma-informedinterventionsby
48IowaACEs360.(n.d.).Aboutus.Retrievedfromhttp://www.iowaaces360.org/uploads/1/0/9/2/10925571/central_iowa_aces_360_steering_committee_timeline.pdf49Felitti,V.J.,Anda,R.F.,Nordenberg,D.,Williamson,D.F.,Spitz,A.M.,Edwards,V.,Koss,M.P.,&Marks,J.S.(1998).Relationshipofchildhoodabuseandhouseholddysfunctiontomanyoftheleadingcausesofdeathinadults.AmericanJournalofPreventiveMedicine.14(4),245–258.DOI:http://dx.doi.org/10.1016/S0749-3797(98)00017-850OhioMentalHealthandAddictionServices.(n.d.).Ohio’sTraumaInformedCareInitiative.Retrievedfromhttp://mha.ohio.gov/traumacare
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improvingopportunitiesforpractitioners,facilities,andagenciestobecomecompetentintrauma-informedpractices.AnannualTrauma-InformedSummitthatpromotesknowledgeabouttheimpactoftrauma,implementationoftrauma-informedpractice,sustainability,andcollaborationamongagencieshasbeenheldforfouryears.TheNationalCenterforTrauma-InformedCare(NCTIC)hasprovidedconsultationandtrainingtodifferentsectors.TheTICInitiativehasprovidedtrainingtoallRegionalPsychiatricHospitalsandtheDODDDevelopmentalCenters,createdatrain-the-trainermodelfortrauma-informedapproaches,developedaneducationalandcommunicationcampaignontrauma,initiatedareductionofseclusionandrestraintinitiative,supportedatrauma-informedinitiativeacrosssocialservicesystems,andcreatedastatewideTICAdvisoryCommittee.Oregon
TraumaInformedOregon(TIO)51reflectsthestate’scommitmenttopromotetraumapreventionandtobetteralignpoliciesandpracticewiththeprinciplesofTIC.Thestatewidecollaborationwasinitiatedin2014whentheOregonHealthAuthority’sHealthSystemsDivisioncontractedwithPortlandStateUniversityinpartnershipwithOregonHealthandScienceUniversity(OHSU)andtheOregonPediatricSocietytopromoteandsustainTICacrosschild-andfamily-servingsystems.In2015,thecollaborativewasexpandedtoincludeadultbehavioralhealth-servingsystems.TIOcoordinatesandprovidestrainingandservesasasourceofinformationandresources.Italsoworkswithstateagencies,stateandlocalproviders,communities,familyandyouthorganizations,andotherstakeholderstobringperspectivestogethersothattheymaylearnfromeachotherandtoadvocatefortrauma-informedpoliciesandpractices.StateResolutionsThefollowingstatespassedresolutionstopromoteexpansionoftrauma-informedpracticesandpolicies.California
In2014,theCaliforniaSenatepassedAssemblyConcurrentResolution155(ACR155),whichencouragesstatewidepoliciestoreducechildren’sexposuretostressandACEs.52The
51TraumaInformedOregon.(n.d.).Abouttrauma-informedOregon.Retrievedfromhttp://traumainformedoregon.org/about52TraumaInformedOregon.(n.d.).Abouttrauma-informedOregon.Retrievedfromhttp://traumainformedoregon.org/about
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resolutionencouragesofficialstosupportresearch-basedsolutions,investinpreventivehealthcare,andpromotementalhealthandwellnessinterventions.Pennsylvania
InApril2013,PennsylvaniaHouseResolution191,whichdeclaressupportforapublichealthapproachtoviolenceandstatewidetrauma-informededucation,waspassed.53Theresolutionacknowledgestheimpactoftraumaandesblishesaframeworkfordialogueontheissue.ItalsosecuredapprovalbytheNationalConferenceofStateLegislaturesanactionwhichiscommunicatedtoCongressandthePresident,movingtheissuetoanationalstage.Theresolutiondidnotauthorizeorfundnewmandatesorprograms,andtheSenatedidnotissueasimilarresolution.Washington
In2011,HouseResolution1965,whichwasintendedtoidentifyandpromoteinnovativestrategiestopreventorreduceACEs,waspassed.Italsodevelopedapublic-privatepartnershiptosupporteffectivestrategieswhichformedtheWashingtonStateACEsPublic-PrivateInitiative(APPI).APPIexamineseffectivecommunity-basedapproachestoreducingACEsanddocumentingpublicsavingsresultingfromthiswork.54TheAPPIconductedatwo-and-a-half-yearevaluationthatstudiedhowfivecommunitiesinthestateimplementedcommunity-basedapproaches.
53Prewitt,E.(2014,April30).State,federallawmakerstakeactionontrauma-informedpolicies,programs.Retrievedfromhttp://acestoohigh.com/2014/04/30/state-federal-lawmakers-take-action/54Prewitt,E.(2014,April30).State,federallawmakerstakeactionontrauma-informedpolicies,programs.Retrievedfromhttp://acestoohigh.com/2014/04/30/state-federal-lawmakers-take-action/
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What Does Trauma-Informed Care Look Like in Texas? TounderstandhowTICisdeliveredtochildren,youth,andfamiliesinthechildwelfare,juvenilejustice,andmentalhealthsystemsinTexas,weneededtoexplorethefollowingactions:
• EstimatehowmanychildrenandadolescentsinTexashaveexperiencedtrauma• ReviewstatewidelegislationthataddressestraumaandTIC• IdentifyandreviewTICtrainingavailabletoprofessionalsandcaregiversthroughoutthe
state• ReviewtheprimarymodelsofTICutilizedinTexas• Meetwithkeyinformantsinthestate’schild-servingsystemstofindouthowTICis
beingoperationalizedanddeliveredincommunitiesacrossthestate,whichtrauma-focusedmodelsarebeingused,andwhatorganizational-andsystem-levelsuccessesandbarrierstheyhaveexperienced
• Identifysuccessfulcross-systemTICcollaboratives• ReviewthefundingstreamsthatareavailabletofundTICandtrauma-focused
approachesHow Many Children in Texas Have Been Affected by Trauma?
Anadversechildhoodexperienceisapotentiallytraumaticeventthatcanhavealasting,negativeeffectonachildoryouth’sphysicalandemotionalwellbeing.55TheprevalenceofACEsismeasuredbywhetherachildhasbeenavictimofviolence,experiencedeconomichardship“somewhatoften”or“often,”livedwithaparentwhodivorcedorseparated,livedwithaparentwhodiedorwasincarcerated,witnessedviolenceathomeorinhisorherneighborhood,orlivedwithaparentwhohadamentalillnessorstruggledwithasubstanceabuseproblem.ChildrenandyouthwhohaveexperiencedmultipleACEsareathighestriskfornegativeoutcomes,includinghealthandbehavioralproblems.56JustunderhalfofchildrenintheUnitedStateshaveexperiencedonetraumaticlifeeventorACE.57Areviewofnationalprevalenceestimatesandstate-leveldataindicatesthatapproximately10%ofTexaschildrenhaveexperiencedthreeormoreACEsintheirlifetime.58Manyhaveexperiencedeightormoreepisodesofviolence.Inaddition,childrenandyouthwhoareinvolvedinthechildwelfareandjuvenilejusticesystemsaresignificantlymorelikelythan
55Felitti,V.J.,Anda,R.F.,Nordenberg,D.,Williamson,D.F.,Spitz,A.M.,Edwards,V.,Koss,M.P.,&Marks,J.S.(1998).Relationshipofchildhoodabuseandhouseholddysfunctiontomanyoftheleadingcausesofdeathinadults.AmericanJournalofPreventiveMedicine.14(4),245–258.DOI:http://dx.doi.org/10.1016/S0749-3797(98)00017-856Sacks,V.,Murphy,D.,&Moore.,K.(2014).Adversechildhoodexperiences:Nationalandstate-levelprevalence.ResearchBrief:ChildTrends.Publication#2014-28.57AmericanPsychologicalAssociation.(n.d.).Childrenandtrauma:Updateformentalhealthprofessionals.Retrievedfromhttp://www.apa.org/pi/families/resources/children-trauma-update.aspx58Sacks,V.,Murphy,D.,&Moore.,K.(2014).Adversechildhoodexperiences:Nationalandstate-levelprevalence.ResearchBrief:ChildTrends.Publication#2014-28.
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thegeneralpopulationtohaveexperiencedanACE.Takingthesefactorsintoconsideration,child-servingsystemsinTexasneedtobeabletoidentify,understand,andtreattrauma.MethodologyforEstimatingPrevalenceMeasuringtheprevalenceofchildandyouthtraumaisdifficultandimprecise.National-andstate-leveldatamustbetriangulatedtoestimatehowmanychildrenandyouthhavebeenexposedtotrauma.ThefollowingestimatesforTexaschildrenandyouthdrawontheNationalSurveyofChildren’sExposuretoViolenceandtheNationalSurveyofChildren’sHealth.Otherdataincludethenumberofyouthwhohavebeenidentifiedwithmentalhealthneedswithinthesocialservicesandjuvenilejusticesystem.FindingsonChildandYouthTraumaExposure(TE)inTexas
• Finding1:Statewide,approximately730,000childrenandyouth,or1in10children/youthoverall,haveexperiencedthreeormoreACEs.ThemostprevalentACEsamongTexaschildrenandyouthareexposuretoeconomichardship,livingwithadivorcedparentorguardian,livingwithsomeonewhohasasubstanceuseproblem,andlivingwithsomeonewithamentalillness.
Table1:ChildrenandYouthWhoHaveExperiencedThreeorMoreAdverseChildhoodExperiences59,60
AdverseChildhoodExperiences(ACEs)TexasPrevalence
Proportion(Age0–17)
TexasPrevalenceCount
(Age0–17)Threeormoreadversechildhoodexperiences 10.0% 728,289Livedwithaparentorguardianwhogotdivorcedorseparated
20.0% 1,456,577
Livedwithaparentorguardianwhodied 2.6% 189,355Livedwithaparentorguardianwhoservedtimeinjailorprison
6.9% 502,519
Livedwithanyonewhowasmentallyillorsuicidal,orseverelydepressedformorethanacoupleofweeks;livedwithanyonewhohadaproblemwithalcoholordrugs
8.0% 582,631
Livedwithanyonewhohadaproblemwithalcoholordrugs 10% 728,289Witnessedaparent,guardian,orotheradultinthehouseholdbehavingviolentlytowardanother(e.g.,
7.9% 575,348
59Sacks,V.,Murphey,D.,&Moore,K.(2014).Adversechildhoodexperiences:Nationalandstate-levelprevalence.ChildTrends:ResearchBrief,Publication#2014-28.Retrievedfrom:https://www.childtrends.org/wp-content/uploads/2014/07/Brief-adverse-childhood-experiences_FINAL.pdf60AdditionaldatanotfoundinSacksetal.(2014)wasretrievedfromtheDataResourceCenterforChild&AdolescentHealth:http://www.childhealthdata.org/browse/survey.
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AdverseChildhoodExperiences(ACEs)TexasPrevalence
Proportion(Age0–17)
TexasPrevalenceCount
(Age0–17)slapping,hitting,kicking,punching,orbeatingeachotherup)Waseverthevictimofviolenceorwitnessedanyviolenceinhisorherneighborhood
7.3% 531,651
Experiencedeconomichardship“somewhatoften”or“veryoften”(i.e.,thefamilyfoundithardtocovercostsoffoodandhousing)
29.0% 2,112,037
• Finding2:Forchildrenandyouthage0–17,nearly90,000havebeenexposedto10or
moreepisodesofviolence.AccordingtoTheNationalSurveyofChildren’sExposuretoViolence,approximately90,000Texaschildrenandyouthmayhavebeenregularlyexposedtoanyformofviolence.ThetablebelowsummarizestheestimatedprevalenceofchildandyouthexposuretoviolenceinTexasbasedonnationalprevalenceestimatesbythetypeofviolenceandthegeneralfrequencyofmultipleexposureswithina12-monthperiod.
Table2:ChildrenandYouthAnnualExposuretoViolence61
ViolentExperience National12-MonthPrevalence
(Age0–17)
TexasStateCount(Age0–17)
DirectExposuretoOneorMoreEpisodesofViolence(Low)
60.8% 4,427,995
DirectExposuretoSixorMoreEpisodesofViolence(Moderate)
10.1% 735,572
DirectExposureto10orMoreEpisodesofViolence(High)
1.2% 87,395
Direct,IndirectorWitnessedExposuretoOneorMoreEpisodesofViolence
67.5% 4,915,949
AnyPhysicalAssault 37.3% 2,716,517“AnyPhysicalAssault”includesassaultwithaweapon,assaultwithinjury,assaultwithnoweapon,attemptedassault,attemptedorcompletedkidnapping,assaultbyadult,assaultbyjuvenilesibling,assaultbynon-siblingpeer,assaultbygangorgroup,genitalassault,datingviolence,biasattack,threatenedassault,physicalintimidation,relationalaggression,internetorcellphoneharassmentAnySexualOffence 5.0% 364,144
61Finkelhor,D.,Turner,H.A.,Shattuck,A.,&Hamby,S.L.(2015).Prevalenceofchildhoodexposuretoviolence,crime,andabuse:ResultsfromtheNationalSurveyofChildren’sExposuretoViolence.JAMAPediatrics,169(8).Thesedatahaveappliednationalprevalenceratestothe0–17ageTexaspopulation.
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ViolentExperience National12-MonthPrevalence
(Age0–17)
TexasStateCount(Age0–17)
“AnySexualOffence”includessexualassault,completedrape,attemptedrape,sexualassaultbyknownadult,sexualassaultbyadultstranger,sexualassaultbypeer,flashedbypeer,flashedbyadult,sexualharassment,internetsextalk,statutorysexoffense
AnyMaltreatment 15.2% 1,106,999“AnyMaltreatment”includesphysicalabuse,emotionalabuse,sexualabuse,neglect,custodialinterferenceorfamilyabductionAnyPropertyCrime 27.1% 1,973,662“AnyPropertyCrime”includesrobberybynon-sibling,vandalizedbynon-sibling,theftbynon-siblingWitnessedAnyViolence 24.5% 1,784,307“WitnessedAnyViolence”includesfamilyassault,partnerassault,physicalabuse,assaultincommunity,exposuretoshooting,exposuretowar,exposuretohouseholdtheft,indirectexposuretoschoolthreat,bomb,orattack
• Finding3:AmongyouthwithinthejuvenilejusticesysteminTexas,5,900have
experiencedfourormoreACEs.Youthinvolvedinthejuvenilejusticesystemaremorelikelytohaveexperiencedmultipletypesoftrauma,are13timeslesslikelytoreportzeroACEs,andexperience3timestheprevalenceofACEsasthegeneralpopulation.62Amongjuvenileoffenders,themostprevalentACEsarefamilyviolence,parentalseparation/divorce,andhouseholdmemberincarceration.BasedonastudybyBaglivioandEppsexaminingtheprevalenceofACEsamong64,000juvenileoffenders,25%ofjuvenileoffendersreportedfourormoreACEs.63Amongthe23,963youthonprobationinthestateofTexas,anestimated5,900youthhaveexperiencedanACEofsomekind.TheTexasJuvenileJusticeDepartment(TJJD)doesnotuseaformalscreenforcapturingtraumaexposure.However,itcurrentlyscreensformentalhealthtreatmentneeds.InFY2015,morethan11,500juvenileoffenderswereidentifiedwithamentalhealthneeduponenteringtheTJJDsystem.64
62Baglivio,M.T.,Epps,N.,Swartz,K.,Huq,M.S.,&Hardt,N.S.(2014).TheprevalenceofAdverseChildhoodExperiences(ACE)inthelivesofjuvenileoffenders.JournalofJuvenileJustice,3,1–23.63Baglivio,M.T.,Epps,N.,Swartz,K.,Huq,M.S.,&Hardt,N.S.(2014).TheprevalenceofAdverseChildhoodExperiences(ACE)inthelivesofjuvenileoffenders.JournalofJuvenileJustice,3,1–23.64TJJD.(2016).FY2015.Department-identifiedmentalhealthneedsandservicesprovidedtoyouthonprobation.DatasetprovidedtoMMHPIbyPernillaJohanssonofTJJDonMarch9,2016.
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Table3:CharacteristicsofYouthAdmittedtotheTexasDepartmentofJuvenileJusticeinFY201565
OtherYouthCharacteristics(NewAdmissions)
HighMHNeed
ModerateMHNeed
LowMHNeed
NoMHNeed
ParentsUnmarried,Divorced,Separated,oratLeastOneDeceased 16(93%) 117(86%) 223(89%) 351(87%)
OnProbationatCommitment 13(76%) 94(69%) 203(81%) 283(70%)
PrioroutofHomePlacement 11(65%) 94(69%) 195(78%) 238(59%)
FamilyHistoryofCriminalInvolvement 10(59%) 82(60%) 125(50%) 218(54%)
SuspectedHistoryofAbuseorNeglect 14(82%) 80(59%) 95(38%) 117(29%)
SpecialEducationEligible 14(82%) 45(33%) 105(42%) 81(20%)
• Finding4:AmongallchildrenandyouthlivinginfostercareinthestateofTexas,
approximately24,300haveexperiencedoneormoreACEs.RelativelylittleresearchhasexaminedtheprevalenceratesofACEsamongyouthinsubstitutecare.Childwelfareresearchestimatesthat6%ofallU.S.childrenandyouthwillexperienceentryintoafostercaresystembeforeage18.66AfricanAmericansandNativeAmericansaremuchmorelikelytoenterafostercaresystem(12%and15%respectively).67Basedonthe2011–2012NationalSurveyofChildren’sHealth(NSCH),76%ofallyouthinfostercare(orpreviouslyinfostercare)experiencedoneormoreACEs,comparedto33%amongchildrenwithoutexposuretothefostercaresystem.68In2016,therewere31,943totalfostercareplacementsstatewide.Basedoncurrentresearch,asmanyas24,300childrenandyouthinfostercareinTexasmayhaveexperiencedanACE.The2011–2012NSCHisbasedonarepresentativesampleofparentsintheUnitedStates.ThereislikelytobesomeunknowndegreeofmisclassificationofACEstatusassomeguardiansandparentsoffostercaredependentsmaynotknowthecompletehistoryoftheirchildoryouth.Forthisreason,somechildwelfareexpertssuspectACEprevalenceamongchildrenwithexposuretothefostercaresystemtobegreaterthanreported.
• Finding5:AmongchildrenandyouthenrolledinserviceswiththeLMHA,7,700(or
19%)childrenandyouthwhowereassessedfortraumahaveexperiencedatraumatic
65TJJD.(2016).ResidentialmentalhealthservicesprovidedtoyouthonprobationinFY2015.DatasetprovidedtoMMHPIbyPernillaJohanssonofTJJDonMarch9,2016.66Turney,K.,&Wildeman,C.(2016).Adversechildhoodexperiencesamongchildrenplacedinandadoptedfromfostercare:Evidencefromanationallyrepresentativesurvey.ChildAbuse&Neglect,64:117–129.67Wildeman,C.,&Emanuel,N.(2014).Cumulativerisksoffostercareplacementbyage18forU.S.children,2000–2011.PublicLibraryofScience,9(3),1–7.68Turney,K.,&Wildeman,C.(2016).Adversechildhoodexperiencesamongchildrenplacedinandadoptedfromfostercare:Evidencefromanationallyrepresentativesurvey.ChildAbuse&Neglect,64:117–129.
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lifeevent;nearlyhalfoftheseindividualsshowedevidencethatthetraumaticexperiencewasimpactingoneormorelifedomains.TheLMHAcompletedthetraumaitemontheCANSassessmentformorethan41,000childrenandyouthinFY2016.Approximately7,700or19%childrenandyouthassessedhadexperiencedatraumaticlifeevent,ofwhom,nearlyhalfshowedevidencethatthetraumaticexperiencewasimpactingoneormorelifedomains.AmongchildrenandyouthwhowereassessedfortraumathroughtheCANSassessment,1%(566childrenandyouth)reportedfeaturesconsistentwithoneormorePTSDsystemsinthepast30days.
Table4:ChildandYouthTraumaExposureAssessedThroughCANSFY201669
CANSAssessmentFindings NumberofYouth
PercentofTotal
CANSAssessment-Total 49,275 100%
TraumaHistorynotrecordedbytheLMHA 8,040 16%
TotalCompletedCANSTraumaSection 41,221 100%
NoHistoryofTraumainpast30days 29,674 80%
HistoryofTraumaticLifeEvent 7,698 19%
Traumaimpacts³1lifedomain 3,297 8%
Experiencing³1PTSDsymptomsinpast30days 566 1%
Trauma-Informed Care Legislation in Texas
Texaslawmakershavebeguntolayafoundationtoaddresstraumastatewide.Betweenthe82ndand84thlegislativesessions,sevenbillscontainingmandatesrelatedtoTICwerepassed(seeTable5,below).Therewerenobillspassedduringthe85thlegislativesessionthatrequiredstatewidesystematicchangestoaddresstrauma,specifictochildrenandyouth.Sixofsevenpastmandatesfocusedontrainingthechildwelfare,juvenilejustice,statehospital,andstatesupportivelivingcenterworkforceaswellasfostercarefamiliesandcaregivers.Theintensityandfrequencyoftrainingvariesbylegislativemandate.Atminimum,thoseagenciesarerequiredtoprovidenewemployees,fostercarefamilies,andcaregiverswithweb-basedorface-to-faceintroductorytrainingonTIC.Themandatesaroundjuvenilejusticetrainingrequirementsarethemoststringent.Theyrequireface-to-facetrainingthatincludesbestpracticesinbehaviormanagementandseclusionandrestraints.
69Lynch,C.(June16,2017).Email.TexasCANSAggregateData.HealthandHumanServicesCommission-OfficeofGeneralCounsel
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Duringthe84thlegislativesession,lawmakerstookstepstoensurethatchildrenandyouthenteringthechildwelfaresystemarescreenedfortrauma.SenateBill(SB)125requiredtheDepartmentofFamilyandProtectiveServices(DFPS)toimplementastatewide,developmentallyappropriatecomprehensiveassessmentthatincludesascreeningfortraumaandmentalhealthneedswithin45daysofachildoryouthenteringthesystem.DFPSbeganimplementingtheChildandAdolescentNeedsandStrengths(CANS)AssessmentstatewideinSeptember2016.InpreparationforCANSimplementation,thestatewasrequiredtotrainstaffontraumaandhowtousethistooltomaketrauma-informeddecisionsforchildren,youth,andfamilies.Thefollowingtableoffersanoverviewoflegislationrelatedtotraumaandtrauma-informedcareinTexas,datingbacktothe82ndLegislativeSession.Legislationcoverstrainingrequirementsandassessmentsusedforchildrenandyouth.Table5:Trauma-InformedCareLegislationinTexas
LegislativeSession
BillNumber
Description
82nd SB219 MandatestheDFPStoincludetrainingintrauma-informedprogramsandservicesinanytrainingthedepartmentprovidestofosterparents,adoptiveparents,kinshipcaregivers,departmentcaseworkers,anddepartmentsupervisors.AlsorequiresallDFPScaseworkerstocompleteaninitial,in-persontrainingontrauma-informedcareduringtheirbasicskillsdevelopmenttrainingandcompleteanonlinerefreshercourseannually.70
83rd SB1356 Relatedtohumantraffickingandcareofjuvenileswhohaveexperiencedtrauma.Requirestrauma-informedtrainingforprobationofficers,juvenilesupervisionofficers,correctionalofficers,andcourt-supervisedcommunity-basedpersonnel.Thetrainingmustincludebestpracticesinbehaviormanagementaswellasappropriaterestrainttechniques,whichshouldonlybeusedinemergenciesasalastresort.71
83rd SB7 TheDepartmentofAgingandDisabilityServices(DADS)mustensurethatprofessionalsworkingonabehavioralinterventionteamthatissupportinganindividualwithadevelopmentaldisabilityandabehavioralhealthneedwhoisatriskforinstitutionalizationhavetrainingonTICpractices.72
70CodifiedatTexasFamilyCode§264.015.Retrievedfromhttp://www.statutes.legis.state.tx.us/Docs/FA/htm/FA.264.htm71CodifiedatHumanResourcesCodeSection221.002.Retrievedfromhttp://www.statutes.legis.state.tx.us/Docs/HR/htm/HR.221.htm72PortaltoTexasHistory.83rdTexasLegislature,RegularSession,SenateBill7,Chapter1310.Retrievedfromhttps://texashistory.unt.edu/ark:/67531/metapth438730/m1/71/
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LegislativeSession
BillNumber
Description
83rd SB152 Relatedtotheprotectionandcareofpersonswhoareelderlyordisabledorwhoarechildren.Ensuresthatdirectstaffatstatehospitalshavetrainingintrauma-informedcare.73
84th HB2789 Requiresweb-basedTICtrainingfornewemployeeshiredatstatesupportedlivingcenters(SSLCs)andintermediatecarefacilities(ICFs)forpeoplewithintellectualdisabilities.RequiresDADStodeveloporadoptTICtrainingforemployeeswhoworkwithindividualswithIDDinSSLCsandICFs.
84th SB125 RequiresthatchildrenwhoareenteringintoDFPSconservatorshipreceivea“developmentallyappropriatecomprehensiveassessment”thatincludesascreeningfortraumaandmentalhealthneedswithin45daysofthechild’sentranceintoDFPScare.Thetoolmustincludeatraumaassessmentandaninterviewwithatleastoneindividualwhohasknowledgeaboutthechild’songoingmentalhealthneeds.Alsorequireschildwelfaresystemstakeholdertrainingontraumaandontheassessmenttool,includinghowtoemploythetoolandtomaketrauma-informeddecisionsonbehalfofchildrenandfamilies.
84th HB781 RequiresDFPStodetermineandevaluatethehomescreening,assessment,andpre-servicetrainingrequirementsusedbysubstitutecareprovidersbeforetheverificationandapprovalofcaregivers.RequiresDFPStoadoptcertainpoliciestoensurecertaincaregiversreceiveatleast35hoursofpre-servicetrainingbeforebeingverifiedasafostercareoradoptivehome.
FederallegislationonTIChasbeenproposedincurrentandpreviouslegislativesessionsbutnolegislationhasbeenenactedto-date.Trauma-Informed Training in Texas
ThefirststepindeliveringTICistoensurethateveryindividualwhoencountersachildoryouthcanrecognizeandunderstandtrauma.Mostchild-servingagenciesinthestateoffersomeworkforcetrainingontraumaandTIC.Areviewoftrainingopportunitiesthroughoutthestateindicatesthatthereisavarietyoftrainingavailableinvariousformats(seeAppendixTwo).TICtrainingisofferedthroughcommunity-widefaith-basedinitiatives,onlinetraining,smallgroups,andlargeconferencesandtrainings(TICofCentralTexas,ReachingTeens©-ElPaso,TBRI®SummerSeminar,FosteringConnections-Teleconference,BouncingForward).Theyvaryinlength,quality,targetaudience,andcost.Alldiscusstheimpactoftraumaonthebrain,the
73PortaltoTexasHistory.83rdTexasLegislative,RegularSession,SenateBill152,Chapter395.Retrievedfromhttps://texashistory.unt.edu/ark:/67531/metapth438186/m1/3/?q=children
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needtounderstandhowtraumaimpactsbehaviors,andtheuseofaccepteddefinitionsandresearch.Legislativemandatesrequireallchildwelfarepersonnel,juvenilejusticestaff,caregivers,andfosterfamiliestoreceivetrainingonTIC.Inaddition,mostmentalhealthprofessionalsareintroducedtotheACEstudy74andTIC.Schoolpersonnelsuchasteachersandothercommunityproviders,dependingonthecommunityanddistrict,havemuchlessexposureoraccesstoTICtraining.Despitetheavailabilityoftrainingandcurrenttrainingrequirements,respondentstotheTexasCASA201575surveyonTICselected“increasingmandatedtrainingrequirementsforfosterparentsandCPSworkers”astheirtoprecommendationsforpolicymakers.ThetableinAppendixTwooffersanoverviewofTICtraininginTexas.Asnotedabove,sometrainingshaveresultedfromlegislationreferencedinthepriorsection.Thislistisnotexhaustive.Trauma-Informed Approaches in Texas
ThreeapproachespermeatetheTIClandscapeinTexas.Twoofthem,NeurosequentialModelTherapeutics/NeurosequentialModelofEducationandTrust-BasedRelationalIntervention(TBRI®),originatedinTexas.Thethird,ReachingTeensã,originatedinPennsylvaniabutwasadoptedbyMentalHealthConnectionsinFortWorth,TexasandhasbecomethefoundationfortheirTICefforts.Allthreemodelsshareacommonunderstandingofhowtraumaimpactsthebrainandafocusonsafety,attachment,control,andself-regulation.Anoverviewofeachapproach,trainingrequirements,andhowtheapproachisbeingimplementedinTexasisprovidedbelow.ChildTraumaAcademy–NeurosequentialModelofTherapeutics(NMT)andNeurosequentialModelofEducation(NME)ChildTraumaAcademy(CTA)isanot-for-profitorganizationinHouston,Texas.Dr.BrucePerryisitsfounderandSeniorFellow.JanaRosenfeltistheExecutiveDirector.CTAwasfoundedin1990asa“centerforexcellence”attheUniversityofChicagoandlaterBaylorCollegeofMedicine.In2001,itbecameanot-for-profitthatfunctionsasa“communitypractice”thatpromotessocialchange.CTA’sworkfocusesonthedevelopmentofnon-medicalmodelsofcareandcross-agencycollaborationwithintherapeutic,childprotection,andeducationsystems.CTA’sstatedmissionis“tohelpimprovethelivesoftraumatizedandmaltreatedchildren…by
74Felitti,V.J.,Anda,R.F.,Nordenberg,D.,Williamson,D.F.,Spitz,A.M.,Edwards,V.,&Koss,M.P.(1998)Relationshipofchildhoodabuseandhouseholddysfunctiontomanyoftheleadingcausesofdeathinadults:AdverseChildhoodExperiences(ACE)Study.AmericanjournalofPreventiveMedicine,14(4),245–258.75TexasCASA(2015).Understandingtrauma-informedcareintheTexaschildwelfaresystem:Dataandrecommendationsfromthefield.Retrievedfromhttps://texascasa.org/understanding-trauma-informed-care-in-texas/
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improvingthesystemsthateducate,nurture,protectandenrichthesechildren.[Theyfocustheir]effortsonservicedelivery,programconsultation,researchandinnovationsinclinicalassessment/treatment.”76NMTintegratesthecoreprinciplesofneurodevelopmentandtraumatology.Itisgroundedintheawarenessthatthebraindevelopssequentiallyandcanbenegativelyimpactedbyneglect,chaos,attachmentdisruption,andtraumaticstress.NMTisnotatherapeuticapproach.Itisamultidimensionalassessment“lens”thatguidesclinicalproblem-solvingandoutcomemonitoringbyprovidingapictureofachild’scurrentstrengthsandvulnerabilitiesinthecontextofhisorherdevelopmentalhistory.Itisawaytoorganizeachild’shistoryandcurrentfunctioning.Themodelhasbeenwidelyusedwithchildrenandyouthpresentingthemostcomplexcasesofmaltreatmentandpsychologicaltrauma.TheNMTprocessgathersinformationonachild’spastandcurrentexperiencesandfunctioningincludingtraumaandrelationshiphistory.Thisinformationcreatesanestimateoftheseverityandtimingofriskandresiliencyfactorsthatmayhaveinfluencedachild’sbraindevelopment.Thisestimateispairedwithareviewofachild’scurrentfunctioning.Theinformationisthenorganizedintoafunctionalmapofthebrainthatidentifieswhichpartsofthebrainappeartohavefunctionalordevelopmentalproblems.Thefunctionalbrainmapisusedtoguidetheselectionandsequencingofinterventionsthataredevelopmentallysensitive.NMTislistedasevidence-based.NeurosequentialModelforEducation(NME),77aspin-offofNMT,isdesignedtohelpeducatorscreateoptimallearningbyactingontheprinciplesofdevelopmentandbrainfunctioning.NMEisamultifacetedapproachthatprovidesa“picture”ofthechild’sbraininrelationtosame-gradepeers.Themini-maplooksatreading/verbalskills,mathskills,reactivity/impulsivity,communication/languageskills,relationalskills,self-regulation,threatresponse,coordination,finemotorskills,andattention/distractibility.NMEoffersteachersclassroommanagementtoolsincludingtakingbrain/regulationbreaks,havingstudentsmonitortheirheartrateduringafightorflightstate,anddailyjournaling.Teachersarealsotaughttomanagechallengingbehaviorsbyfirstprovidingregulatingopportunities,relatingtothestudent,and,finally,reasoningwiththestudent.
76ChildTraumaAcademy.(n.d.).Retrievedfromhttp://childtrauma.org/about-childtrauma-academy/mission/77Walters,S.(2016).Earlyexperiencesintheneurosequentialmodelineducation.TheCanadianJournalforTeacherResearch:TeachersleadingTransformations.Retrievedfromhttp://www.teacherresearch.ca/blog/article/2016/10/30/314-early-experiences-in-the-neurosequential-model-in-education
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TrainingRequirements
NMTisdesignedtobedeliveredbylicensedsocialservicesprofessionalswhoarecurrentlyworkingwithchildren,youth,orfamilies.Itfeaturesmulti-mediatrainingthatrequiresparticipantstoviewonlinematerials,readassignedarticles,andcompletereportsthatarewrittentofidelity.CTAstaffestimatethatittakesapproximately15months(atotalof90–120hours)tocompleteallrequiredtraining.AllcertifiedNMTpractitionersarerequiredtocompletebi-annualfidelityexercises.TexasImplementationofNMTandNMECTAhasoneflagshiporganization,CalFarley’sBoy’sRanchinTexas.Thisorganizationhas19certifiedsitesinthenation,and3ofthemareinTexas:theCenterforChildProtection,theDallasChildren’sAdvocacyCenter,andtheRegionalCaseyFamilyProgramsHeadquarters.TheCenterforChildProtectionandCaseyFamilyProgramsarealsoNMTTrainers.TherearetwoNMEsitesinTexas:AustinTexasAreaSchoolsandTalithaKoumInstitute.TheCTAdescribesitsfootprintinTexasas“quietly”growingovertime.BecausebothNMTandNMErequireasignificanttimecommitment,andbothstressfidelitytothemodel,CTAiscarefultoworkonlywithorganizationsthathaveastrongorganizationalcommitmenttoimplementation.TheyalsoareintheprocessofdevelopingaNeurosequentialModelforCaregivers(NMC).CTAstaffindicatethatitwillbeayearortwobeforetheformalizedtrainingforthisnewmodeliscomplete.FosteringResilience–ReachingTeens©–Dr.KennethGinsburgReachingTeens©isatextbook/videoprojectpublishedbytheAmericanAcademyofPediatricsfornon-physicianprofessionals.Dr.KennethGinsburgisapediatricianspecializinginadolescentmedicineattheChildren’sHospitalofPhiladelphiaandaprofessorofpediatricsattheUniversityofPennsylvaniaSchoolofMedicine.HeisalsotheDirectorofHealthServicesatCovenantHousePennsylvania.ThethemethattiestogetherDr.Ginsburg’sclinicalpractice,teaching,research,andadvocacyeffortsisthatofbuildingonthestrengthofyouthbyfosteringtheirinternalresilience.FosteringResiliencetranslateswhatisknownfromresearchandpracticesintopracticalapproachesthatparents,professionals,andcommunitiescanusetopreparechildrenandyouthtothrive.78Dr.Ginsburgworkswithcommunitiestodevelopafoundationalframeworktopromoteresilienceinyouth.ThisframeworkdrawsfrompositiveyouthdevelopmentandTICpracticestohelpcareprovidersintegrateanunderstandingofwhatayouthhasbeenthroughwithhighexpectationsfortheyouth.Dr.Ginsburgbelievesthatunderstandingtraumaiscritical.78FosteringResilience:PreparingchildrenandteentoTHRIVEthroughbothgoodandchallengingtimes.Retrievedfromhttp://www.fosteringresilience.com/professionals/about.php
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However,Dr.Ginsburgargues,TICalonecanbetooflexibleanddoesnotholdyouthaccountable.Thepositiveyouthdevelopmentapproachseesyouthastheexpertsintheirlife,considersthemexcellentrolemodelsforotheryouth,encouragesindependence,understandstheimportanceofacaringandtrustedadultinthehealingprocess,andprovidesalternativecopingstrategies.79ReachingTeens©80
ReachingTeensãisacomprehensive,interdisciplinary,evidence-informedandexpert-drivenapproachtoaddressingriskbybuildingonayouth’sstrengths.ItistheoreticallygroundedinpositiveyouthdevelopmentandresilienceapproachesandTIC.Thecurriculumconsistsofatextbook,445videos,livelinkstoresources,anddownloadsforyouth,parents,andprofessionals.Itprovidesstrategiesforparaprofessionalsandprofessionalstoengageyouthintrustingrelationships,promotepositivebehaviors,engageandinformparents,andaddressspecificemotionalandbehavioralconcerns.ReachingTeensãispublishedbytheAmericanAcademyofPediatrics.TrainingRequirements
Therearenospecifictrainingrequirementsforthiscurriculum.The69chapters,videos,andadditionalresourcescanbenavigatedbyindividualsorwithagroup.Chaptersandadditionalcontentcanbeselectedandprioritizedbasedonrelevanceandpopulation.TheReachingTeens©websiteprovidestipsforindividuallearnersandgroupsoflearners.TheAmericanAcademyofPediatricsandtheNationalAssociationofSocialWorkersoffer65hoursofcontinuingprofessionaleducationcreditsforprofessionals.TexasImplementation
ItisdifficulttodeterminethescopeorimpactofReachingTeensãinTexasbecauseallorpartofthecurriculumcanbeusedbyindividualsoragencieswithouttrainingorcertificationbyDr.GinsburgortheNationalAcademyofPediatrics.However,twocommunity-wideimplementationeffortswereidentified:ElPaso,whichisintheinitialstagesofcommunityengagementandimplementation,andFortWorth,whichhasledthecountryinpilotingReachingTeensãatacommunitylevel.In2014,withthesupportoftheRees-JonesFoundation,MentalHealthConnections(MHC)andDr.KenGinsburglaunchedathree-yearpilotprojectofReachingTeensãintheFortWorthcommunity.Thegoaloftheprojectwasthat“[a]llpeoplewhoworkwithteens–fromparentstomentalhealthproviderstopediatricianstolawenforcement–couldspeakthesamelanguage
79Excerptsfrom“OurKidsarenotBroken:RecognizingandBuildingontheStrengthofMarginalizedandTraumatizedYouth”apresentationgivenbyDr.GinsburginElPaso,TexasonMay7,2017.80FosteringResilience.http://www.fosteringresilience.com/professionals/
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andprovideconsistenttrauma-informedandstrength-basedapproachestoteensacrossmultiplesystems.”81ThirteenMHCpartnersagreedtoparticipateinthepilot,whichtrained250communitymembersduringitskick-offworkshop.TheprojectconcludedinJuneof2017.KarynPurvisInstituteofChildDevelopment–Trust-BasedRelationalIntervention(TBRI®)–Dr.KarynPurvisandDr.DavidCrossTheKarynPurvisInstituteofChildDevelopmentishousedinthecollegeofScienceandEngineeringatTexasChristianUniversity(TCU).DavidCross,Ph.D.istheRees-JonesFoundationDirector.TBRI®isdescribedasacaregivingmodel,notaclinicalmodel.Itcanbeusedinallenvironmentswithchildrenandyouthfrom“hardplaces.”82Itisatrauma-informed,whole-child,ecologicallyvalidmodel.TBRI®isrootedintheworkofBesselvanderKolk,M.D.andalignswiththethreefactorsheidentifiedasbeingnecessaryinanyprogramdesignedtotreatcomplextrauma-development:safety,promotionofhealingrelationships,andteachingofself-managementandcopingskills.TheoverarchinggoalsofTBRI®aretohelpcaregivers“see”(compassionateunderstanding)theneedsofchildrenwhohaveexperiencedrelationaltraumaand“do”(knowledgeandskills)whatisnecessarytomeettheseneeds.83Trust-BasedRelationalIntervention(TBRI®)84,85
TheTBRI®modelcomprisesaclearsetofdevelopmentalprinciplesthataredesignedtobringhealingtoat-riskchildrenandyouth.TBRI®encompassesthreeinteractingandsynergisticsetsofprinciplesandpractices:empowering,connecting,andcorrecting.Eachprinciplehastwosetsofstrategies.
• EmpoweringPrinciples:Caregiverscanenhanceachild’scapacityforself-regulation,decreasethelikelihoodofdisruptivebehaviors,andincreasethelikelihoodofsuccessfullyconnectingandcorrectingiftheyattendtoexternal(ecological)andinternal(physiological)strategies.Thisprinciplesetsthestageforpositivechangebycreatinghealthyconditionsandanenvironmentthatfosters”feltsafety.”Ecologicalstrategiesincluderecognizingandmanagingtransitionsandestablishingrituals.Physiologicalstrategiesincluderegularphysicalexerciseandsensoryexperiencesandmeetingnutritionalneeds.
81MentalHealthConnectionsofTarrantCounty.ResiliencyCommittee.(n.d.).Retrievedfromhttp://www.mentalhealthconnection.org/committees/resiliency-committee82Purvis,K.B.,Cross,D.R.,Dansereau,D.F.,&Parris,S.R.(2013).Trust-basedrelationalintervention(TBRI®):Asystematicapproachtocomplexdevelopmentaltrauma.Child&YouthServices,34:360–386.83Purvis,K.,Call,C.,&Cross,D.(2014).TBRI®andtheTCCC.84Purvis,K.B.,Cross,D.R.,Dansereau,D.F.,&Parris,S.R.(2013).Trust-basedrelationalintervention(TBRI®):Asystematicapproachtocomplexdevelopmentaltrauma.Child&YouthServices,34:360–386.85Purvis,K.,Call,C.,&Cross,D.(2014).TBRI®andtheTCCC.
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• ConnectingPrinciples:TheTBRI®connectingprinciplesarebasedonattachmenttheoryandaretheessentialmechanismsforbuildingtrustingrelationshipsandensuringthattheempoweringandcorrectingprincipleswork.Theyareconsideredthesourceof“feltsafety”andself-regulation.Therearetwoconnectingprinciples:mindfulawarenessandengagementstrategies.MindfulnessisaTBRI®’scorecapacity.Ithelpsacaregiverseeboththechild’sandtheirownneeds.MindfulnessAwarenessPractice(MAP)strategiesincludeyoga,taichi,enteringprayer,mindfulwalking,andmindfulnessmeditations.Empowermentassumesthatmostcommunicationisnon-verbal.
• CorrectingPrinciples:TheTBRI®correctingprinciplesareusedtoshapebehaviors.Inordertobeeffective,theseprinciplesmusthaveafirmfoundationofconnectingandempowering.Thecorrectingprinciplesareproactivestrategiesandresponsivestrategies.Proactivecorrectingprinciplesinclude“LifeValueTerms”and“BehavioralScripts.”
TBRI®iscurrentlylistedontheCaliforniaEvidence-BasedClearinghouse(CEBC)forChildWelfare.Itisratedasbeing“highly”relevantbecauseitisdesignedtobeusedwithchildren,youth,youngadults,and/orfamiliesreceivingchildwelfareservices.TheCEBCgaveitascientificratingofthreeandconsidersittohavepromisingresearchevidence.TrainingRequirements
TBRI®isdesignedtoprepareprofessionals(e.g.,therapists,caseworkers,fosterandadoptioncarespecialists,occupationaltherapists,medicalprofessionals,counselors,CASAworkers,andearlychildhooddevelopmentspecialists)toworkwithchildrenandyouthwhohaveexperiencedtraumaandtheirfamilies.Phase1ofthetrainingconsistsoffiveunitsofonlinecourseworktobecompletedinthe10weekspriortotheon-sitetraining.Thisinitialworkestablishesaknowledgebasefortheon-sitetraining.Phase2ofthetrainingrequiressuccessfulcompletionofPhase1andconsistsoffivedaysofintensiveon-sitetraining.TexasImplementationAlmost700professionals,paraprofessionals,caregivers,andfaith-basedleadersareidentifiedasTBRI®campalumni.Morethan75havecompletedthetrainingrequirementstobecomeeducators.Child-placingagencies,emergencyshelters,generalresidentialoperations,andtreatmentfacilitiesthroughoutthestatehavechosentoimplementTBRI®.Inadditiontoagency-wideimplementation,therearetwocommunity-basedsystemeffortstoimplementTBRI®,oneinTravisCountyandoneinFortWorth.MentalHealthConnections(MHC)isexaminingthefeasibilityofaTBRI®collaborationwithTarrantCountyandTexasChristianUniversity(TCU)andtheKarenPurvisInstituteofChildDevelopment(KP-ICD).TheTravisCountyCollaborativeforChildren(TCCC)waslaunchedin2014toimproveoutcomesforfosterchildrenthroughthepowerofcollectiveimpact.
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Summary of Key Informant Interviews
MMHPIconducted75keyinformantinterviewsfromFebruary2017toJune2017togainabetterunderstandingoforganizationalandsystemeffortstoimplementTICinTexas.KeyinformantswereaskedtodefineTIC,todiscusshowtheywereoperationalizingtheirdefinition,toidentifythekeycomponentsrequiredtobeatrauma-informedagency,todiscussthebarrierstheyhadexperiencedwhenimplementingTIC,andtodescribetheirsuccesses.Weengagedawidearrayoforganizationsandsystemsthatworkwithchildreninfostercare,includingstateagencies,childwelfareagencies,fostercareagencies,CourtAppointedSpecialAdvocates(CASAs),judges,researchersandtrainersfromTICmodelsandapproaches,andothercommunityagencies.TheorganizationaldiversityoftheseinterviewswasintendedtoincorporatetheexperiencesandperspectiveofmultiplechildwelfareentitiesintoacommonunderstandingofTICinTexasandtoalignprioritiesforimplementingTICinTexaswhenappropriate.Belowisasummaryoftheirresponses.AlistofallkeyinformantscanbefoundinAppendixThree.HowTexasDefinesTrauma-InformedCare(TIC)WeaskedkeyinformantshowtheydefineandimplementTIC.Allrespondentseasilydefinedthisconceptanddemonstratedasolidunderstandingoftheprevalenceandimpactoftraumaonthechildrenandyouththeyserved.Theirresponsesalignedwiththecorecomponentsoftheprimarydefinitionsprovidedaboveandincludedreferencestovariousnationalandregionaldefinitionsandmodels,includingthosebytheSubstanceAbuseMentalHealthServicesAdministration(SAMHSA),theNationalChildTraumaticStressNetwork(NCTSN),theCenterforHealthCareStrategies(CHCS),theThreePillarsforTraumaWiseCare,86DanSiegel’sWholeBrainChild,87theNationalCoalitionforTrauma-InformedCare,theTrauma-InformedCareConsortium(TICC)ofCentralTexas,andtheTravisCountyCollaborativeforChildren(TCCC).Thefollowingcorecomponentswereidentifiedconsistentlyacrossthemajorityofkeyinformants.
• TICstartswiththeawarenessthattraumaexistsandanunderstandingoftheimpacttraumahasonchildren,youth,andtheirfamilies.
Trauma-informedcare“startswithadeepunderstandingofACEsandtheimpactoftrauma,includinghowtraumaimpactsachild'sabilitytocope.”DallasChildAdvocacyCenterkeyinformant
86Bath,H.(2015).Threepillarsoftraumawisecare:Healingintheother23Hours.ReclaimingChildrenandYouth.23(4).Retrievedfromhttp://traumebevisst.no/kompetanseutvikling/filer/23_4_Bath3pillars.pdf87Dr.DanSiegel.Inspiretorewire.Retrievedfromhttp://www.drdansiegel.com/about/biography/
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Allindividualsinterviewedwereknowledgeableoftheeffecttraumahasonthedevelopingbrainandhowtraumacanresultincopingbehaviorsthatcanbemisunderstoodasdefianceoraresultofattentionproblems.TheworkofDr.DanSiegel,founderandco-directoroftheMindfulAwarenessResearchInstituteatUCLA,wasmentionedseveraltimestounderscoretheimportanceofthisawareness.Keyinformantsstressedhowimportantitwasforeveryoneinachild’ssphere—includingparents,fosterfamilies,caseworkers,advocates,attorneys,mentalhealthandfostercareproviders,andprobationofficers—tounderstandtraumaandtheimpactsoftrauma.Inaddition,severaldiscussedtheintergenerationalimpactoftraumaandtheimportanceofworkingwiththewholefamilytoeliminatethenegativeimpactsoftraumaandsetthestageforhealing.Oncethereisanunderstandingoftraumaanditsimpact,assessingfortraumaandrecognizingrelatedbehaviorsandsymptomsisneededtoimplementTIC.Thiscanbedonethroughformalassessmentsorconversationswiththechildandfamily.AfewkeyinformantssuggestedthatuniversalscreeningsandassessmentsarenecessarytoimplementTIC.
• TICmustbeacoreorganizationalvalueandanintegralpartoftheculture.
“You[organization/agency]cannotgothroughonetrainingandthinkyouaretrauma-informed.Itisashiftinculture.”TheVillageNetwork-Ohiokeyinformant
ThemajorityofrespondentsstressedthatTIChastobepartofthefoundationanorganizationisbuilton.Itneedstobeatthecoreofeverythinganorganizationoragencydoes.Thisrequiresashiftinorganizationalcultureandoperations.TICshouldbewoventhroughitspolicies,procedures,training,andservicedelivery.Everydecisionanorganizationmakesshouldbeintentionalandtrauma-informed.Allstaffintheorganization,fromthefrontdesktoleadership,shouldrecognizethewidespreadimpactoftrauma.IntegratingTICintoalllevelsofanorganizationimprovestheorganization’sabilitytoeffectivelyrespondtotheimpactsoftraumaonitsworkforceandonthechildren,youth,andfamiliesitserves.
• Organizationsmustprovideservicesandsupportsinawaythatistransparent,instillstrust,andensuresthatchildren,youth,theirfamilies,andthestaffthatservethemfeelsafe.
Trauma-informedcare“startsatthefrontdoorandcontinuesthroughmultiplelevels.”AustinTravisCountyIntegralCarekeyinformant
Themajorityofkeyinformantsmentionedsafety,transparency,andtrustwhendefiningTIC.ManyindicatedthattheyachievetheseaspectsofTICbyprovidingservicesinasafeand
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confidentialenvironment,usingclearlanguagetocommunicateexpectationsandnextsteps,andtreatingpeoplewithdignityandrespect.Respondentsunderscoredtheimportanceofensuringthatstaffandclientsfeltphysicallyandemotionallysafewhenenteringthebuilding,seekingservices,orbeingprovidedsupport.Therewasageneralconsensusthatinordertoachievethis,allstaffmemberswhointeractwithachildoryouth,includingfront-linestaff,neededtobetrainedinTIC.Severalkeyinformantsdescribethisasviewingallchildren,youth,andtheirfamiliesthrougha“trauma-informedlens.”
• Relationshipsareintegraltotrauma-informedcare.
“Themembersofthecourtconsidertrustandattachmentascriticaltohavingpositiverelationshipswithchildrenandtheirfamilies.”The321stCourtofSmithCountykeyinformant
Developingandmaintainingrelationshipswasidentifiedbymanyofthekeyinformantsasthefoundationfortreatingtrauma.Severalrespondentsdescribedrelationshipsashealingandreparative.Othersnotedthatastrongconnectionorattachmenttoanadultcaregiverwasnecessarytodevelopingfeelingsofsafetyandtrust.Stillothersstressedthatinordertoconnectwithachildoryouth,theyfirsthadtounderstandthattheirbehaviorswerenotpersonallydirectedtocaregiversandstaff;rather,theseinformantsnotedtheneedtobemindfuloftheirownabilitytoconnect.
• Providingtrauma-informedcaremeansprovidingindividualizedcare.KeyinformantssaidthatTICrequiresmeetingchildrenandyouth“wheretheyare.”Eachchildisunique,includingthetraumatheyhaveexperienced,theimpactithashadonthem,andtheneedsthatresultfromit.Atrauma-informedtreatmentplantakesintoconsiderationachild’shistoryoftrauma,isholistic,andaccountsfortheemotional,educational,physical,andbehavioralneedsofthechild.Selectedinterventionsneedtotakeintoconsiderationachild’sbraindevelopmentandshouldaddressthetraumathechildhasexperienced.Thisapproachrequiresindividualizedcareandtreatmentoptions.Nosingleinterventionwillmeettheneedsofeverychild.
• Servicesandsupportsshouldnotre-traumatizeachildoryouth.
Whenprovidingservices,providers“wanttopreventtraumaandpreventre-traumatization.”TexasChildrenRecoveringfromTraumakeyInformant
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Finally,afewkeyinformantsdiscussedtheimportanceofavoidingre-traumatizationwhenprovidingservicesandsupportstochildren,youth,andtheirfamilies.Severalrelayedconcernsthatthechild-servingsystemsinTexasoftenminimizetheimportanceofattachmentandcommunity,therebyre-traumatizingthechildrentheyserve.ASharedCommunityDefinitionKeyinformantsfromTravisCountyusetheTICdefinitionthatwascreatedbytheTravisCountyCollaborativeforChildren(TCCC).Thiscollaborative,cross-disciplinarydefinitionprovidesacommonunderstandingofTICacrossmultipledisciplines,child-servingagencies,andcommunitymembers.TheTCCCdefinitionoftrauma-informedcareiscontainedinAppendixSix.HowTrauma-InformedCareIsOperationalizedWhenkeyinformantswereaskedhowtheyoperationalizedorimplementedTIC,allrespondentsindicatedthattheytrainedstaffinrecognizingandunderstandingtheimpactoftrauma;formallyorinformallyscreenedandassessedfortrauma;providedasafeenvironment;andimplementedtrauma-focused,evidence-basedapproaches.Someofthekeyinformantsdiscussedtheneedtounderstandhowtraumaimpactstheworkforce.However,thesestepswerenotcoordinatedorintegratedintosomeorganizations’missions,strategicplans,policies,andprocedures,norweretheyreflectedinorganizationalculture.Onlyahandfultalkedabouttakingstepstodrivetrueorganizationalorsystemchange.Themajorityofrespondentsthatdidtakethesestepswereinvolvedinabroadersystem-wideefforttoaddressTICthatprovidedalenstoviewtrauma,acommonlanguage,andasetoftoolstoaddresstraumathatcouldbeusedbyabroadcross-sectionofstaffandcommunitymembers.Trauma-InformedTraining
KeyinformantsemphasizedthatinitialandongoingtrainingwerenecessarytoimplementTIC.Allidentifiedtheneedtotraineveryone,includingsupportstaff,front-linestaff,leadership,andboardmembers.MostrespondentsreportedthattheyprovideTICtrainingaspartoftheirnewemployeeorientation,andsomenotedthattheyprovideannualrefreshertraining.Allkeyinformantsstressedthefactthatagency-widetrauma-informedtrainingeffortsrequireleadershipsupportandacommitmentofresources.ScreeningandAssessmentBeingtrauma-informedrequiresstafftorecognizethesignsandsymptomsoftrauma.Themajorityofthekeyinformantsdiscussedtheneedtoscreenandassessfortrauma.SeveralkeyinformantsrecognizedtraumascreeningtoolssuchastheAdverseChildhoodExperience(ACE)Questionnaire,ChildandAdolescentTraumaScreening(CATS),ChildandAdolescentNeedsandStrengthsAssessment(CANS),ortheChildhoodTrustEventSurveytoassessfortrauma.Other
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respondentsnotedthattheyinformallyscreenedandassessedfortraumabyintegratingquestionsontraumaintotheircurrentassessment.Safety
WhenkeyinformantswereaskedabouthowtheyoperationalizedTIC,theirmostfrequentresponseswererelatedtosafety.Mostrespondentsdescribedcreatingawelcoming,comforting,safe,andpredictableenvironmentforchildrenandfamilies.Thiswasaccomplishedinavarietyofways,includingaddingmoreseatingandatelevisiontowaitingareas,confirminglightsinparkinglotsfunctioned,offeringsnacksandwater,fillingroomswithstuffedanimals,bringinginservicedogs,andensuringchildrenandyouthhadaccesstoaprivate,quietspace.Organizationswithresidentialfacilitieshavecreatedplayrooms,regulationsrooms,chillspaces,andcomfortzonesforchildrenandyouth.SecondaryTraumaticStressandCompassionFatigue
Mostkeyinformantsfeltstronglyabouttheneedtoaddresssecondarytraumaticstressandcompassionfatiguewithintheirworkforce.Describedstrategiesincludeprovidingregularsupervision,implementingbreaks,adjustingcaseloads,beingflexiblewithworkschedules,andencouragingself-care.Severalkeyinformantsdescribedpromotingteam-buildingactivities,usingagroupapproachtohandlechallengingsituations,andofferingstaffwellnessprogramsthatpromotephysicalactivityandprovideaccesstocounselingservices.However,amajorityofrespondentsindicatedthatregulatorystatutes,stateandorganizationalpolicies,andfundingconstraintslimitedtheirabilitytoeffectivelyaddressthelevelsofsecondarytraumaticstressexperiencedbystaff.Trauma-InformedCulture
SuccessfulimplementationofTICrequiresachangeinorganizationalculture.KeyinformantsdescribedTICasachangeinphilosophyandculturethatisfullyembracedbytheorganization’sleadership;isrootedintheorganization’smission,vision,values,policies,andprocedures;isdrivenbyanorganizationchampion;andhasstaffbuy-in.Theyprovidedmultipleexamplesofhowtheirorganizations’culturesandoperationsshiftedtobemoretrauma-informed.TheseshiftsincludedincorporatingTICtrainingintonewemployeeorientation,changingjobtitlesandjobdescriptionstobemoretrauma-informed,updatingagencyforms,creatingTICstudyguidesforsupervisorsanddirectcarestaff,creatingTIC-specificformstoproblem-solveday-to-daysituations,andadjustingstaffcaseloadsizeanddistribution.Informantsfromresidentialfacilitiesalsodiscussedtakingmeasurestoreduceseclusionsandrestraints,doingawaywithlevelsystems,andpromotingrelationshipbuildingasameanstoindividualizecare.SeveralofthekeyinformantsnotedthatorganizationalchangesaroundTICwerenotalwaysuniversallyacceptedandcouldresultinsomeinitialstaffturnover.
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SomekeyinformantsidentifiedTICchampionswithintheirorganizationwhohelpedspearheadTICefforts.TICchampionshelpimplementTICwithinanorganizationoragencybyfosteringinterestandgrowth,boostingmorale,providinginspiration,andsupportingandcoachingstaff.SomeorganizationshaveTICnewslettersore-mailsthatincludetipsandexamples,whileothershavedesignatedspaceintheirbuildingwherestaffcanwritedownTICideasandlessonslearned.OrganizationshavealsocreatedcoreTICinternalteamsthatmeetconsistentlyandprovidemonthlypeerlearningactivitiesandbi-monthlycoachingsessions.TheseadjustmentsensurethatTICcontinuestoexpandwhithinanorganizationoragency.Collaboration
KeyinformantsemphasizedtheimportantceofcommunitycollaborationtoimplementingTIC.Thecourtsdescribedtheneedtoengagecommunitiestosupportfoster,kinship,andbiologicalparents.Severalchild-placingagenciesexpressedtheneedtodevelopasupportivewebofpositiverelationshipsthatreachedbeyondtheserviceprovidersandincludedeveryoneachildorfamilymightencounter.ThebackboneagenciesforTravisCountyandFortWorthdescribedthecommunitycollaborative’sroleinsupportingtheimplementationofasingletrauma-informedintervention.Theydescribedtheprocessofselectingasingleapproachasacatalystforcommunitybuy-in.Thistacticprovidedthecommunitywithacommonlanguagethatwasunderstoodacrossdisciplinesandservicesystems.KeyinformantsincommunitieswhereasingleapproachhadbeenidentifiedoperationalizedTICwithinthecontextofthatapproach.Evidence-BasedTrauma-FocusedApproaches
Basedoninformationprovidedbykeyinformants,thereareareasonablenumberoftrauma-focusedapproachesandinterventionsavailableinTexas.However,accesstotheseapproachesandinterventionsislimitedbylocation,fundingstreams,reimbursement,prioritypopulations,andprovidercapacity.Themostcommontrauma-focusedapproachidentifiedbykeyinformantsisTBRI®,anattachment-based,trauma-informedinterventiondevelopedbyDr.KarynPurvisandDr.DavidCross.TheTravisCountyCollaborative(TCCC)identifiedTBRI®astheframeworkforreachingtheirgoalofacceleratinghealinganddecreasingtimetopermanencyforchildreninfostercare.Asaresult,variouschild-placingagenciesandproviderswhoservechildrenandyouthinfostercareinTravisCountysharedthesuccesstheyexperiencedthroughthisapproach.Trauma-FocusedCognitiveBehavioralTherapy(TF-CBT),anevidence-basedtreatmentforchildrenandadolescentsimpactedbytrauma,isthemostcommonlyprovidedtrauma-focusedinterventionofferedthroughoutvariouspartsofTexas.TF-CBTisofferedbyawidevarietyofproviders,includingLocalMentalHealthAuthorities(LMHAs),ChildAdvocacyCenters,mentalhealthproviders,childwelfareagencies,andfostercareagencies.SomeproviderspartnerTF-CBTwithotherevidence-basedpractices,suchasEyeMovementDesensitizationand
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Reprocessing(EMDR).Othertrauma-focusedinterventionscommonlyprovidedincludeParentChildInteractionTherapy(PCIT),SeekingSafety,andSolutionFocusedTherapy.Manykeyinformantssharedthatwhenchoosingtrauma-focused,evidence-basedinterventions,itisimportanttoindividuallyassesschildrenandfamiliesandseektheirinputtodevelopthebesttreatmentbecausenosingleinterventionmeetseveryone'sneeds.Acompletelistoftrauma-informedframeworksandinterventionsutilizedbykeyinformantscanbefoundinAppendicesFourandFive.WhatAretheBenefitsofTIC?Accordingtokeyinformants,childrenandfamiliesintrauma-informedenvironmentsaregainingunderstandingoftraumaandwhathashappenedtothem.Familiesarelearninghowtopredicttheirowncycleofcrisis,prepareforstressfultimes,andreducereactionstotrauma.Theyarealsobecomingmoreresilientandopentoservices.Theservicesprovidedarebeingmatchedtothechildandtheirneeds.Assuch,childrenandfamiliesarefeelingmoresecureandknowledgeableintheservicestheyarereceiving.Childrenaredevelopinglong-lastingrelationshipsthatwillcontinuetosupportandempowerthem.Themajorityofkeyinformantsidentifiedmeasurablebenefits,suchasadecreasesinphysicalholds,restraintsandseclusions,runaways,medicationuse,psychiatrichospitalizations,andno-shows.Theyalsosawincreasedreunificationsandchancesofpermanency.TherearealsostaffbenefitsfromimplementingTIC.Keyinformantsstatedthatstafffeelincreasedempathyforthechildrenandfamiliestheyserve.AlthoughsomeagencieshaveexperiencedturnoverwhenfirstimplementingTIC,mostkeyinformantsnotedthattheyhavehigherstaffretentionandjobsatisfaction.Stafffeelempoweredandinvestedintheirroles.Theytakeprideintheirworkandfeeltheyaremakingadifference,creatingadeepersenseofvalueandsupport.TICalsoimpactshowstafftreateachother;staffhaveamorerelationalapproachandsupportoneanotherintheworkthattheydo.Finally,keyinformantssaidthatTIChelpsdecreaseinstitutionaltraumaandreducesthechanceofre-traumatizingchildrenandfamilies.BarrierstoImplementationKeyinformantsidentifiedvariousbarrierstoimplementingTICwithintheirorganizationoragencyincludinglimitedresources,staffingneeds,regulatorystandards,andstafftrauma.AdditionalbarriersincludedchallengesdefiningTIC,measuringprogresstowardbecomingtrauma-informed,andovercomingalackoftrauma-informedcommunityproviders.Noneofthebarriersidentifiedwererelatedtodeliveringbillableservicesandsupports.
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Developingandsustainingtrauma-informedcarerequireschangeatmultiplelevelsoftheorganizationandthefundingstructuresthatsupporttheprinciplesunderlyingthisapproach.Traditionalfundingstreamsallowfortheprovisionofevidence-basedtraumascreening,assessment,treatment,andrecoverysupports.Texas’sMedicaidStatePlanfundstraditionaltrauma-focusedoffice-basedtherapies.Thelocalmentalhealthauthority(LMHA)providestraditionaltrauma-focusedtherapies,casemanagement,rehabilitationskillstraining,andfamilysupportservices.TheYouthEmpowermentServices(YES)Waivercoversnon-traditionalservicesandsupportforchildrenatriskofpsychiatrichospitalizationorout-of-homeplacement.Communityprovidershaveaccesstofreetrainingontrauma-focusedtherapies,andgeneralrevenuecoversaportionoftheLMHA’scostfortrainingandsupervision.However,thesefundingstructuresdonotsupportthedevelopmentofappropriateandsafefacilities;peerandsupervisorysupportforprofessionals,staff,andcaregivers;thedevelopmentandimplementationofgeneraltraumatrainingforallstaff;thedevelopmentofcross-agencycollaborations;andtheevaluationoftrauma-informedprogramsandservices.Keyinformantsindicatedthattherearecoststodevelopingandimplementingorganization-widetrainingonTIC.TheydescribedthestafftimerequiredtoattendtrainingsingeneralTICandintrauma-informedevidence-basedpracticesandtoparticipateinthesupervisionrequiredforcertification.Theydiscussedthecostoftrainingprofessionals,staff,caregivers,andcommunitymembersintrauma-informedcommunicationstrategies(ReachingTeensã)andmodelsofcaregiving(TBRIâ).Tworespondentsindicatedthattheyneededafull-timepositiondedicatedtoTIC.ThispositionwouldensurethatTICisconsideredinallorganizationaldecisionsandisinterwoventhroughtheagencies’policiesandpractices.Organizationsthataretrauma-informedprovideasupportiveworkenvironmentthatrecognizes,andguardsagainst,theimpactsofsecondarytraumaticstressandcompassionfatigueontheirstaffmembers.Thisawarenessincludesensuringthatstaffarefairlycompensatedfortheworktheydo,caseloadsizesaremanageable,intensivecasesarebalanced,andstaffareprovidedwithadequatesupportandsupervision.Someoftherespondentsindicatedthatthiscanbedifficultduetolimitedagencyresources,regulatorystandards,andstateservicerequirements.KeyinformantsalsoindicatedthatunresolvedstafftraumaandresistancetochangecanbebarrierstoimplementingTIC.Attachmentandattachmentstylesplayaroleinastaffperson’sabilitytodeveloppositiverelationshipswiththechildrenandfamiliestheyworkwith.Inaddition,staffresistancetochange,adherencetocontradictorymodels,orbeliefthatTICismerelyanadditionaljobdutycanmakeimplementingTICverydifficult.SeveralrespondentsnotedthatTICismostsuccessfulwhenallchild-servingentitiesandstakeholderswhoworkwithchildrenandfamiliesembraceandimplementTIC.Theysharedthatitcanbechallenging
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tooperatewithotherentitiesinthechild-servingsystemthatarenoteducatedonTICordonotbelieveintheTICphilosophy.SuccessfulCommunity-BasedCross-SystemEffortsThereareseveralnoteworthycommunitiesacrossTexasthathavebeensuccessfulindevelopingcross-systemeffortstoimplementTIC.Sixarehighlightedbelow.Thesecommunityeffortsshareahandfulofcharacteristicsthatappeartohaveledtotheirsuccess.Allofthecommunityeffortsareledbyanindividualororganizationinaleadershiproleinthecommunity.Allthecross-systemeffortsaresupportedbygrantorfoundationfunding.Threeofthesixeffortsarerootedinatrauma-focused,evidence-informedapproachthatiseasilyunderstoodandcanbeutilizedbyprofessionals,families,andcommunitymembers.TwoweresupportedbytheNCTSN—oneatastatelevelandonethroughauniversity.Finally,twotookanecologicalorcollectiveimpactapproachtocommunitychange.MentalHealthConnections(MHC)–FortWorth,Texas88
MHCisuniqueinthestateofTexas.Itisacommunityofnot-for-profitorganizationsthatusesacollectiveimpactmodeltoaddresscommunityneed.MHCissustainedbyadues-basedmembership.Itslong-termstrategicapproachtochangeismultifacetedanddesignedtoensuresustainability.BelowisabriefoverviewofselectMHCinitiativestoaddressTIC.
• Evidence-BasedPractices:In2008,MHCprovidedtrainingonTF-CBTto59practitionersfrom13agenciesandthreehospitals.Thispilotwastheresultofalearningcommunityontrauma.AnthonyMarrino,PhD,co-developerofTF-CBT,providedtraining,andMollyLopez,PhD,fromtheUniversityofTexasatAustinconductedanevaluationoftheyear-longproject.ThisprojectprovidedthefoundationforMHC’sgoaltobecomeatrauma-informedcommunity.
• SocialMediaCampaignonTrauma:Asafoundationforitstrauma-informedefforts,MHClaunchedathree-yearsocialmarketingcampaignin2013designedtoeducatethecommunityabouttrauma.Thecampaigneducatedparents,teachers,andprofessionals.
• TraumaSymposiums:MHCconductedcross-agencytrainingsonevidence-basedtraumapracticesandheldthreesymposiumsontrauma.In2013,KennethGinsburg,MD,presentedinformationonbuildingresiliencewithtraumatizedchildren.In2014,StuartAblon,PhD,provided1,000practitionerswithanoverviewofCollaborativeProblemSolving.In2016,VincentFelitti,MD,founderoftheDepartmentofPreventativeMedicineforKaiserPermanenteandco-principalinvestigatoroftheAdverseChildhoodExperienceStudy,providedapresentationonACEStoover1,000communityproviders.
• Resilience:AfterhostingaReachingTeens©trainingwithDr.KenGinsburg,MHCenteredintoathree-yearpilotproject.In2014,theMHCResiliencySubcommitteeand
88MentalHealthConnectionsofTarrantCounty.Retrievedfromhttp://www.mentalhealthconnection.org/committees
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“ReachingTeensCaptains”from10partneringagenciesbeganmeetingtocoordinateimplementation.EmilySpence-Almaguer,PhD,fromtheUniversityofNorthTexasHealthScienceCenter,developedandconductedanevaluationwiththesupportoftheRees-JonesFoundation.AfinalreportwillbepresentedtothecommunityinSeptember2017.TheseeffortshavebeensosuccessfulthatMHCiscurrentlyworkingwithseveralcommunitiesoutsideofTexastoimplementtheReachingTeensãcurriculum.Inaddition,MHCiscompletingthedevelopmentofa“TarrantCountyGuide”toimplementingReachingTeensã,acompaniontoReachingTeensãthatwillbepublishedbytheAmericanAcademyofPediatricians.
• Trust-BasedRelationalInterventions(TBRI®):TheMHCTraumaTransitionCommitteeisfocusedonthreeareas:determiningtheneedforfurthercommunityeducationandtraining,completingtheanalysisofacommunity-wideimplementationoftheACEsscreeningtool,anddetermininginterestinandfeasibilityofdoingacollaborativepilotwithTexasChristianUniversity’sKarynPurvisInstituteforChildDevelopment.
• AdverseChildhoodExperiences:MHChasavisiontomakeFortWorththefirstcityintheUnitedStateswithacomprehensiveapproachtoaddressingAdverseChildhoodExperiences.IthasbeenimplementingACEquestionnairesacrossthecountyandhasinternsanalyzingthisdata.MHChasbroughtinDr.VincentFelitti,oftheCaliforniaInstituteofPreventativeMedicine,andisplanningamulti-stakeholderplanningmeetinginthesummerof2017.
• Resilient/Trauma-InformedCommunityStrategicActionPlan:InJune2017,MHCapprovedastrategicactionplantoadvanceitsgoaltobecomeaResilient/Trauma-InformedCommunity.InadditiontoTBRIâimplementation,theplanwillfocuson(1)creatingacomprehensivetrauma-focusedsocialmarketingandcommunicationsplanformultiplestakeholdergroups;(2)creatingalearningcommunitytoidentifyandreviewassessmentandscreeningtoolsforresilienceandtraumaandmakerecommendationstoappropriatedisciplinesforutilizationinTarrantCounty;(3)creatingalearningcommunitytostudybestpracticesforself-careandmakerecommendationsforutilizationacrossagenciesinTarrantCounty;and(4)creatingacentralizedrepositoryofallresilienceandtraumatrainingoptionsinTarrantCounty.
SmithCounty’s321stDistrictCourtwithJudgeCaroleClark–Tyler,Texas
JudgeCaroleClarkleadsthe321stDistrictCourtinTyler,Texas,whichhandlesfamilylawcases.JudgeClarkandherteambegantheirtrauma-informedjourneyabout10yearsago,afterhearingthelateKarenPurvisfromTCUpresentontraumaandonTBRI.TheCourt’sunderstandingoftraumaisrootedintheprinciplesofTBRI(Connecting,Correcting,andEmpowering),anditisthroughthislensthatthecourtroomisrun.AllofthecourtstaffandattorneysaretrainedintraumaandTBRI.
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JudgeClarkandherteamrecognizetheimpactoftraumaonbraindevelopmentandhowitaffectschildrenandtheirparents.Theyviewthefamilyastheclientandaimtoprovideasafeandpredictableenvironmentinthecourtroom.Theyviewattachmentandtrustascriticaltohavingpositiverelationshipswithchildrenandtheirfamilies.Tomakecompletetreatmentplanandachievingreunificationlessoverwhelmingforfamilies,theCourthasmodifiedittreatmentplanintothreephases.Phase1addressessafety,includingdrugtreatment.Phase2addressesriskfactorsandincludesapsychologicalassessmentandenrollmentinservicesandsupportssuchasEMDR,trauma-informedtherapy,TraumaGroup,CircleofSecurity,parentinggroups,andAA.Phase3ismonitoredreturn,duringwhichthecourtprovidesin-homeservicesandsupportstoparentstohelpthemmanagechildren’sbehaviorswhentheyreturnhome.Theprogramtriestoensurebondingbetweeninfantsandtheirmothersthroughincreasedvisitations.TheCourthasalsoincorporatedatransitionperiodinwhichfosterparentsandbiologicalparentscanmeettodiscusstheroutineofthechild,hisorherlikes,triggers,andthingsthathelpsoothehimorher.AllserviceprovidersandfosterparentsutilizedbythecourtaretrainedinTBRIandprovideservicesandsupportsinmannersthatalignswiththetrauma-informedvaluesofthecourt.ParentsandfosterparentsareencouragedtoreadTheConnectedChildandviewthevideoseriesasaresourcetounderstandtraumaandwaystoaddressit.Acoremanagementteammeetstwiceamonthtodiscussprocesses.ThecourtteamalsoholdsbookclubsduringwhichmembersreviewbooksrelatedtoTIC.Resourcesarededicatedtothedevelopmentoftrauma-informedservicesandsupportsinthecourtroomandinthecommunity.TexasChildrenRecoveringfromTrauma(TCRFT)–DepartmentofStateHealthServices(DSHS)89Throughafour-yearcooperativeagreementfromtheNationalChildTraumaticStressNetwork(NCTSN),DSHS’sTCRFTestablishedthefollowinggoals:
• Transformthepublicchildren’smentalhealthservicesystemintoatrauma-informedsystembytrainingtheworkforce,enhancingtrauma-informedpoliciesandpractices,increasingtheuseoftrauma-informedscreeningtools,providingtrauma-specificpracticesandtreatments,andincreasingaccesstotrauma-informedservices
• CreatepartnershipsthatpromoteaccesstoTIC• Evaluateoutcomesoftrauma-informedtreatment
89Lopez,M.A.,Borah,E.,Oh.,S.,Patmore,J.(2016,December).Texaschildrenrecoveringfromtrauma:finalevaluationreport.TexasInstituteforExcellenceinMentalHealth,SchoolofSocialWork,UniversityofTexasatAustin.
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• Increasechildfunctioning,increasechildandcaregiverstrengths,anddecreaseneedsandriskbehaviorsthroughtheprovisionoftrauma-focusedtreatments
• Increasethenumberofchildrenscreenedbyintegratingtraumascreeningpracticesintocommunity-basedmentalhealthorganizations
TheTCRFTinitiativeofficiallyendedin2016.Theinitiative’sfinalprogramevaluationbytheTexasInstituteforExcellenceinMentalHealthyieldedseveralfindingsandrecommendations.Notablefindingsrelevanttotrauma-informedsystemchangeincludedthefollowing:
• Thecreationofastrongimplementationteamwasacriticalfactorintrauma-informedorganizationalchange.
• Organizationsbegantheirchangeinitiativesbybuildingbuy-infromleadershipandbytrainingtheworkforce.
• OrganizationscouldachievemoderateprogressacrosstwoorthreeofSAMHSA’strauma-informedorganizationaldomains.
Relevantsystem-levelrecommendationsincludedthefollowing:
• Amodestamountoffiscalsupportresultedinsignificantgainsinbuildingatrauma-informedsystem.Thestateshouldconsiderutilizingasmallamountofdiscretionaryfundingtocontinuesupportingtheimplementationoftrauma-informedtreatmentapproachesandtrauma-informedpracticeswithinthesystem.
• Texasshouldconsiderencouragingtheuseofhigh-quality,highfidelity,evidence-basedtreatmentapproachesthroughfinancialincentivessuchastheuseofhigherreimbursementratesforcounselingprovidedbycertifiedTF-CBTorPCITproviders.
• Opportunitiesforcommunitiesorregionsofthestatetoshareresourcesandbuildcompetencyintrauma-informedapproachesshouldbesupportedastheseapproachesarelikelytomaintainbuy-inofkeychampionsacrossthestateandcreateefficienciesintransformationalefforts.
TravisCountyCollaborativeforChildren(TCCC)–Austin,Texas90,91
TCCCwaslaunchedin2013withthesupportofseveralcommunityfoundations.Itisintendedtocreatesystem-widechangetoimprovetheoutcomesofchildreninTravisCountythroughtrainingandcollaborationinthedeliveryoftrauma-informedservices.ThefollowingareTCCC’sobjectives:92
• Provideintensivetrainingandfollow-upsupportintrauma-informedpracticessuitableforthispopulation
90TCUInstituteofChildDevelopment(2016).Helpingat-riskchildren:Learningtochangetheworld…forchildren.YearinReview:2015–2016.91TravisCountyCollaborativeforChildren.Retrievedfromhttps://www.tccc-tx.org92Purvis,K.,Call,C.,&Cross,D.(2014).TBRI®andtheTCCC.
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• Buildtrauma-informedcollaborativeagenciesandindividualsthatcanimplementandsustainahighlevelofTIC
• Evaluatethiseffortsothatthisprojectandsubsequentprojectsareinformedandimprovedbywhatislearned
Thecollaborativeisguidedbythreeconceptualmodels:authoritativecommunity,bioecologicalmodel,andcollectiveimpact.Theauthoritativecommunitymodelpurportsthatthebrainisprimedforrelationshipsandcommunity,therootofhumancommunitycanbefoundinearlyrelationships,andrelationshipsandcommunityarethewellspringtowell-being.Keycriticalfeaturesofthebioecologicalmodelaretransitions,connections,and“proximalprocess”(interactionsbetweenanindividualandenvironments).Finally,thecollectiveimpactmodelsupportsfundingsystemsofcaretoachievethesynergynecessarytoaddressasocialproblem.93TCCCisledbytheKarynPurvisInstituteforChildDevelopmentandMissionCapital.Itisoverseenbyasteeringcommitteeandanadvisorycouncilrepresentingnearly40differentagencies.Notableaccomplishmentsincludedraftingacommunity-widedefinitionofTIC,providingTBRI®trainingtoover1,550professionalsrepresentingmorethan350organizations,andimplementingthe“MeetingtheNeedsofChildreninCare”researchstudyinpartnershipwithTCU’sInstituteforChildDevelopment,theTravisCountyModelCourtforChildrenandFamilies,andCASATravisCounty.Trauma-InformedCareConsortiumofCentralTexas(TICC)–Austin,Texas94
TheTICCofCentralTexaswasfoundedin2013withthesupportoftheSt.David’sFoundation.LedbytheAustinChildGuidanceCenter,theTICC’smissionistocreateacomprehensivetrauma-informedcommunityforchildren,families,andprovidersthrougheducation,outreach,andtraining.ThegoaloftheTICCistoincreaseknowledgeoftraumathataffectschildrenandfamilieswithinthecommunity.Morethan60organizationsrepresentingmentalhealthproviders,medicalprofessionals,lawenforcement,school,andchildwelfarearemembersoftheTIC.TheTICChasdevelopedtraumascreeningstandardsforavarietyofdifferentsettings,providestraumatraining,onlineresourcesfortraumascreeningsandassessments,distributesamonthlynewsletter,maintainsaconsolidatedcalendaroftrauma-informedtraining,andholdsquarterlymeetings.Inadditiontothesecommunityeducationefforts,theconsortiumhoststheCross-DisciplineTraumaConferenceofCentralTexas.Thisbiannualconferenceshowcasesnationalexpertsandcommunityefforts.
93Purvis,K.,Call,C.,&Cross,D.(2014).TBRI®andtheTCCC.94TheTrauma-InformedCareConsortiumofCentralTexas.Retrievedfromhttps://www.traumatexas.com
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TheTICCdevelopedanddistributedaTrauma-InformedOrganizationalReadinessSurveyin2014,2015,and2016.Eighty-sevenindividualsfrom70agenciesrespondedtothe2015survey.Keyfindingsindicatedthateventhoughmorethanhalfoftheorganizationsthatrespondeddescribedthemselvesastrauma-informed,justover10%hadanofficialtrauma-informedpolicy.Onlyonethirdofagenciesscreenedfortrauma.Costandadministrativebuy-inwerethebiggestbarrierstoimplementingTIC.Finally,229trainingswerereportedtotrain7,553professionalsinTIC.95TraumaandGrief(TAG)CenterforYouth–Houston,Texas
TheTexasTraumaandGrief(TAG)CenterforYouth,housedwithinTexasChildren’sHospital,isoneof25SAMHSA-funded,CategoryIITreatmentandServicesAdaptationCentersoftheNationalChildTraumaticStressNetwork.ItistheonlyCategoryIICentertospecializeinchildandadolescentbereavement.Itsprimarymissionistoincreasethestandardofcareandaccesstobest-practicecareamongtraumatizedandbereavedchildren,youth,andtheirfamilies.TheTAGCenterusesstate-of-theart,empiricallyvalidatedscreeningtoolstoensurethatyouthreceivethemostappropriateandeffectiveintervention.TheirprimarytreatmentsincludeTrauma-FocusedCognitiveBehavioralTherapy(TF-CBT)andTraumaandGriefComponentTherapy(TGCT).Theyservedapproximately300childrenandyouthbetweentheages7-17in2016.TheTAGCenterhastrainedtheHoustonIndependentSchoolDistrict,YESPrep,andtheSpringBranchIndependentSchoolDistrictonassessmentofchildhooldtraumaandbereavementandTGCT.TheyarecurrentlytalkingwiththePasadena,Alief,andHumbleIndependentSchoolDistricts.Inadditiontoitsworkwiththeschools,theTAGCenterhasinitiatedtheHoustonChildTraumaConsortiumtopromotenetworkingrelatedtotraumaandtoconductacommunity-widetraumaneedsassessment.Thegrouphasmetfourtimesoverthepastyear.Finally,asaNCTSNCategoryIICenter,theTAGCenteriscurrentlypreparingtofacilitatealearningcommunitycomprisedof10differentorganizationsacrosstheUnitedStates.LocalMentalHealthAuthorities(LMHAs)TICEffortsRepresentativesfromfiveTexasLocalMentalHealthAuthorities(LMHAs)thatservechildrenparticipatedinkeyinformantinterviewsfortheMMHPIresearchdescribedinthisreport.AlltheLMHAsareinvolvedinactivities,consortiums,orcollaborativestomovethemtowardsprovidingTIC.TheirexperiencesinimplementingTICwerelikethoseofotherkeyinformants,buttheysharedadditionalbarriersthatarespecifictoLMHAs.
95Crosbie,S.(2015).TICC’sTrauma-InformedOrganizationalReadinessSurvey.Retrievedfromhttps://www.traumatexas.com/publications-newsletter/
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TICatanOrganizationalLevel
ThreeoftheLMHAsthatparticipatedinkeyinformantinterviewswerelearningcommunitiesintheTexasChildrenRecoveringfromTrauma(TCRFT)LearningCommunitiesinitiativethroughtheTexasDSHS.TheinitiativewasfundedbySAMHSAandincludedcollaborationwithNCTSN.ThelearningcommunitieswerepartofastatewidetransformationofbehavioralhealthsystemsintendedtohelpcommunitiesimplementTIC.Thecommunitiescreatedcoreimplementationteams,whichincludedpeoplewithlivedexperience.Theyselectedareaswithintheirorganizationsthattheywantedtofocusonimproving.Theyreceivedtraining,participatedinnetworkingevents,andparticipatedinmonthlycallswiththeNationalCouncilonBehavioralHealth.TheKlara’sCenterforFamilies,oftheHeartofTexasRegionMHMRCenter,wasanearlygranteeinthisinitiative.ItreceivedsupporttobecomeaNCTSNCategoryIIICommunityTreatmentServiceCenter.Aspartoftheinitiative,theKlara’sCenterforFamiliesprovidedservicestochildrenandyouthwhohadbeenexposedtotraumaticeventsorwhowerechildrenofmilitaryfamiliesimpactedbymilitarytransitions.TheLMHAkeyinformantsindicatedthattraumaawarenessneededtobeembeddedintheirorganizationsatalllevels.Theyareallmakingorhavemadeeffortstoensurethatallstaff(fromadministrativetoleadership)aretrainedinTIC.Theybelievethatitisimportanttounderstandtraumawheninteractingwithandprovidingservicestotheirclients.Informantsalsodiscussedtheireffortstowardsbecomingatrauma-informedagency,notjustonethatprovidesservicesthataddresstrauma.Theydiscussedtheimportanceofensuringthatstafffeelsupportedinfindingawork-lifebalancegiventhedemandsoftheircontracts.Somestressedtheimportanceofhavingbuy-infromleadershipandaddressingpoliciesandproceduresasnecessarycomponentstowardsbecomingatrauma-informedagency.LMHArepresentativesdiscussedhowmakingchangesintheiragenciestobemoretrauma-informedimpactsclientoutcomesandstafflongevity.LMHATrauma-FocusedApproachesLMHAshavebeentrainedinandareimplementingseveralevidence-basedpractices.TheytypicallyprovidetheinterventionsthathavebeenapprovedbytheTexasDSHS,whichformostLMHAsincludeSeekingSafety,Trauma-FocusedCognitiveBehavioralTherapy(TF-CBT),andParentChildInteractionTherapy(PCIT).SomearealsotrainedinAttachment,Regulation,andCompetency(ARC);EyeMovementDesensitizationandReprocessing(EMDR);andTraumaAffectRegulation:GuideforEducationandTherapyforAdolescents(TARGET-A).OneLMHAexpressedinterestinhavingcliniciansandstafftrainedinTrust-BasedRelationalInterventions(TBRI®).
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LMHA-SpecificBarriers
LMHAsfacesimilarbarriersasotherprovidersinbecomingtrauma-informedagencies,includingthecostoftrainingandthetimeneededforstafftoparticipateintraining.Whenstaffareattraining,theyarenotavailabletoprovideservicestoclients,andthisinavailabilityimpactsdirectservicehours.Largescaleoragency-widetrainingisalsoachallengeforthisreason.Additionally,staffturnoveraffectsthetraininginvestmentagenciesmake.Whenstaffwhohavebeentrainedinspecificinterventionsleave,agenciesmustinvestintrainingfornewstaff.LMHAsalsofacechallengesingettingallstafftobuyintobeingtrauma-informed.Staffmayhavebeentaughtindifferentmodelsormaynotaccepttheimpactoftraumaonpeople’slives.LMHAsalsofaceinsufficientstaffingfordedicatingonestaffpersontoensurethattheagencyremainsfocusedonTIC.Somehavedevelopeda“champions”modelinwhichonepersonateachlocationisresponsibleforensuringthattrauma-informedprinciplesareinfusedintoeverythingthatfacilitydoes.Severalhaveembeddedtraumaawarenesstrainingintotheirnewemployeeorientations.LMHAsalsofacebarriersthataremoreparticulartoindividualagencies.DSHSapprovestrainingthroughspecifictrainingproviders,andonlyspecificinterventionsareauthorizedfortraining.Theapprovedinterventionsdonotincludealltheevidence-basedinterventionsthataddresstrauma.LMHArepresentativesindicatedthatthereshouldbemoreflexibilityinthetrauma-focusedinterventionstheycanprovidesincethatflexibilitywouldresultinmoreindividualizedservices.LMHAstaffaretrainedinotherinterventions,buttheycannotimplementthemthroughtheircontractwiththestate.LMHAscannotbereimbursedforinterventionsthatarebeyondthescopeofwhattheyareauthorizedtoprovide.InterventionssuchasEMDRarenotpaidforthroughMedicaid.OthernontraditionalinterventionsthataclientmayneedarenotreimbursablethroughMedicaidunlesstheyouthiscoveredundertheYESWaiver.
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Funding TIC
Texas’sMedicaidStatePlanfundssomeofthetraditionaloffice-basedtherapiesforchildrenandyouthwhohaveexperiencedtrauma.TheseincludeservicessuchasTF-CBT,EMDR,Theraplay,andPCIT.CaregiversseekingservicesandsupportthroughanLMHAandahandfulofchild-placingagenciesalsohaveaccesstotargetedcasemanagement,rehabilitationskillstraining,andfamilysupportservices.AsofSeptember2016,childreninDFPSconservatorship,throughtheYouthEmpowermentServices(YES)Waiver,haveaccesstoservicesandsupporthistoricallynotfundedbyMedicaid.Areviewofthestate’sMedicaidplanisprovidedbelow.MedicaidStatePlan
ThebasisfortheTexasMedicaidprogramistheMedicaidStatePlan,acontractbetweenthestateandtheCentersforMedicareandMedicaidServices(CMS)thatoutlinesMedicaideligibility,benefits,providerqualifications,andreimbursementsallowedbythestate.ThefederalgovernmentmatchesstatefundingthroughitsFederalMatchAssistancePercentages(FMAP).InTexas,thismeansthatthefederalgovernmentpays$56.18oneverystatedollarusedforMedicaid.Underthefederalplan,therearemandatoryandoptionalMedicaidStatePlanservices.Statesmustcovermandatorybenefitssuchasinpatientandoutpatientmedicalservicesandmaycoveralternativebenefitssuchasrehabilitationandpharmacyservices.CMSallowsstatestoamendtheirstateplantomodifyproviderqualificationsandprovidetargetpopulationswithservicesnotallowedforallconsumersunderthestateplan.Forexample,the“1115demonstration”waiverinTexasmodifiesthestateplanbyaddingpopulationsandservicesnototherwisepermittedunderMedicaid.TherearealsowaiverstoimplementMedicaidmanagedcare.MCOsunderTexasMedicaidManagedCareManagedcareorganizations(MCOs)havetheresponsibilitytooverseetheservicedeliveryofphysicalhealthandbehavioralhealthcare.MCOsmaydirectlymanagebehavioralhealthcareormaycontractwithbehavioralhealthmanagedcareorganizations(BHOs)tooverseetheutilizationandqualityofservices.Also,MCOsandtheirrespectiveBHOs(ifany)maycontractfordifferentMedicaidprogramsthatcoverdifferentpopulationsanddifferenthealthandmentalhealthbenefitsforchildren,youthandadults.Theseprogramsaredescribedbrieflybelow.
• STARisaMedicaid-managedcareprogramforwomenandchildrenwithlowincomeswhoreceiveTemporaryAssistanceforNeedyFamilies(TANF)and/orforpregnantwomenandnewbornswithlimitedincome.Theprogramalsocoversyoungadultsfromages21to26yearswhoareeligibleforMedicaidforFormerFosterCareChildren(FFCC).
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• STAR+PLUSisaMedicaid-managedcareprogramforadultswithSupplementalSecurityIncome(SSI)ordisabilities,whoareage65orolder,andwhoareeligibleforSTAR+PLUSHomeandCommunity-BasedServices(HCBS)Waiverservices.
• STARHealthisaMedicaid-managedcareprogramforchildrenunderage18whoareinDFPSconservatorship,youngadultsinDFPSextendedfostercare,andyoungadultswhowerepreviouslyunderDFPSconservatorshipandhavereturnedtofostercarethroughvoluntaryfostercareagreements(ages18to20).SuperiorHealthPlanistheonlyMCOtoofferSTARHealthandcoverschildrenandyouthinfostercarestatewide.
• STARKidsisaMedicaid-managedcareprogramforyouthandyoungadultsundertheageof21whohaveSSIordisabilities;areeligibleforMedicallyDependentChildrenProgram(MDCP)HomeandCommunity-BasedServices(HCBS)WaiverservicesorYouthEmpowermentServices(YES)Waiverservices;liveinacommunity-basedintermediatecarefacility(ICF)oranursingfacilityforindividualswithanintellectualordevelopmentaldisability(IDD)orrelatedcondition;receiveservicesthroughaMedicaidbuy-inprogram;orreceiveservicesthroughDepartmentofAgingandDisabilityServices(DADS)intellectualanddevelopmentaldisability(IDD)waiverprogramssuchasCommunityLivingAssistanceandSupportServices(CLASS),DeafBlindwithDisabilities(DBMD),HomeandCommunity-BasedServices(HCBS),andTexasHomeLiving(TXHmL).
ExpandedAccesstoAdditionalMedicaidMentalHealthServicesBefore2013,community-basedorganizations(CBOs)couldonlybillMedicaidforMentalHealthRehabilitativeServicesandTargetedCaseManagement(TCM)throughLMHAs.In2013,SenateBill(SB)58,83rdLegislature,RegularSession,integratedMentalHealthRehabilitativeServicesandTCMintothestate’sMedicaidmanagedcareprogram—reimbursedthroughcapitated(orfixed,predetermined)rates—andenabledproviderentitiesotherthanLMHAstobecomecredentialedandobtainreimbursementforprovidingtheseservices.Thiswasanimportantfirststepinexpandingthecapacitytoprovidetheseservicesstatewide.OnlyLMHAsandproviderentitiesthatareorganizations—notindividualpractitioners—canbillforTCMandMentalHealthRehabilitativeServices.Today,allMentalHealthRehabilitativeServicesandTCMproviderentities(notindependentpractitioners)enrolledinMedicaidmustutilizetheTexasHealthandHumanServicesCommission’s(HHSC)TexasResilienceandRecoveryUtilizationManagementGuidelines(RRUMG),whichwereoriginallydesignedforLMHAuse.InformationonhowtobecomeaMentalHealthRehabilitativeServicesandTCMproviderandhowtoaccessthecurrentHHSCMedicaidmanagedcarecontractsandmanualisincludedintheRecommendationssectionofthisreport.Duringthe85thLegislature,RegularSession,additionaleffortsweremadetohelpincreasethestate’scapacitytoassistchildrenlivinginpovertyandinvolvedinfostercarewhohaveacute
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mentalhealthneedsgainaccesstoMentalHealthRehabilitativeServicesandTCM.SB74,whichstreamlinestheMedicaid-managedcarecredentialingprocess,increasingthestate’scapacitytoconnectchildrenandyouthtotheintensivetreatmenttheyrequire,overwhelminglypassedbothhousesofthelegislatureandnowawaitsGovernorAbbot’ssignature.Keyprovisionsofthebillincludeclarifyingthatnon-LMHAproviderscancontractwithMCOstoprovideMentalHealthRehabilitativeServicesandTCMtochildren,youth,andtheirfamilies.Thebillalsoclarifiesthatnon-LMHAprovidersarenotrequiredtoprovidecrisisservicessuchascrisishotlinesormobilecrisisteams.ItalsorequiresHHSCtoupdateMedicaid-managedcarecontractsandrelatedmanualsandguidelines.Inaddition,SB74isassociatedwithabudgetriderthatmakes$2millionavailabletoestablishagrantprogramtoincreaseaccesstoMentalHealthRehabilitativeServicesandTCMtochildrenandyouthinthechildwelfaresystem.Thisone-timegrantprogramwillprovidefundstoLMHAsandothernonprofitentitiesthataremakinginvestmentseithertobecomeprovidersofTargetedCaseManagementandMentalHealthRehabilitativeServicesforchildreninfostercareattheIntenseServiceLevelortoexpandtheirexistingcapacitytoprovidetheseservices.Toreceivegrantfunds,anentitymustprovidelocalmatchingfundsinanamountdefinedbyHHSC,basedontheentity’sgeographicallocation.Fundsmayonlybeusedtopayforcostsdirectlyrelatedtodeveloping,implementing,andtrainingteamstoprovideTargetedCaseManagementandMentalHealthRehabilitativeServicestochildreninfostercareattheIntenseServiceLevel.TheHealthandHumanServicesCommission,incollaborationwiththeDepartmentofFamilyandProtectiveServices(DFPS),mustestablishtheinitiativenolaterthanNovember1,2017.
YouthEmpowermentServices(YES)MedicaidWaiver96,97
Asnotedabove,mostchildrenandyouthinvolvedinthechild-servingsystemhaveaccesstotrauma-focusedortrauma-specifictherapeuticinterventions.ThemostcommonisTF-CBT.However,manyoftheexpertsontraumaanditsimpactonthedevelopingbrain(Perry,98vanderKolk,99Siegel100)recommendinterventions,services,andsupportsthatarenottraditionallypaidforbyMedicaid.TheYESWaivercanprovideaccesstotheseinterventions.
96TexasDepartmentofStateHealthServices(2016).YouthEmpowermentServices(YES)Waiver:PolicyManual.Retrievedfromhttps://www.dshs.texas.gov/mhsa/yes/Resources-for-Families.aspx97TexasDepartmentofStateHealthServicesYESWaiverwebsite.(n.d.).ResourcesforFamilies.Retrievedfromhttps://www.dshs.texas.gov/mhsa/yes/Resources-for-Families.aspx98Cross,D.,&Purvis,K.B.(2013).Non-pharmacologicalinterventionsforchildrenandyouthincare.InstituteofChildDevelopmentTexasChristianUniversity.Retrievedfromhttp://texascasa.org/wp-content/uploads/2013/11/Non-pharmacological-Interventions-Dr.-Purvis.pdf99VanderKolk,B.(2014).Thebodykeepsthescore:brain,mind,andbodyinthehealingoftrauma.PenguinBooks.NY,NY.100InformationbyDr.SiegelattheTrauma-informedCareConsortiumofCentralTexas.May2017.
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TheYESWaiverprovidescomprehensivehome-andcommunity-basedmentalhealthservicestochildrenandyouthaged3–18whohaveaseriousemotionaldisturbance(SED).Italsooffersflexiblesupportsandspecializedservicetochildrenandyouthatriskofinstitutionalizationorout-of-homeplacementduetotheirSED.Anditusesthewraparoundplanningprocesstocreateaplanspecificallyforeachchildoryouthwithservicesdesignedtoidentifyandsupportthestrengthsofthechildoryouth.AnoverviewofYESWaiverservicesisprovidedbelow.
• AdaptiveAidsandSupports:Adaptiveaidsandsupportsaredesignedtohelpchildrenimprovetheirfunctioningindifferentsettingssuchashome,school,andthecommunity.Theseservicesincludeconsumablegoods(e.g.,artsupplies,psychoeducationalmaterials),durablegoods(e.g.,exerciseequipment,musicalinstruments),lessons,classes,seasonalactivities,memberships,andcamps.
• CommunityLivingSkills(CLS):Thisgroupofservicesisdesignedtohelpafamilyadjusttothespecialchallengesrelatedtothechild’smentalhealthneed.Skillstrainingcanberelatedtodailylivingskills,socialization,communication,relationshipbuilding,andintegrationintocommunityactivities.Inadditiontoskillsforthechildoryouth,CLScanprovidethefamilycaregiverwithskillstraining,includingbasicparentingandotherformsofguidancetoassistthecaregiverincopingwithandmanagingthechild’soryouths’symptoms.
• EmployeeAssistanceandSupportedEmployment:Theseservicesspecificallyaimtoassistyouthinfindingemployment.
• FamilySupports:FamilySupportsprovidepeermentoringandsupporttoprimarycaregiversofachildoryouthwhohasreceivedservicesandsupportfromacommunitymentalhealthproviders.Thefamilysupportproviderdeliverspeermentoringandcanmodelself-advocacyskills,provideinformation,assistintheidentificationoftraditionalandnontraditionalsupport,andoffernon-clinicalskillstraining.
• MinorHomeModifications:Thesearemodificationstohelpkeepchildrenoryouthandtheirfamiliessafe.Theycanincludealarmsystems,alertsystems,andothersafetydevices.
• Non-MedicalTransportation:ThisserviceensuresthatachildoryouthenrolledintheYESWaiverhasaccesstoanynon-medicalYESWaiverserviceswhenthereisnootheravailabletransportation.
• ParaprofessionalServices:Theseareskillstrainingandmentoringtoaddressachild’soryouth’ssymptomsthatmayinterferewithfunctioninginhisorherlivingandlearningenvironment.
• RespiteServices:In-andout-of-homerespiteservicescanbeprovidedonashort-termbasisbecauseoftheneedforreliefforthecaregiverofachildoryouthenrolledintheYESWaiverprogram.
• SpecializedTherapies:Thesearetherapiesthatincludeart,recreational,music,andanimal-assistedtherapy.Theymayalsoincludenutritionalcounseling.
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• SupportiveFamily-BasedAlternatives:Theseinterventionsprovidesupportandmodelappropriatebehaviorsforthecaregiverofachildoryouthresidinginahomeotherthanthatofhisorhercaregiver.Theobjectiveistoenablethechildoryouthtosuccessfullyreturnhometoliveinthecommunitywithhisorherfamily.Servicescanincludeguidancewithdailylivingskills,counselingreinforcement,therapyorrelatedactivities,supervisionofthechildoryouthforsafetyandsecurity,facilitiationofinclusionincommunityactivities,socialinteraction,naturalsupportsuse,andassistancewithcommunityandschoolresources.
• TransitionalServices:Transitionalserviceshelpwiththecostsassociatedwithayoungadultmovingintohisorherownhome.
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Findings Finding1:Child-servingsystemsaretrainingstaffintrauma-informedcare.Asaresultofmultiplelegislativemandates,statutes,andorganizationalpolicies,allchildwelfare,juvenilejustice,andfosterfamiliesaretrainedonTIC.Themajorityofmentalhealthstaffareintroducedtotheadversechildhoodexperiencestudyandtrauma-informedcare.However,schoolpersonnelsuchasteachersandothercommunityproviders,dependingonthecommunityanddistrict,havemuchlessexposure/accesstotrauma-informedcaretraining.Finding2:Despitetheavailabilityoftrainingthataddressesunderstandingandtreatingtrauma,thereremainsawidelyexpressedneedtotrainchildwelfarestaffandfosterparents.
TheTexasCourtAppointedSpecialAdvocates(CASA)withthesupportoftheSupremeCourtofTexasPermanentJudicialCommissionforChildren,Youth,andFamilies(TheChildren’sCommission)andtheTexasInstituteforExcellenceinMentalHealthattheUniversityofTexasatAustin(TIEMH)developedanddistributedtheTexasCASAWorkforceSurveyonTrauma-InformedCareWithintheChildWelfareSysteminTexasin2015.Atotalof1,758professionalsfromacrossthestateresponded.Theyself-identifiedasCASAstaffandvolunteers,mentalorbehavioralhealthproviders,attorneys,CPScaseworkers,fosterparents,ChildAdvocacyCenterstaff,judges,medicalhealthprovidersorpsychiatrists,kinshipcaregivers,orother.TheresultingTexasCASAReportonUnderstandingTrauma-InformedCareintheTexasChildWelfareSystemisananalysisofthedataandinformationgatheredfromthesurvey.Thereportstatesthatthemajorityofrespondentsbelievetheyneedmoretrainingandwouldrecommendpolicymakersincreasetrainingrequirements.Responsestoanopen-endedquestionregardingworkforceneedsstressedtheneedforin-person,practical,accessibletraining.Surveyparticipantswerealsoprovidedwithalistofrecommendationsforpolicy-makerstohelpmakethechildwelfaresysteminTexasmoretrauma-informedandwereaskedtoselecttheirtopthree.AreviewoftheresponsesindicatedthatrespondentsbelievethereshouldbeincreasedtrainingforfosterparentsandCPScaseworkersandincreasedaccesstotrauma-focusedtreatmentforchildreninchildwelfare.Respondentsplacedlessfocusonimprovingorchangingstate-levelpolicyandsupportingcommunitiesandagenciestoimproveandchangetheirpoliciestobemoretrauma-informed.Minimalemphasiswasplacedoncreatingaplantomakethechildwelfaresystemmoretrauma-informed.Littletonoemphasiswasplacedbyrespondentsondevelopingprogramstoincreaseself-careforchildwelfarestaff.Participantsidentifiedneedforfurthertraining,andthewaytheyprioritizedtherecommendationsdoesnotrecognizetheneedtobuildanorganizationalframeworkthatwillsupportstaff,families,andcommunitymembersinapplyingthisinformation.
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Finding3:Themainchild-servingsystemsinthestateofTexashavetakensomestepstowardsbecomingtrauma-informed.
• ChildWelfare:TheDepartmentofFamilyandProtectiveServices(DFPS)hasadoptedtheCANSassessment,whichscreensfortrauma;hasaddedaTICtrainingtoitspreservicetrainingrequirements;hasmandatedresidentialfacilitiesandchild-placingagenciestotrainallstaffandfosterfamiliesinTIC;andisworkingwiththeKarynPurvisInstituteofChildDevelopment(KP-ICD)atTCUtodevelopatrainingonsecondarytraumaticstress.
• JuvenileJustice:TheTexasJuvenileJusticeSystem,inresponsetolegislationtotrainallstaffinTIC,hasdevelopedanintensiveTICtraininginpartnershipwiththeNCTSN.Somedepartmentshaveimplementedatraumascreening,andWilliamsonCountyhastrainedallitsstaffinTBRIâ.
• MentalHealth:TheLocalMentalHealthAuthoritieshaveaddedTICtrainingtotheiremployeeorientation.ManyoftheLMHAshaveintroducedtraumascreening,andsixLMHAshaveparticipatedinthestate’sSAMHSAgrantTexasChildrenRecoveringfromTrauma,whichprovidedsupportinbecomingtrauma-informed.ThemajorityoftheLMHAshaveclinicianswhoaretrainedinTF-CBT.AhandfulhavestaffwhoaretrainedinEMDR,AggressionReplacementTherapy,SeekingSafety,Solution-FocusedTherapy,andParentChildInteractionTherapy.However,theirabilitytoimplementtheseinterventionsislimitedbytheTexasResiliencyandRecovery(TRR).
Inadditiontotheseinitiatives,childwelfare,juvenilejustice,andmentalhealthprofessionalshaveworkedtoincreasethenumberofevidence-based,trauma-focusedtreatmentprovidersavailabletochildrenandyouthintheirsystems.Training,screening,andevidence-basedpracticesneedtobeembeddedinacultureofTICinwhichpoliciesandpracticesaddresstheexperienceoftheworkforcealongwiththeexperienceofthechildrenandyouthseekingservicesandsupports.Mostofthecurrenttrainingisprovidedduringpre-servicetrainingornewemployeeorientation,withashorterrefresherofferedannually.Tobesuccessful,thistrainingmustbesupportedbyleadershipinanenvironmentwherepolicies,procedures,andpracticesaretrauma-informed.Feworganizationshavedevelopedformalizedeffortstoprovidestaffwithtrauma-informedapproachesandcontinuedsupporttoimplementthem.Theseapproachesandsupportincludetrainingontrauma-informedinterventionsandongoingsupervisionandcoachingtobuildstaffunderstandingandskills.Inaddition,staffarefacedwithhighcaseloads;therefore,itisdifficulttoachieveservicedeliverystandards.Staffalsoarefacedwithunsupportiveworkenvironmentsandexperiencesecondarytraumaticstressandcompassionfatigue.Staffareprovidedinformationaboutrecognizingandrespondingtotrauma;however,giventhedemandsplaced
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onthem,itcanbedifficulttoutilizethisknowledge.Theseconditionscanleadtohighstaffturnoverandburnout,impactingthechild’sabilitytobuildpositiverelationshipswithhisorherprovidersandultimatelydecreasingthequalityofcare.Finding4:Theprimarycross-systemtrauma-informedapproachesbeingimplementedinTexasareallbasedontheAdverseChildhoodExperiences(ACEs)researchandaregroundedinthesametrauma-informedframework.Commonthemesincludethefollowing:
• Traumaandbraindevelopment:Childhoodtraumacanimpactbraindevelopment,whichcanresultinavarietyofchallengingbehaviorsandcanaffectachild’soryouth’sabilitytobuildpositive,trustingrelationshipswithcaringadults.
• Safety:Childrenandyouthneedtofeelsafebothpsychologicallyandphysically.Predictabilityandperceivedcontrolcanprovideasenseofsafety.
• Connection:Trustingrelationships/attachmentarecriticaltohealing.Childrenandyouthcanhealwhentheyareinaloving,stablerelationshipwithanurturingcaregiver.Adultcaregiversneedtobeawareoftheirownabilitytoconnect.
• Control:Childrenandyouthwhohavebeentraumatizedhavehadcontroltakenawayfromthem.Therefore,itisimportanttoreturncontrol.
• Self-managementandcorrecting:Childrenandyouthbenefitfrombeingtaughtself-regulation,self-awareness,andstressmanagementskills.
• DevelopmentallyappropriateInterventions:Interventionsandtherapeuticapproachesneedtomeetachildoryouthatdevelopmentallyappropriatelevelsinordertobesuccessful.
• Strength-based:Allapproachesarestrength-based.Finding5:ReachingTeensãandTBRIâprovideaphilosophicalframework,sharedlanguage,andcommonsetofapproachesthatallowprovidersinacommunitytooperationalizetheconceptoftrauma-informedcare.Thesetwoapproachesareeasytounderstandandcanbeimplementedbyalargecross-sectionofprofessionals,parents,andfosterparents.Thecommunities,systems,andorganizationsthathavebeenthemostsuccessfulinimplementingTIChaveagreedtostartwithasingleinterventionthatiseasilyunderstoodbyallstaffandfamiliesandthatisembeddedinastrongphilosophyandculture.Nocommunityorcollaborativehaschosenatherapeuticapproach(i.e.,TF-CBT,PCIT).FoundationalapproachesbeingusedacrossthestateareTrust-BasedRelationalIntervention(TBRIâ)andReachingTeensã.SimilarinterventionsbeingutilizedoutsideofTexastochangephilosophicalapproachandbuildatrauma-informedcultureincludeCooperativeandProactiveSolutions(Dr.Greene,CaliforniaEvidence-BasedClearinghouse)andDanSiegel’swork.
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TheNeurosequentialModelofTherapeutics(NMT)approachalignswiththemodelsmentionedabovebutistargetedspecificallytoprofessionals,requiresasignificantamountoftrainingtobeimplementedtofidelity,andismuchmoreexpensivetoimplement.TheNeurosequentialModelinEducation(NME)iseasiertounderstandandisdesignedforteachers,buttrainingandcostremainabarriertowidespreadimplementation.TheChildTraumaAcademyisworkingondevelopingamodelforparentsandcaregivers.Finding6:Inadditiontoasharedapproach,successfultrauma-informedcross-systemeffortsinTexasallhaveanexternalfunderandacommunitychampion.
Allcross-systemeffortsinthestatehaveutilizedfoundationdollarsandothercommitmentsofresourcestosupporttheirefforts.FoundationsthathavecontributedtoTexasinitiativesincludebutarenotlimitedtoSt.David’sFoundation,Rees-JonesFoundation,MichaelandSusanDellFoundation,andSAMHSA.InarecentTravisCountyCollativeforChildren’s(TCCC)meeting,Dr.DavidCrossreportedthattheKP-ICDatTCUhasdonatedover$2.5millionintrainingandtechnicalassistanceoverthepastfiveyears.Eachcommunity-widecollaborativeisledbyarespectedorganizationorpassionatecommunityleaderwithavisionforchildrenandyouth.Dr.DavidCrossfromTCUleadstheTCCC,JudgeCarolClarkleadsSmithCounty’sefforts,andAustinChildGuidancehasspearheadedtheTCCC.Finding7:Thelocalmentalhealthauthoritiesarelimitedtoacoresetoftrauma-focusedinterventionsthatlimittheirabilitytoselectaninterventionbasedonthechild’soryouth’straumahistory,needs,orbraindevelopment.
TheTexasResilienceandRecovery(TRR)Guidelineslimitthetrauma-focusedevidence-basedtreatments(TF-EBTs)throughLMHAstoART,PCIT,TF-CBT,andSeekingSafety.SeveraloftheLMHAsindicatedtheyhavestafftrainedinotherTF-EBTsandwouldliketheTRRtoexpandthelistofallowableservicesandsupport.Thecurrentlimitationscancausedifficultyforcasemanagerstoselecttheservicesandsupportnecessarytoeffectivelymeettheneedsofchildrenoryouth.Verbalorcognitivetherapyaloneforchildrenoryouththathaveexperienceddevelopmentalorcomplextraumaisnotalwaysthebestintervention.101Alternativeinterventionssuchasphysicaltherapy,occupationaltherapy,artandmusictherapy,equinetherapy,yoga,andmartialartshavebeenfoundtoeffectivelyaddresstheneedsofchildrenandyouthwhohaveexperiencedcomplexordevelopmentaltrauma.102,103NMTwasfoundedonthepremisethattherapeutic
101Walters,F.(2005).Whentreatmentfailswithtraumatizedchildren…Why?JournalofTrauma&Dissociation,6(1).DOI:10.1300/J229v06n01_01102Perry,B.D,&Szalavitz,M.(2008).Theboywhowasraisedasadog:Andotherstoriesfromachildpsychiatrist’snotebook:Whattraumatizedchildrencanteachusaboutloss,love,andhealing.NewYork:BasicBooks.103VanderKolk,B.A.(2014).Thebodykeepsthescore:Brain,mind,andbodyinthehealingoftrauma.NewYork:Viking.
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interventionsmustfollowthesequenceofnormaldevelopmentalmilestonesofbraindevelopment.104Inadditiontotheactivitiesabove,thefollowingtherapeuticactivitiesandorganizingeventshavebeenfoundtoeffective:healthymassage,EMDR,canineinteractions,socialplay,andperformingandcreativearts.Theonlywayforchildrenandyouthinthechildwelfaresystemtoaccessthesemore“nontraditional”servicesiscurrentlythroughtheYESWaiver.Approximately1,700youthinTexasarepresentlyenrolledinthisprogram,and50ofthemareinCPSconservatorship.Finding8:Medicaid(StarHealth)paysfortraditionaloffice-basedtrauma-informedservicesandsupports,andSTARHealthprovidestraininginTF-CBTandPCIT.However,providersstillidentifiedfundingasabarriertoexpandingTF-EBTcapacity.Thereareseveralissuesassociatedwiththecostofexpandingtrauma-focusedevidence-basedtreatmentsinTexas.First,Medicaidandfreetrainingdonotnegatethecostassociatedwiththelossofarevenuestreamwhilestaffareattendingtraining,nordotheycompensatefortheadditionalcostofcoachingandsupervisionrequiredtoensurestaffaredeliveringtheservicetofidelity.Second,STARHealthonlyprovidesTF-CBTtrainingandalimitedamountofPCITtraining.Consequently,ifaproviderwantstodeliveradditionalTF-EBT,itmustassumethefullcostoftrainingstaff,coaching,andsupervisingstaff.Third,Medicaiddoesnotcoverthecostoftraininganddeliveringevidence-informedapproachessuchasTBRIâ,ReachingTeensã,andDr.DanSiegel’swork.Anumberofresidentialfacilitiesandchild-placingagencies(CPA)traintheirstaff,clinicians,andfosterparentsduringtheirpre-serviceorannualtraining.Otherorganizationshaveusedgrantorphilanthropicdollarstotrainalargenumberofcommunitystakeholders,courts,providers,DFPSstaff,parents,andfosterparentsintheseinterventions.Finally,asnotedabove,theonlyMedicaidfundingstreamavailablefornontraditionalapproachesisthroughtheYESWaiver.
104Cross,D.R.,&Purvis,K.B.(2013).Non-pharmacologicalInterventionsforchildrenandyouthincare.Retrievedfromhttp://texascasa.org/wp-content/uploads/2013/11/Non-pharmacological-Interventions-Dr.-Purvis.pdf
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Appendix One: National Evidence-Based Practices Repositories TheNationalRegistryforEvidence-BasedProgramsandPractices(NREPP)andtheCaliforniaEvidence-BasedClearinghouseforChildWelfare(CEBC)areregistriesforevidence-basedpractices.Theoverridingpurposeofbothistopromotetheimplementationofevidence-basedpractices.Therepositorieseachfocusonadifferentsetofinterventionsandusedifferentratingscalestodistinguisheffectiveness.Abriefoverviewofthepurposeandcontentofeachdatabaseandadescriptionoftheirratingscalesisprovidedbelow.TheNationalRegistryforEvidence-BasedProgramsandPractices(NREP)isSAMHSA’sNationalRegistryofEvidence-basedProgramsandPractices.105Overview:NREPPisarepositoryandreviewsystemformentalhealthandsubstanceuseinterventions.Itspurposeistohelppeopleidentifyandlearnmoreaboutavailableevidence-basedprogramstodeterminewhichonesbestmeettheirneeds.Itisdesignedtogivereliableinformationoneachprogram’seffectonindividualoutcomes.AllinterventionsareindependentlyassessedandratedbycertifiedNREPPreviewers.NREPPassessestheresearchthatevaluatestheoutcomesofaprogramorpracticeandprovidesinformationoneffectivedisseminationandimplementation.Allratingstakeintoaccountthemethodologicalrigoroftheevaluationstudies,thesizeofimpactoftheprogramonoutcomes,thedegreetowhichtheprogramwasimplementedasintended,andthestrengthoftheprogram’sconceptualframework.Aprogramprofileisprovidedforeachpracticeandincludesadescriptionoftheintervention,itsgoals,itsmajorcomponents,andaside-barsnapshotwithoutcome-levelratings.RatingScale:106NREPPusesgreen,yellow,red,andblackcircleswithcorrespondingsymbolstodepicttheoutcomeevidencerating.Theoutcomeratinglevelsaredescribedbelow.
• Effective:Theevaluationevidencehasstrongmethodologicalrigor,theshort-termeffectsfavortheinterventiongroup,andthesizeoftheeffectissubstantial.
• Promising:Theevaluationevidencehassufficientmethodologicalrigor,andtheshort-termeffectontheoutcomeislikelytobefavorable.
• Ineffective:Theevaluationevidencehassufficientmethodologicalrigor,butthereislittletonoshort-termeffect.
105NationalRegistryforEvidence-basedProgramsandPractices:SAMHSA’sNationalRegistryofEvidence-basedProgramsandPractices.http://nrepp.samhsa.gov/about.aspx.106NationalRegistryforEvidence-basedProgramsandPractices:SAMHSA’sNationalRegistryofEvidence-basedProgramsandPractices.http://nrepp.samhsa.gov/about.aspx
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• Inconclusive:Aprogramisclassifiedasinconclusiveiftheevaluationevidencehasinsufficientmethodologicalrigororthesizeoftheshort-termeffectcannotbeclassified.
TheCaliforniaEvidence-BasedClearinghouseforChildWelfare(CEBC)Overview:TheCaliforniaEvidence-BasedClearinghouse’smissionisto“advancetheeffectiveimplementationofevidence-basedpracticesforchildrenandfamiliesinvolvedwiththechildwelfaresystem.”107Evidence-basedpracticesaredefinedbytheCaliforniaClearinghouseaspracticesthatincorporatethebestresearchevidenceandthebestclinicalexperienceandareconsistentwithfamily/clientvalues.108AprogramiseligibletoberatedontheCEBCscientificratingscaleifithasbeenreportedinapublished,peer-reviewedjournal;thereisabookormanualthatdescribeshowithasbeenadministered;itmeetstherequirementsofoneofCEBC’stopicareas;ithasoutcomemeasuresthathavebeendeterminedtobereliableandvalid;andtheprogramhasbeenadministeredwithconsistencyandaccuracy.CEBChasascientificratingscale(describedbelow)andaChildWelfareRelevanceLevel.ScientificRatingScale:109
• 1-Well-supportedbyResearchEvidence:Theprogrammusthaveatleasttworigorousrandomizedcontrol(RCTs)trialsindifferentusualcareorpracticesettingsandhavebeenfoundtobesuperiortoanappropriatecomparisonpractice.AtleastoneoftheRCTshasshownasustainedeffectofayearormorebeyondtheendoftreatmentwhencomparedwiththecontrolgroup.
• 2-SupportedbyResearchEvidence:TheprogrammusthaveatleastonerigorousRCTinausualcareorpracticesettingandmusthavebeenfoundtobesuperiortoanappropriatecomparisongroup.
• 3-PromisingResearchEvidence:Theprogrammusthaveatleastonestudyutilizingsomeformofcontrolgroup(untreated,placebo,matchedwaitlist)andhaveestablishedthebenefitsofthepracticeoverthecontrol.oritmustbefoundcomparabletoapracticerated3orhigherontheCEBCorsuperiortoanappropriatecomparisonpractice.
• 4-EvidenceFailstoDemonstrateEffect:TheprogramhasnotresultedinimprovedoutcomeswhencomparedtousualcareinRCTs.
• 5-ConcerningPractice:OverallevidencefromRCTssuggeststheprogramhasanegativeeffectontheclientsitserved.Orthecasedatasuggeststhereisariskofharmorthere
107CaliforniaEvidence-basedClearinghouseforChildWelfare.http://www.cebc4cw.org108CaliforniaEvidence-basedClearinghouseforChildWelfare.Practice-basedevidenceandhowitisdifferentfromevidence-basedpractice.http://www.cebc4cw.org/files/PBEvsEBP.pdf109CaliforniaEvidence-basedClearinghouseforChildWelfare.OverviewoftheCEBCScientificRatingScale.http://www.cebc4cw.org/files/OverviewOfTheCEBCScientificRatingScale.pdf
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isalegalorempiricalbasissuggestingthatcomparedtoitslikelybenefits,thepracticeconstitutesariskofharm.
• NR-NotAbletobeRated:Theprogramdoesnothaveanypublished,peer-reviewedstudyutilizingsomeformofcontrolgroup.
ChildWelfareSystemRelevanceLevels:110
• High:Theprogramwasdesignedoriscommonlyusedtomeettheneedsofchildren,youth,andadultsorfamilieswhoarereceivingchildwelfareservices.
• Medium:Theprogramwasdesigned,orcommonlyused,toservechildren,youth,youngadults,and/orfamilieswhoaresimilartothechildren,youth,andfamiliesinthechildwelfaresystemandarelikelytoincludecurrentandformerrecipients.
• Low:Theprogramisdesignedorcommonlyused,toservechildren,youth,youngadultsand/orfamilieswithlittleornoapparentsimilaritytothechildwelfarepopulation.
Thereareanumberoforganizationsthathavedevelopedscalestoratetheresearchevidencethatsupportstheeffectivenessofprogramsandpractices.Forthesakeofefficiencyandconcision,theselevels,ratings,andgradingscalesarenotincludedwithinthisdocument.
110CaliforniaEvidence-basedClearinghouseforChildWelfare.ChildWelfareSystemRelevanceLevels.http://www.cebc4cw.org/home/how-are-programs-on-the-cebc-reviewed/child-welfare-relevance-levels/
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Appendix Two: Trauma-Informed Care Training OrganizationandTrainingName
DesignatedAttendees
TrainingDescription
BeyondConsequencesInstitute
Parents,professionals,andschools
Nationallyavailableprogramthatprovideseducationalmaterials,trainingprograms,andresources.Trainingisthroughbooks,webinars,coaching,andonsiteworkshops.http://www.beyondconsequences.com/about-bci
ChildTraumaAcademy
Anyoneworkingwithsomeoneaffectedbytrauma
Offersfouronlinecoursesforallparticipants.However,theacademydoesnotofferCertificatesofCompletionorCEUsforanyoftheonlinecourses.Resourcelibraryisalsoavailablefromhttp://childtrauma.org.http://www.childtraumaacademy.com
CircleofSecurity Parentsandprofessionals
CircleofSecurityInternationalofferstrainingaroundtheworldfocusingontheearlyinterventionmodelstoincreaseattachmentandsecuritydevelopedbyGlenCooper,KentHoffman,andBertPowell.https://www.circleofsecurityinternational.com/training
CognitiveBehavioralInterventionforTraumainSchools(CBITS)
Schools TheCognitiveBehavioralInterventionforTraumainSchools(CBITS)programisaschool-based,groupandindividualintervention.https://cbitsprogram.org
CommunitiesinSchoolsofCentralTexasTraumaTraining
Educators Freeonlinetrainingresourcedesignedtogiveinformationabouthowstudentlearningandbehaviorisimpactedbytrauma.http://www.ciscentraltexas.org/resources/traumatraining/
DanSiegel’sNoDramaDiscipline
Caregiversandparents
TrainingisavailableonlineandthroughabookbyDanSiegelcalledNo-DramaDiscipline:TheWhole-BrainWaytoCalmtheChaosandNurtureYourChild’sDevelopingMind.Dr.Siegelalsohoststrainingeventsnationally.http://www.drdansiegel.com/books/no_drama_discipline/
DepartmentofAgingandDisabilityServices(DADS)andDepartmentofStateHealthServicesTraumaInformedCareforIndividualswithDevelopmentalDisabilities(IDD)
AnyonewhosupportssomeonewithIDD.
Onlinetrainingmoduleaspartofcomprehensiveonlinecourse,"MentalHealthWellnessforIndividualswithIntellectualandDevelopmentalDisabilities(IDD).”ResultedfromHB2789,84thRegularLegislativeSession.https://tango.uthscsa.edu/mhwidd
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OrganizationandTrainingName
DesignatedAttendees
TrainingDescription
DepartmentofFamilyandProtectiveServices(DFPS)Trauma-InformedCareTraining
Parents,fosterparents,counselors,therapists,andshelterworkers
AsaresultofSB219,82ndRegularSession,DFPSnowprovidesthistrainingopportunitytoassistfamilies,caregivers,andothersocialserviceprovidersinfosteringgreaterunderstandingoftrauma-informedcareandchildtraumaticstress.Thistrainingaimstohelpunderstandtheeffectsthattraumacanhaveonchilddevelopment,behaviors,andfunctioningaswellasrecognize,prevent,andcopewithcompassionfatigue.Thetrainingalsodoesthefollowing:Providespracticalinformationthatpreparesthecaregivertoputintopracticewhatheorshehaslearned;Includesacomponentonadversechildexperiences(ACEs);andIncludestrainingandresourcesrelatedtopreventionandmanagementofsecondarytraumaticstressandcompassionfatigue.Thistrainingisonlineandisestimatedtotaketwohours.https://www.dfps.state.tx.us/training/trauma_informed_care/https://www.dfps.state.tx.us/Training/Trauma_Informed_Care/begin.asp
DFPSCaseworkerInitialTraining
DFPSCaseworkers AsaresultofSB219,82ndRegularSession,DFPScaseworkersarerequiredtocompleteaninitialtrainingontrauma-informedcareduringtheirbasicskillsdevelopmenttrainingandcompleteanonlinerefreshercourseannually.Thistrainingisofferedin-person.Thereisalsoatwo-houronlinerefreshercourseforCPSprogramandcontractstafftocompleteannually.TrainingrequirementsareincludedinTexasFamilyCode§264.015.http://www.statutes.legis.state.tx.us/Docs/FA/htm/FA.264.htmhttp://www.dfps.state.tx.us/About_DFPS/Title_IV-B_State_Plan/2010-2014_State_Plan/Health_Care_Oversight_and_Coordination_Plan.pdf
DFPSSecondaryTraumaticStressTraining
DFPSCaseworkersandcaregivers
TexasChristianUniversity(TCU)developedatrainingspecificforDFPScaseworkersandcaregiversonsecondarytraumaticstress.ThetrainingwasrolledoutSummer2017andiscalled,“BuildingResilienceintheFaceofTrauma.”
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OrganizationandTrainingName
DesignatedAttendees
TrainingDescription
DFPSSTARHealthCenpaticoTrauma-InformedCareTrainingandCenpaticoU
Fosterfamilies,caregivers,CASAworkers,educators,schoolcounselors,judges,andattorneys
STARHealthisthestatewideMedicaid-managedcareprogramforchildreninDFPSconservatorshipandyoungadultsinDFPSpaidplacements.CenpaticomanagesthebehavioralhealthbenefitsforSTARHealth.CenpaticotrainersareregionallyassignedacrossTexastopartnerwithlocalchildwelfarestakeholderstoprovidefreein-persontrainingtocaregivers,caseworkers,teachers,therapists,judges,andotherswhoareinvolvedinlivesofchildreninfostercare.CenpaticoU,anonlineresource,alsooffersfreetrainingtoallfostercarestakeholders.TrainingisalsoavailableinSpanish.https://www.cenpaticointegratedcareaz.com/providers/education-training/trauma-informed-care.htmlhttps://www.envolveu.com
EducationKinesiologyFoundation’sBrainGym
Primarilyforeducators
TrainingisavailablenationallythroughcoursestaughtbylocalBrainGymfacilitators.http://www.braingym.org/schedule?level=1
EmpoweredtoConnect(ETC)
Pre-andPost-adoptiveandfosterparents
BasedheavilyonTBRI®,thistrainingisspecificallyforadoptiveandfosterparents.ThetrainingistaughtfromaChristianperspective.Therearetwocourses:“Prepare”isforpre-placementparents,and“Connect”isforpost-placementparents.Eachcourseistaughtinnineweeklytwo-hoursessionsforsmallgroups.http://empoweredtoconnect.org/training/
EyeMovementDesensitizationandReprocessing(EMDR)Institute
MentalHealthPractitioners
TheEMDRTherapyBasicTraining(Weekend1and2)isdesignedforlicensedmentalhealthpractitionerswhotreatadultsandchildreninaclinicalsetting.http://www.emdr.com/us-basic-training-overview/
KarenPurvisInstituteofChildDevelopmentatTCUTBRI®Training
Caregivers,parents,caseworkers,medicalprofessionals,counselors,CASAworkers,andteachers
Attachment-based,trauma-informedintervention.Trainingiscenteredonchildrenfromplacesofabuse,neglectand/ortrauma.PractitionerTrainingisavailableforcaseworkers,fosterandadoptioncarespecialists,medicalprofessionals,counselors,andCASArepresentatives.ParenttrainingandresourcesareavailableonlineandinabookbyDr.PurviscalledTheConnectedChild.https://child.tcu.edu/professionals/tbri-training/#sthash.vDnwozxB.dpbs
TheNationalChildTraumaticStressNetwork
Mentalhealthprofessionals,parents,caregivers,educators,andpolicymakers
Onlinelearningcenterthatoffersfreewebinarsandcontinuingeducationcertificatesonvarioustopics,includingtrauma-informedcare.TrainingofferedincludesChildTraumaToolkitforEducators,ChildWelfareTraumaTrainingToolkit,ResourceParentCurriculumOnline,andTrauma-InformedJuvenileJusticeSystemResourceSite.https://learn.nctsn.org
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OrganizationandTrainingName
DesignatedAttendees
TrainingDescription
TheNationalChildTraumaticStressNetworkPsychologicalFirstAid
Firstresponders Onlinesix-hourinteractivecoursethatputstheparticipantintheroleofaproviderinapost-disasterscene.https://learn.nctsn.org/course/index.php?categoryid=11
ProblematicSexualBehaviorCognitiveBehavioralTherapy(PSB-CBT)
Childadvocacycenters,lawenforcement,clinicians,andpractitioners
TrainingisprovidedthroughtheNationalCenterontheSexualBehaviorofYouth(NCBY)http://www.ncsby.org/content/about-us
SatoriLearningDesignsSatoriAlternativestoManagingAggression(SAMA)
Schools,lawenforcement,fostercareproviders,RTCs,andhospitals
SAMAisa16-hourtrainingprogramthatfocusesonriskmanagementofaggressivebehavior.Programisnational;however,itisheadquarteredinTexas.http://www.satorilearning.com/index
Solution-FocusedTherapyattheInstituteforSolution-FocusedTherapy
Practitioners Nationalprogramtaughtasanonlinehybridcourseconsistingofthreein-personclassdaysand14classesusingaweb-basedprogram.https://solutionfocused.net/training/
StarrCommonwealthNationalInstituteforTraumaandLossinChildren(TLC)StructuredSensoryInterventionProgramforTraumatizedChildren,AdolescentsandParents(SITCAP)
Educators,caseworkers,counselors,andpractitioners
Nationalonlineandin-persontrainingdesignedtoenableschools,crisisteams,childandfamilycounselors,andprivatepractitionershelptraumatizedchildrenandfamilies.https://www.starr.org/training/tlc/courses-training
TexasCenterfortheJudiciary
Texasjudges AnnualChildWelfareConferenceisacontinuingeducationprogramforTexasjudgeswhohearchildprotectioncases.Pastconferencesincludedageneralsessionon“CreatingTrauma-InformedCourts.”http://www.yourhonor.com/Web/Online/Events/2016_Conferences/2016ChildWelfareConference/Event_Details.aspx?EventTabs=2&EventKey=16CWC#EventTabs%20class
TexasHealthStepstrainingonChildhoodTraumaandToxicStress
Healthcareproviders FreeonlinecontinuingeducationtrainingavailabletoTexasHealthStepsprovidersandotherinterestedhealthcareprofessionals.https://www.txhealthsteps.com/cms/?q=node/250
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OrganizationandTrainingName
DesignatedAttendees
TrainingDescription
TexasJuvenileJusticeDepartment(TJJD)TraumaInformedCareTraining
Juvenileprobationandsupervisionofficers
AsaresultofSenateBill1356,83rdTexasLegislature,whichrequiresalljuvenileprobationandsupervisionofficerstohaveTICtrainingpriortocertificationorrenewal(forexistingofficers),theJuvenileJusticeTrainingAcademy(JJTA)createdandimplementedaTICtraining.TJJDworkedwithNationalChildTraumaticStressNetwork(NCTSN)todevelopthetraining.TJJDdevelopedtwotrainings:oneforStateProgramsandFacilitiesandoneforCommunity-BasedPrograms.DepartmentscansubmitaTrainingTechnicalAssistanceRequestorassistincoordinatingaRegionalTrainingeffortforTICTraining.Todate,alloftheregionaltrainingacrossthestatehaveofferedtheTICtraining.https://www.tjjd.texas.gov/regionaltraining/training_news.aspx#trauma-informed-care
TexasLawyersforChildren
Attorneysandjudges FreeonlinetrainingandsupportresourceforTexasjudgesandattorneysforchildwelfarecases.www.texaslawyersforchildren.org
TreatmentInnovationsTrauma-InformedCareandSeekingSafety
Cliniciansandagencies
Providestrainingandotherresourcestoclients,clinicians,andagencieswhoservepeoplewithsubstanceabuseandtrauma-relatedproblems.Trainingcanbeonsite,onlinewebinar,orDVDs.
TraumaAffectRegulation:GuideforEducationandTherapyforAdolescents(TARGET)
Correctionsfacilities,healthprovidersandchildren’sserviceproviders
TrainingisthroughAdvancedTraumaSolutions.http://www.advancedtrauma.com/Services.html
TheTraumaCenteratJusticeResourceInstituteAttachment,RegulationandCompetency(ARC)Training
Clinicians,schools,andRTCs
TheARCframeworkisbuiltaroundthefollowingcoretargetsofintervention.Thesetargetsareaddressedinclient-andsystem-specificways,withanoverarchinggoalofsupportingthechild,family,andsystem’sabilitytoengagethoughtfullyinthepresentmoment(TraumaExperienceIntegration).http://www.traumacenter.org/research/ascot.php
Trauma-InformedCareConsortiumofCentralTexas
Professionalsandparents
TraumatrainingisofferedthroughtheAustinChildGuidanceCenteronavarietyoftopicscenteredontrauma.ThewebsitealsohasacalendarlistingofallupcomingprofessionaldevelopmentopportunitiesandpublictrainingrelatetotraumaintheCentralTexasregion.https://www.traumatexas.com/trauma-training/
TraumaRecoveryandEmpowermentModel(TREM)
Clinicians SAMHSArecommendstrainingthroughCommunityConnections.CommunityConnectionsprovidesmanuals,training,andongoingconsultations.https://www.samhsa.gov/nctic/trauma-interventionshttp://www.communityconnectionsdc.org/training-and-store/training
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OrganizationandTrainingName
DesignatedAttendees
TrainingDescription
UniversityofCaliforniaDavisChildren’sHospitalParentChildInteractionTherapy(PCIT)
MentalHealthAgencies
ThePCITTrainingCenterprovidestrainingandsupporttohelpagenciesdevelopeffectivementalhealthprograms.Trainingisavailableaswebinars.https://pcit.ucdavis.edu/training/
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Appendix Three: Key Informants 2017KeyInformantParticipants
Name Title Organizational/DepartmentalAffiliationGeneralResidentialOperation-ChildWelfare
RayBaca BehavioralResourceCounselor
CalFarley’sBoysRanch
MichelleMaikoetter SeniorVicePresidentofPrograms
CalFarley’sBoysRanch
JimTaylor AssistantAdministratorforResidentialServices
CalFarley’sBoysRanch
RobertMarshall AdministratorofResidentialHomes
CalFarley’sBoysRanch
JoyfulandJudithBrown HouseParents CalFarley’sBoysRanch
TiffanyCarpenter DirectorofCounseling CalFarley’sBoysRanch
CarolHumbert Counselor CalFarley’sBoysRanch
ShannaTipton NeurofeedbackCounselor
CalFarley’sBoysRanch
KatherineClay Counselor CalFarley’sBoysRanch
MikeWilhelm Chaplin CalFarley’sBoysRanch
RayBaca SchoolSupportSpecialist
CalFarley’sBoysRanch
JoshSprock Trainer CalFarley’sBoysRanch
SuzanneWright DirectorofTraining CalFarley’sBoysRanch
RachelKing Trainer CalFarley’sBoysRanch
JohnHazle AdministratorofCaseWorkServices
CalFarley’sBoysRanch
TedKeyser ExecutiveDirector HelpingHandHomeforChildren
VanessaDavila DirectorofStrategicInitiatives,ResearchandGrants
HelpingHandHomeforChildren
DavePaxton ChiefClinicalOfficer TheVillageNetwork
JerryHartman ClinicalDirector TheVillageNetwork
MarkWelty,PhD DirectorofResearchandInnovation
TheVillageNetwork
RandySpencer VicePresidentofOrganizationalImpact
PresbyterianChildren’sHomesandServices
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Name Title Organizational/DepartmentalAffiliationMentalHealthServices
BridgetSpeer ChildandFamilyServicesManager
AustinTravisCountyIntegralCare
TelawanaKirbie DirectorofClinicalServices
HeartofTexasRegionMHMRCenter
RonKimbell DivisionDirector,Klara’sCenterforFamilies
HeartofTexasRegionMHMRCenter
TriciaBoodhoo SocialServicesDirector YsletadelSurPueblo
AngelMontoya AlcoholandSubstanceAbuseProgramCoordinator
YsletadelSurPueblo
ViridianaSigala Therapist YsletadelSurPueblo
CathyGaytan ExecutiveDirector ElPasoChildGuidanceCenter
BradSchwall,PhD ExecutiveDirector PastoralCounselingCenter
SeannaCrosby DirectorofServicePrograms
AustinChildGuidanceCenter
EvelynLocklin ProgramDirector HarrisCenterMCOT
RossRobinson ExecutiveDirector HillCountyMHDDCenters
AnneTaylor DirectorofBehavioralHealthServices
HillCountryMHDDCenters
TheresaThompson Children’sDirector HillCountryMHDDCenters
JulieKaplow AssociateProfessorDirector
TraumaandGriefCenterforYouth
KayBrotherton DirectorofSpecialProjectsandChangeInitiatives
CentralPlainsCenter
AnnBradford CEO CentersforChildrenandFamilies,Inc.(CENTERS)
KristiEdwards ClinicalDirector CentersforChildrenandFamilies,Inc.(CENTERS)
RobinBirkla PostAdoptionDirector CentersforChildrenandFamilies,Inc.(CENTERS)
MichaelGomez,PhD DirectorofChildandAdolescentMentalHealth
DepartmentofPedicatrics-CenterforSuperheros,TexasTechUniversityHealthScienceCenter
PattiPatterson,MD Professor DepartmentofPedicatrics-CenterforSuperheros,TexasTechUniversityCenter
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Name Title Organizational/DepartmentalAffiliationDepartmentofFamilyandProtectiveServices
LindseyVanBuskirk Region7DeputyRegionalDirector
DepartmentofFamilyandProtectiveServices
FosterCareAgencies
JessicaKilpatrick DirectorofTrainingandProgramDevelopment
StarryCounselingandFosterCareProgram
ReneeCalderPrice DirectorofChildWelfareServices
DePelchinChildren’sCenter
DarcieDeSchazo ExecutiveDirector TheSettlementHomeforChildren
CourtAppointedSpecialAdvocates(CASA)
AndyHomer PublicAffairsExecutiveDirector
TexasCASA
SarahCrockett PublicPolicyCoordinator
TexasCASA
LauraWolf ExecutiveDirector CASAofTravisCounty
DonBinnicker ChiefExecutiveOfficer CASAofTarrantCounty
OtherCommunityAgencies
IvonneTapia ChiefExecutiveOfficer Aliviane
SandyCouder ExecutiveAssistantforCEO
Aliviane
CarolinaGonzalez DivisionalDirector Aliviane
IreneSilva MethadoneClinicSupervisor
Aliviane
JuliePriego PreventionandInterventionServicesSupervisor
Aliviane
JudgeCaroleClarkandCoreTICTeam
PresidingJudgeand30pluscommunitypartners,providers,contractlawyers,andCPSstaff
321stDistrictCourtofSmithCounty
AnuPartap,MD(takenfrompreviousinterviews)
Pediatrician;MedicalDirector
Rees-JonesCenterforFosterCareExcellenceatChildren’sMedicalCenter
LenaZettler BehavioralHealth CookChildren’sHealthCareSystem
ChristineGendron ExecutiveDirector TexasNetworkofYouthServices(TNOYS)
JulieKouri FounderandExecutiveDirector
FosteringHopeAustin
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Name Title Organizational/DepartmentalAffiliationKatyBourgeois SeniorConsultant MissionCapital(BackboneagencyTravisCounty
Children’sCoalition)
NicholeAston GrantManager MichaelandSusanDellFoundation
MarisolAcosta ProgramSpecialistV/ProjectDirector
TexasHealthandHumanServices/TexasChildrenRecoveringfromTrauma
CandaceAylor Owner CandaceAylorConsulting
IanSpechler RegionalAttorney DisabilityRightsTexas
KristenHowell ChiefProgramsOfficer DallasChildren’sAdvocacyCenter(CAC)
GwendolynDowning ManagerofHopeandResilience
OklahomaDepartmentofMentalHealth
Trauma-InformedCareApproaches
Dr.DavidCross Reese-JonesDirector TexasChristianUniversity(TCU)
JanaLihnRosenfelt ExecutiveDirector ChildTraumaAcademy
EmilyPerry DirectorofTrainingandEducation
ChildTraumaAcademy
KenGinsburg,MD(Presentation)
Pediatrician Children’sHospitalofPhiladelphia
DanSiegel,MD(Presentation)
ChildandAdolescentPsychiatristandExecutiveDirector
MindfulAwarenessResearchCenteratUCLAandtheMindsightInstitute.
SarahMercado TrainingSpecialist KarynPurvisInstituteofChildDevelopment
BehavioralHealthManagementCompany
RoyVanTassel DirectorofTraumaandEBPInterventions
Cenpatico
DavidAllen SeniorDirectorofTrainingandEducation
Cenpatico
CherylFisher SeniorDirectorforFosterCareandSpecialtyPopulation
Cenpatico
KarenRogers DirectorofFosterCare Cenpatico
CourtSystem
TheHonorableAuroraMartinezJones
AssociateCourtJudge TravisCountyDistrictCourts
TheHonorableDarleneByrne
Judge TravisCountyDistrictCourts126thCivilDistrictCourt
JuvenileJustice
KristyAlmager DirectorofTraining TexasJuvenileJusticeDepartment(TJJD)
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Name Title Organizational/DepartmentalAffiliationMattSmith AssistantExecutive
DirectorDirectorofMentalHealthServices
WilliamsonCountyJuvenileDetentionCenter
LynnKessel AssistantDirectorMentalHealthServices
WilliamsonCountyJuvenileDetentionCenter
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Appendix Four: Trauma-Focused Approaches Utilized by Key Informants ChildandAdolescentEvidence-BasedandEvidence-InformedPracticesAcrossKeyInformantsTrauma-InformedPractice Agencies/OrganizationsTrauma-InformedFoundationalFrameworks NeurosequentialModelofTherapeutics(NMT)TheChildTraumaAcademyreportsthatitmeetstheevidence-basedcriteriaLevelIII(Opinionsofrespectedauthorities,basedonclinicalexperience,descriptivestudies,orreportsfoexpertcommittees),LevelII(Evidenceobtainedfromwell-designedcohortorcase-controledanalyticstudies),andLevelI(Evidenceobtainedfromwell-designedcontrolledtrial).
CalFarley'sBoysRanch;HelpingHandsHomeforChildren
NeurosequentialModelofEducation(NME)NMEisnotanintervention;itisawaytoeducateschoolstaff.
CalFarley'sBoysRanch
Trust-BasedRelationalIntervention(TBRI®)CEBCRatingsTBRIOn-lineCaregiverTraining:ScientificRating(SR)-3,ChildWelfareSystemRelevanceLevel(CWL)-HighTBRICaregiverTraining:SR-3,CWL-HighTBRITherapueticCamp:SR-NR,CWL-High
KarenPurvisInstituteofChildDevelopment-Texas;ChristianUniversity;321stDistrictCourtofSmithCounty-JudgeCaroleClark;AssociateJudgeAuroraMartinezJones;AustinTravisCountyIntegralCare;CalFarley'sBoysRanch;CASAofTarrantCounty;CASAofTravisCounty;CentersforChildrenandFamilies;DePelchinChildren'sCenter;HelpingHandsHomeforChildren;PresbyterianChildren'sHomeandServices;SettlementHome;STARRY;WilliamsonCountyJuvenileDetentionCenter
Trauma-SpecificInterventions AggressionReplacementTherapy(ART)CEBCRatingsART:SR-3,CWL-Medium
AustinTravisCountyIntegralCare;WilliamsonCountyJuvenileDetentionCenter
Attachment,Regulation,andCompetency(ARC)CEBCRatingsARCClient-LevelIntervention:SR-NR,CWL-High
CentersforChildrenandFamilies;HeartofTexasRegionalMHMR
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Trauma-InformedPractice Agencies/OrganizationsCircleofSecurityCECBRatingCSParenting:SR-NR,CWL-MediumCSHome-visiting:SR-3.CWL-Medium
321stDistrictCourtofSmithCounty-JudgeCaroleClark;AssociateJudgeAuroraMartinezJones;PresbyterianChildren'sHomeandServices
CognitiveBehavioralInterventionsforTraumainSchools(CBITS)NREPPRatingCBITSBounceBack:Effectivefortraumaandstress-relateddisordersandsymptoms.CECBRatingsCBITSBounceBack:SR-3,CWL-MediumCBITS:SR-3,CWL-Medium
PastoralCounselingCenter
DanSiegel-NoDramaDisciplineThisisaparentingapproachandisnotrated.
AustinChildGuidanceCenter;CalFarley'sBoysRanch;HelpingHandsHomeforChildren;PresbyterianChildren'sHomeandServices;STARRY
EyeMovementDesensitizationandReprocessing(EMDR)NREPPRatingEMDR-Includedasalegacyprogramnotcurrentlyratedinthenewsystem.CECBRatingsEMDRChildandAdolecent:SR-1,CWL-Medium
321stDistrictCourtofSmithCounty;AustinTravisCountyIntegralCare;CentersforChildrenandFamilies;DallasCAC;ElPasoChildGuidanceCenter;HelpingHandsHomeforChildren;PastoralCounselingCenter;SettlementHome;STARRY
ManagingAggressiveBehavior(MAB)MABisacrisismanagementprogram.NotratedintheNREPPorCECBdatabases.
PresbyterianChildren'sHomeandServices
MindUpMindUpisreportedtobeandevidence-basedsocialandemotionallearningprogram.
HelpingHandsHomeforChildren
NurturingParentingCECBRatingsNPSR-3,CWL-High
PresbyterianChildren'sHomeandServices
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Trauma-InformedPractice Agencies/OrganizationsParentChildInteractionTherapy(PCIT)CECBRatingsPCIT:SR-1,CWL-Medium
AssociateJudgeAuroraMartinezJones;AustinChildGuidanceCenter;CentersforChildrenandFamilies;CentralPlainsCenter;DallasCAC;ElPasoChildGuidanceCenter;HeartofTexasRegionalMHMR;PresbyterianChildren'sHomeandServices
PathwaystoPermanenceNotcurrentlyevidence-based.DFPSwithUTAustinisintheprocessofconductingastudyonitseffectiveness.
DFPS-Region7
PlayTherapyNoratingforplaytherapyingeneral.Theraplayisratedbelow.
PresbyterianChildren'sHomeandServices
ProblematicSexualBehaviorCognitiveBehavioralTherapy(PSB-CBT)NCTSNprovidesandoverviewofPS-CBT’sclinicalandanecdotalevidence.
DallasCAC
PsychologicalFirstAidCECBRatingsPFA:SR-NR,CWL-Medium
321stDistrictCourtofSmithCounty-JudgeCaroleClark;PresbyterianChildren'sServices
SandtrayThewebsiteforEvidence-basedChildTherapyindicatesthatSandtrayplaytherapyhasonerandomized-waitlistcontrolledstudy,andtwononrandomized-waitlistcontrolledstudies.
PresbyterianChildren'sHomeandServices
SatoriAlternativestoManageAggressiveBehavior(SAMA)SAMAfocusesonriskmanagementofaggressivebehaviors.ThispracticeisnotcontainedintheNREPPortheCECBdatabase.
CalFarley'sBoysRanch;HelpingHandsHomeforChildren
SeekingSafetyNREPPSS:Islistedasalegacyprogramandhasnotbeenratedusingthenewratingscale.CECBRatingsSS:SR-3,CWL-Medium
Aliviane;AssociateJudgeAuroraMartinezJones;AustinChildGuidanceCenter;AustinTravisCountyIntegralCare;CentersforChildrenandFamilies;CentralPlainsCenter;PresbyterianChildren'sHomeandServices
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Trauma-InformedPractice Agencies/OrganizationsSensoryIntegrationTherapySITisnotincludedinNREPPorCECB.TheAmericanOccupationalTherapyAssociationsupportstheimplementationofSITfordisagnosissuchasautism.
AssociateJudgeAuroraMartinezJones;CentralPlainsCenter;HelpingHandsHomeforChildren
Solution-focusedBriefTherapyCECBRatingSFBT:SR-NR,CWL-HighSFBTnotratedbyNREPPorCECB.Itwasratedas“promising”bytheOfficeofJuvenileJusticeandDelinquencyPrevention.
AssociateJudgeAuroraMartinezJones;AustinChildGuidanceCenter;CentersforChildrenandFamilies;PastoralCounselingCenter;PresbyterianChildren'sHomeandServices;WilliamsonCountyJuvenileDetentionCenter
TheraplayNREPPRatingTheraplay:Effectiveforinternalizingproblems.CECBRatingTheraplay:SR-3,CWL-Medium
HelpingHandsHomeforChildren
TraumaAffectRegulation:GuideforEducationandTherapyforAdolescents(TARGET-A)NREPPRatingTARGET:Effectiveforanxietydisordersandsymptoms,coping,generalfunctioningandwell-being,internalizingproblems,andtraumaandstress-relateddisorders.CECBRatingTARGET:SR-3,CWL-Medium
HeartofTexasRegionalMHMR
Trauma-FocusedCognitiveBehavioralTherapy(TF-CBT)NREPPRatingTF-CBT:EffectivefortraumaandstressrelateddisordersCECBRatingsTF-CBT:SR-1,CWL-High
Aliviane;AssociateJudgeAuroraMartinezJones;AustinChildGuidanceCenter;AustinTravisCountyIntegralCare;CentersforChildrenandFamilies;CentralPlainsCenter;DallasCAC;HeartofTexasRegionalMHMR;HelpingHandsHomeforChildren;PastoralCounselingCenter;PresbyterianChildren'sHomeandServices;SettlementHome;TexasTechUniversityHealthSciencesCenter;WilliamsonCountyJuvenileDetentionCenter;YsletaDelSurPueblo
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Appendix Five: Trauma-focused Approaches Utilized by Key Informants ChildandAdolescentEvidence-BasedandEvidence-InformedPracticesbyAgency
Agencies/Organizations Trauma-InformedPractice
321stDistrictCourtofSmithCountyCircleofSecurity,EMDR,PsychologicalFirstAid,andTBRI®
Aliviane SeekingSafetyandTF-CBT
AssociateJudgeAuroraMartinezJones
CircleofSecurity,EMDR,NMT,PCIT,SeekingSafety,SensoryIntegrationTherapy,SolutionFocusedTherapy,TF-CBT,TBRI®,andvariationsofCBT
AustinChildGuidanceCenterDanSiegel-NoDramaDiscipline,PCIT,SeekingSafety,SolutionFocusedTherapy,andTF-CBT
AustinTravisIntegralCare ART,EMDR,SeekingSafety,TF-CBT,andTBRI®
CalFarley’sBoysRanchDanSiegel-NoDramaDiscipline,NMT,NME,SatoriAlternativestoManageAggressiveBehavior,andTBRI®
CASAofTarrantCounty TBRI®
CASAofTravisCounty TBRI®
CentersforChildrenandFamiliesARC,EMDR,PCIT,SeekingSafety,SolutionFocusedTherapyandTF-CBT,andTBRI®
CentralPlainsCenterPCIT,SeekingSafety,SensoryIntegrationTherapy,andTF-CBT
DallasChildAdvocacyCenter EMDR,PCIT,PSB-CBT,andTF-CBTDePelchinChildren’sCenter TBRI®ElPasoChildGuidanceCenter EMDRandPCITHeartofTexasMHMR ARC,PCIT,TARGET-A,TF-CBT
HelpingHandsHomeforChildren
DanSiegel-NoDramaDiscipline,EMDR,Mindup,NMT,SatoriAlternativestoManageAggressiveBehavior,SensoryIntegrationTherapy,TBRI®,TF-CBT,andTheraplay
PastoralCounselingCenterCBITS,EMDR,SolutionFocusedTherapy,andTF-CBT
PresbyterianChildren’sHomeandServices
CircleofSecurity,DanSiegel-NoDramaDiscipline,ManagingAggressiveBehavior,NurturingParenting,PCIT,PlayTherapy,PsychologicalFirstAid,Sandtray,SeekingSafety,SolutionFocusedTherapy,TF-CBT,andTBRI®
SettlementHome EMDR,TBRI®,andTF-CBT
STARRY DanSiegel-NoDramaDiscipline,EMDR,andTBRI®
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Agencies/Organizations Trauma-InformedPractice
TexasTechUniversityHealthSciencesCenter TF-CBT
WilliamsonCountyJuvenileDetentionCenter ART,SolutionFocusedTherapy,TBRI®,andTF-CBT
YsletaDelSurPueblo TF-CBT
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Appendix Six: Travis County Collaborative for Children: Defining a Trauma-Informed Organization, Program, or System
Anorganization,program,orsystemthatistrauma-informeddoesthefollowing:
• Realizestheimpactoftrauma,includinghowitcanemotionally,behaviorally,andphysicallyaffectchildren,families,staff,volunteersaswellastheorganizationsthatworkwiththem.- Understandsaperson’sbehaviorinthecontextofcopingstrategiesthatare
designedtosurviveadversity,includingresponsestoprimaryandsecondarytrauma.Forinstancewhatpresentsasangermaybefear,andwhatpresentsasdisruptivebehaviormaybeself-preservation.
- Understandsthattheneedforatrauma-informedresponseisnotlimitedtomentalandbehavioralhealthspecialtyservicesbutisintegraltoallorganizationsandsystemsinvolvedinchildren’slives.Itmaypreventhealingandwellnessifnotaddressedacrosstheentirewebofthesesystems.
- Understandsthatapharmacologicalresponseand/orreducingtheriskofrepeattraumaalonecannotmeettheneedsofvulnerablechildren.Buildingrelationships,community,andthefeelingofsafetyarenecessaryforneuro-developmentandhealingfromearlytrauma.
• Recognizesthesignsoftraumaandconsistentlyincorporatestraumascreeningandassessmentintoallaspectsofwork,includinginteractionswithchildren,families,staff,andvolunteers.
• Respondsbyapplyingtheprinciplesofatrauma-informedapproachtoallareasoffunctioning.Theseincludethefollowing:- Staffandvolunteertrainingontraumaandtrauma-informedpractices.- Leadershipthatrealizestheroleoftraumaintheirstaffandthechildren/families
theyserve.- Policiesandpracticesthatensurethefollowingthreecorepillarsoftrauma-
informedcareareaddressed:o Connection:focusingontherelationalneedsofchildren,withspecialattention
towardsbuildingandstrengtheningsecureattachmentsbetweencaregiversandchildren
o Safety:creatinganenvironmentofphysical,social,andpsychologicalsafetyandmeetingthechild’sphysiologicalneeds;theseneedsincludegoodnutrition,adequatesleep,attentiontosensoryneeds,andregularphysicalactivity.
o Regulation:providingstructuredexperiencestoenhanceemotionalandbehavioralself-regulationinchildren,enhancingcaregivers’mindfulawarenessandtheirabilitytouseproactivestrategiesforbehavioralchange.
• Avoidsre-traumatizingchildren,caregivers,andstaffbyrecognizinghoworganizationalandsystempracticessuchasplacementdisruptions,seclusion,restraints,andabrupt
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transitionscancauseadditionalharmandinterferewithhealing.Relationshipsandnutritionarenotusedaspartofasystemofawards/consequences.
ExamplesofWhatTrauma-InformedCareLooksLikeIn…
CourtRooms
• Judgesandattorneysareinformedofresearch-based,trauma-informedresponses.
• Wherepossible,courtordersallowadequatetimeforchildrenandfamiliestoprepareforatransitiontoanewplacement.
• Placementdecisionsarebasedonensuringconnection,safety,andregulation.
CaseworkerEnvironment
• Caseworkersareconnectedemotionallywiththechildrentheyserve.
• Caseworkershavesensoryitemsavailableforchildrentouseifdesired.
• Nutritioussnacksandwaterareavailable.
• Caseworkershaveskillsetsthatareinformedbyresearch-based,trauma-informedresponseandpractices.
MedicalProviderOffices
• Medicalprovidersareawareofhowtraumacanemotionally,behaviorally,andphysicallyaffectchildren.
• Medicalprovidersunderstandthatapharmacologicalresponsealonecannotmeettheneedsofvulnerablechildren.
ResidentialTreatmentCenters
• Nutritioussnacksareavailableonrequest,notlockedorusedasrewardsforgoodbehavior.
• Sensoryroomsareavailableforchildrentousewhentheyrequestorchooseto.
• Allstaffandvolunteersaretrainedonresearch-based,trauma-informedresponsesandpractices.
• Behavioralcorrectionstrategiesaretrauma-informed;caregiversandstaffunderstandtheroleoffearinbehavior.
• Childrenmayusesensorytechniques/itemsduringinstructionaltime;theymaymoveanduseotherstrategiestohelpthemfeelincontrolphysically.
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ExamplesofWhatTrauma-InformedCareLooksLikeIn…
Homes • Caregiversfocusontherelationalneedsofchildrenwithspecialattentiontowardsbuildingandstrengtheningsecureattachments.
• Behavioralcorrectionstrategiesaretrauma-informed;caregiversunderstandtheroleoffearinbehavior.
• Caregiverscreateanenvironmentofphysical,psychological,andsocialsafety.
• Childrenhavenutritiousfoodandwateravailableatregularintervalsthroughoutthedaytomaintainstaminaandfocus.
• Childrenaregiventheopportunityforabreakand“re-do”afterdisruptivebehavior.
• Caregiversareself-awareandareabletouseproactivestrategiesforbehavioralchange.
HousesofWorship
• Wraparoundsupportisavailableforchildrenandfamilieswhohaveexperiencedtrauma.
• Learningandworshipsettingsareconducivetophysical,psychological,andsocialsafety.
Classrooms • Studentsmayusesensorytechniques/itemsduringinstructionaltime;theymaymoveanduseotherstrategiestohelpthemfeelincontrolphysically.
• Studentshavenutritiousfoodandwateravailableatregularintervalsthroughoutthedaytomaintainstaminaandfocus.
• Studentsaregiventheopportunityforabreakand“re-do”afterdisruptivebehaviorratherthanhavingamarkmovedorotherpenaltyimposed.