www.cebc4cw.org

Riding the Waves of Change Evidence Based Practice Implementation Science Trauma Informed Systems Charles Wilson, MSSW, Senior Director Chadwick Center for Children and Families Rady Children’s Hospital - San Diego, California

www.ChadwickCenter.org

What starts as a ripple of change

At first looks like unfocused energy

Builds in waves of energy

Often traveling in sets of change

Ultimately impacts when it meets the right environmental trigger

Some Waves of Change have a bigger impact than others

If you are not ready for the waves of change – beware - you will get run over

The trick is to harness the energy

And learn how and when to take advantage of the wave of energy

Even I can do it

What is in Our Set of Change Waves Today?

Admiral Dom Vasco de Gama

100 of the crew of 160 died of scurvy

Captain James Lancaster • In 1601 he conducted an RCT of lemon juice for scurvy • At the halfway point of the trip 110 (40%) of the 278 sailors on the three “control group ships had died of scurvy vs. none on the lemon juice ship • 264 years after the first definitive trial, the British ordered proper diets on merchant marine vessels in 1865

The Rogers Curve

Innovators Early Majority

Late Majority

Early Adopters 2.5%

13.5%

Traditionalists 34%

34%

16%

Distinguishing groundless marketing claims from reality

The Problem: All sorts of “interventions ” are available out there. Ben Saunders MUSC

Waiting Room Sign

Ben Saunders MUSC

Why Evidence-Based Practice Now? •A growing body of scientific knowledge allows us to take a closer look at practices •Increased interest in outcomes and accountability by funders •Increased interest in consistent application of quality services

Why Evidence-Based Practice Now? •Past missteps in spreading untested “best practices” that turned out not to be as effective as advertised •Continuing focus on safety and effectiveness of interventions •Impact of EBPs on worker retention and satisfaction

CEBC’s Definition of EBP for Child Welfare

Best Research Evidence

Best Clinical Experience

EBP

Consistent with Family & Client Values

[Institute of Medicine (IOM), 2001]

Scientific Rating Scale [**Based on a Continuum**]

Not Able to Be Rated

Topics Currently on the Website • Anger Management, Domestic Violence, and Substance Abuse • Behavior Management including Parent Training • Core Child Welfare Services including Placement and Reunification • Engagement and Parent Partnering Programs • Mental Health • Prevention and Early Intervention • Support Services for Youth in the Child Welfare System

Other Materials on CEBC Website • Reviews of commonly used Screening and Assessment tools • Training materials – Webinars and on-line tutorials

• Implementation resources – Selection guide – Program–specific resources

Levels of Implementation • Paper • Process • Performance – Real organic organizational change at the cultural level Fixsen, D., Naoosm, S., Blasé, K., Friedman, R., Wallace, F. (2005) http://nirn.fmhi.usf.edu

Learning is Hard

EPIS: Stages of Implementation

Stages of ChangeMotivational Interviewing • Precontemplation Stage • Contemplation Stage • Preparation Stage • Action and Sustainment

Exploration Phase • Actively considering the possibility of implementing an evidence-based practice • A key step involves awareness of an issue that needs to be addressed in a more effective way – Drill down to core issues

• What problem first and then next?

Sample Tasks in the Exploration Phase • Work with stakeholders to identify factors that may support or detract from effective implementation of a new program – Funding issues – Existing agency policies and practices – Staffing issues

Sample Tasks in the Exploration Phase • Determine what areas need to be addressed with evidence-based practices – Where do weaknesses currently exist in your services? – What data do you have on these issues? – What are the outcomes you want to see? – Drill down past symptoms to causes • Ask why five times

Sample Tasks in the Exploration Phase • Consider which potential EBPs target the core issues you want to address • Develop internal support for the changes at administrative and staff levels • Consider the fit of the potential EBPs in your organization – Supervision process, IT, documentation requirements, referral process, workforce, etc.

Preparation Phase • Agency has made the decision to adopt a specific EBP and is doing the planning and preparation work necessary to effectively implement it – Organizational readiness – Skills acquisition and integration – Referral Pathway development – Find and push leavers of real change

Sample Tasks in the Preparation Phase • Work with stakeholders to develop contracts or memorandums of agreement regarding referral, client engagement, and fidelity monitoring • Determine how the EBP services will be funded

Sample Tasks in the Preparation Phase • Make sure that timetables for staff training and certification meet with existing service and productivity requirements • Address any consumer concerns, such as potential for stigma, applicability of practices for client needs and culture • Create or reinforce referral pathways

Implementation Phase • Agency is actively delivering the new practice in the community – Monitor Fidelity – Routinize Change

Sample Tasks in the Implementation Phase • Execute contracts developed during the Preparation phase • Assess on-going training needs • Monitor program indicators – Process – Outcomes

• Continue working with stakeholders to assess the impact of the program

Sustainment Phase • Agency has the new practice firmly in place and wants to continue it indefinitely • Embedding the New Practice in the organization/system culture so it becomes the new business as usual.

Sample Tasks in the Sustainment Phase • Embed the practice in agency materials – policy and procedure manuals, forms, new employee orientation, annual trainings, etc. • Clarify long-term funding streams • On-going fidelity monitoring and training • Evaluate program to support sustainment

Challenges and Controversies • One Size Does Not Fit All-One model is rarely enough to meet needs • Common Elements • Application to Different Cultural Groups • Practice Based Evidence

Lessons Learned • Importance of Assessment and Referral pathway • Power of a change agent • Importance of sustained effect • How much evidence is enough?

Just when you figure out how to ride one wave of change

It’s time to try a new wave and a different way

Trauma Informed Systems

The Elephant in the Middle of the Room

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

What is Trauma? • First - it is an event or series of events • Second element is defined by the individual experience

What is Trauma? • First - it is an event or series of events • Second element is defined by the individual experience • Third - is the measurable impact

The impact of a potentially traumatic event depends on several factors, including: • Unique biological factors

• The child’s age and developmental stage • The child’s perception of the danger faced • Whether the child was the victim or a witness • The child’s relationship to the victim and/or perpetrator • The child’s past experience with trauma • Cumulative Nature of Trauma

• The adversities the child faces following the trauma • The presence/availability of adults who can offer help and protection

What Is Child Traumatic Stress? • Child traumatic stress refers to the physical and emotional responses of a child to events that threaten the life or physical integrity of the child or of someone critically important to the child (such as a parent or sibling) • Traumatic events overwhelm a child’s capacity to cope and elicit feelings of terror, powerlessness, and out-of-control physiological arousal

Types of Traumatic Stress • Acute trauma is a single traumatic event that is limited in time • Chronic trauma refers to the experience of multiple traumatic events • Complex trauma describes both exposure to chronic trauma - usually caused by adults entrusted with the child’s care - and the impact of such exposure on the child

Other Factors That Influence Meaning and Impact of Trauma • • • •

Historical Trauma Community Trauma World View Shaped by Personal Experience System Induced Adversities – e.g. Child Welfare

Link Between Environment and Behavior Abnormal Environment Violence, Abuse, Constant Arousal

Normal Environment

Absence of Violence and Threat

Adaptive Behaviors Survival, Fight, Flight, Rapid Emotional Change

Maladaptive Behaviors Survival, Fight, Flight, Rapid Emotional Change

Childhood Trauma and Other Diagnoses • Other common diagnoses for children in the child welfare system include: – Reactive Attachment Disorder – Attention Deficit Hyperactivity Disorder – Oppositional Defiant Disorder – Bipolar Disorder – Conduct Disorder • These diagnoses generally do not capture the full extent of the developmental impact of trauma • Many children with these diagnoses have a complex trauma history Dr. Gene Griffin, Northwester University

Symptoms that Overlap with Child Trauma and Mental Illness - (AACAP, 2010) DSM Diagnosis

Overlapping Symptoms

Trauma

1. Anxiety Disorders Avoidance of feared stimuli, physiological and psychological hyperarousal upon exposure to feared stimuli, sleep problems, hypervigilance, and increased startle reaction 2. Attention Deficit / Restless, hyperactive, disorganized, and/or Hyperactivity agitated activity; difficulty sleeping, poor Disorder concentration, and hypervigilant motor activity 3. Bipolar Disorder Hyperarousal and other anxiety symptoms mimicking hypomania; traumatic reenactment mimicking aggressive or hypersexual behavior; and maladaptive attempts at cognitive coping mimicking pseudo-manic statements 4. Major Depressive Self-injurious behaviors as avoidant coping with Disorder trauma reminders, social withdrawal, affective numbing, and/or sleep difficulties

Child Trauma

Child Trauma Child Trauma

Child Trauma

Gene Griffin, J.D., Ph.D. Northwestern University Medical School

Symptoms that Overlap with Child Trauma and Mental Illness - (AACAP, 2010) DSM Diagnosis

Overlapping Symptoms

Trauma

5. Oppositional Defiant Disorder

A predominance of angry outbursts and irritability

Child Trauma

6. Panic Disorder

Striking anxiety and psychological and physiologic distress upon exposure to trauma reminders and avoidance of talking about the trauma Severely agitated, hypervigilance, flashbacks, sleep disturbance, numbing, and/or social withdrawal, unusual perceptions, impairment of sensorium and fluctuating levels of consciousness Drugs and/or alcohol used to numb or avoid trauma reminders

Child Trauma

7. Psychotic Disorder

8. Substance Abuse Disorder

Child Trauma

Child Trauma

Gene Griffin, J.D., Ph.D. Northwestern University Medical School

Adverse Childhood Experiences •Abuse and Neglect (e.g., psychological, physical, sexual) •Household Dysfunction (e.g., domestic violence, substance abuse, mental illness)

Impact on Child Development •Neurobiologic Effects (e.g., brain abnormalities, stress hormone dysregulation) •Psychosocial Effects (e.g., poor attachment, poor socialization, poor self-efficacy) •Health Risk Behaviors (e.g., smoking, obesity, substance abuse, promiscuity)

Long-Term Consequences Disease and Disability •Major Depression, Suicide, PTSD •Drug and Alcohol Abuse •Heart Disease •Cancer •Chronic Lung Disease •Sexually Transmitted Diseases •Intergenerational transmission of abuse

Social Problems •Homelessness •Prostitution •Criminal Behavior •Unemployment •Parenting problems •Family violence •High utilization of health and social services -- F. Putnam, 2008 Data: www.AceStudy.org, www.nasmhpd.org

Developmental Cascade of Transgenerational Child Maltreatment Risk -- F. Putnam, ‘08

Child Adolescent

Adult OhioCanDo4Kids.Org

Some Trauma Comes at the Hands of the Good Guys

Emotional Chain of Custody

Seeing Through a Trauma Lens

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

Essential Elements of a TraumaInformed Child Welfare System

Element #1: Maximize Physical and Psychological Safety for Children and Families Safety is one of the priorities of the child welfare system – but for a child and family who have experienced trauma, they may still feel unsafe even when they are no longer in a dangerous situation. Given this, in addition to ensuring physical safety, it is important to help children and families feel psychologically safe.

Key Terms in Thinking About Psychological Safety • Trauma Reminder •

“The child’s memory retains those learned links, and such thoughts and memories are sufficient to elicit ongoing fear and make a child anxious” - National Scientific Council on the Developing Child (2010)

• Trauma Trigger

Element #2: Identify Trauma-Related Needs of Children and Families • One of the first steps in helping trauma-exposed children and families is to understand how they have been impacted by trauma • Trauma-related needs can be identified through trauma screening and assessment • It is important to consider trauma when making service referrals and service plans

Element #3: Enhance Child WellBeing and Resilience • Many children are naturally resilient • It is important for the child welfare system to recognize and build on children’s existing strengths • Both individual caseworkers and overall agency policies should support the continuity of children’s relationships • Child welfare staff and agencies should also ensure that children who have been traumatized have access to evidence-based trauma treatments and services

Core Components of Trauma-Focused, Evidence-Based Treatment •

Building a strong therapeutic relationship

•

Psychoeducation about normal responses to trauma

•

Parent support, conjoint therapy, or parent training

•

Emotional expression and regulation skills

•

Anxiety management and relaxation skills

•

Trauma processing and integration

•

Personal safety training and other important empowerment activities

•

Resilience and closure

Element #4: Enhance Family WellBeing and Resilience •

•

•

Families are a critical part of both protecting children from harm and enhancing their natural resilience Providing trauma-informed education and services to parents and other caregivers enhances their protective capacities Child welfare agencies should recognize that caregivers themselves may have trauma histories

Element #5: Enhance the Well-Being and Resilience of Those Working in the System

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•

While child welfare staff play an important role in supporting children, working with people that have experienced abuse, neglect, violence, and other trauma can cause staff to develop secondary traumatic stress reactions

•

Child welfare agencies should collect information about trauma and secondary trauma experienced by staff, implement strategies and practices that build resilience and help staff manage stress, and address the impact of secondary traumatic stress on both individuals and on the system as a whole

Element #6: Partner with Youth and Families •

Youth and families should be given choices and an active voice in decisionmaking on an individual, agency, and systemic level

•

Youth and family members who have been in the system have a unique perspective and can provide valuable feedback

•

Partnerships with youth and families should occur at all levels of the organization

Element #7: Partner with Agencies and Systems that Interact with Children and Families •

Child welfare agencies need to establish strong partnerships with other child and family-serving systems

•

Service providers should develop common protocols and frameworks

•

Cross-system collaboration enables all helping professionals to see the child as a whole person, thus preventing potentially competing priorities and messages

•

Collaboration between the child welfare and mental health systems promotes cohesive care and better outcomes

Key Points About These Waves of Change • EBP is the answer sometimes • Know what you are gettingbuyer beware • The key is in the system change • Beware of over-generalizing

Resources • • • • • • •

Chadwick Trauma-Informed Systems Project - www.ctisp.org California Evidence-Based Clearinghouse for Child Welfare www.cebc4cw.org National Child Traumatic Stress Network - www.nctsn.org and http://learn.nctsn.org Chadwick Center for Children and Families - www.ChadwickCenter.org Child Welfare Trauma Training Toolkit http://www.nctsn.org/nccts/nav.do?pid=ctr_cwtool Caring for Children who Have Experienced Trauma: A Guide for Resource Parents - www.nctsn.org/rpc Journal of Child Welfare – Special Issue on “Effectively Addressing the Impact of Child Traumatic Stress in Child Welfare.” Volume 90, No. 6. Published in 2011

Tragic Events Do Not Need to Rob Children of Happiness - We can Give Them the Tools to Move Beyond the Pain

Contact Information Charles Wilson E-mail: [email protected] Ph: 858-966-5421

Trauma Informed Systems Lisa Conradi E-mail: [email protected] Ph: 858-576-1700 x6008 CEBC Cambria Walsh E-mail: [email protected] Ph: 858-576-1700 x2736