Creating Policies to Support
Trauma-informed
Perspectives and Practices
Janice L. Cooper, PhD
Interim Director
3rd Annual Symposium, Bridging the Gap
Fort Worth, Texas | November 3, 2009
Who We Are

NCCP is the nation’s leading research and policy
center dedicated to the economic security, health, and
well-being of America’s low-income children and
families.

Part of Columbia University’s Mailman School of
Public Health, NCCP promotes family-oriented
solutions at the state and national levels.

Our ultimate goal: Improved outcomes for the
next generation.
www.nccp.org
Outline

Background

Trauma and Its Effects

Special Populations

Current Services and Policy Challenges

Best Practices

Specific Policy Interventions

Policy Recommendations
www.nccp.org
Background

1982 Jane Knitzer’s seminal
study, Unclaimed Children: The
Failure of Public Responsibility to
Children and Adolescents in Need of
Mental Health Services

2005 work began for “Unclaimed
Children Revisited: The Status of
Children’s Mental Health in the
United States 25 Years Later ”

2007 released Trauma Report

2008 released national report
www.nccp.org
Throughout her remarkable life and its many diverse
experiences and achievements, Dr. Jane Knitzer
embodied one consistent theme:
that every child and every family
is sacred, and that it is every
person’s duty to reach out to the
most marginalized and vulnerable
among us.
NCCP Director
2004-2009
Her life’s work reflects these values at every stage.
Most recently on the IOM Committee on Depression,
Parenting Practices, and the Healthy Development
of Children
www.nccp.org
Unclaimed Children Revisited: Interests & Aims

Identify effective state fiscal, infrastructure, training
and related policies
 Research-informed
 Developmentally appropriate
 Family/youth driven
 Culturally competent

Promote research informed dialogue to move policy

Complement President’s New Freedom
Commission’s initiatives by disseminating
information on specific policy options
www.nccp.org
Understanding Trauma and its Effects

Trauma is pervasive.

Trauma refers to the severe distress, harm or
suffering that results from overwhelming mental or
emotional pain or physical injury.
www.nccp.org
Understanding Trauma and its Effects

A core feature of the impact of the trauma is the long
and short term loss experienced by those exposed to
traumatic events.

Critical elements of child development undermined
by trauma (Cloitre, Cohen and Koenen, 2006):
 healthy attachment,
 social and emotional competency,
 self-assurance, confidence,
 independence
www.nccp.org
Lessons from ACES Study
(Dube et al., 2001, Felitti et al., 1998)

Strong relationship between adverse childhood
experiences (5+)
 Suicide and Suicidal Attempts
 Chronic Illness (Obesity, Heart Disease, Liver Disease)
 Addictions
 Mental Health Problems
 Premature Death
www.nccp.org
What We Mean By Trauma-informed

Trauma-informed strategies ultimately seek to
(Harris & Fallot, 2001):
 do no further harm;
 create and sustain zones of safety for children, youth and
families who may have experienced trauma;
 promote understanding, coping, resilience, strengths-based
programming, growth, and healing
www.nccp.org
Children & Youth Disproportionately At-risk

Children from Military Families

Survivors of Abuse, Neglect & Sexual Violence

Children & Youth with Disabilities

Youth in Juvenile Justice

Children who Experienced Natural and Man-Made Disasters

Youth with Substance Use Disorders

Homeless & Runaway Youth

Children & Youth at Risk of Suicide

Youth of Color
www.nccp.org
Children from Military Families

Over 1.2 million children live in military families

Approximately 700K have at least one parent deployed
(Johnson et al., 2007)

Deployment predictive of:
 2X increase risk of child maltreatment (Gibbs et al., 2007)
 Increased risk of child trauma across developmental span from infancy
through adolescence (Lincoln, Swift, Shorteno-Fraser, 2008)
 32% child psychological morbidity; 42% high parental stress (5-12 yo)
(Flake et al., 2009)*
 High parental stress put children at more than 7X increase risk for poor
child psychological functioning*
 Among young children (U 5yo) those 3-5 higher levels of externalizing
behaviors independent of parental distress (Chartrand,et al., 2008)
www.nccp.org
Children and Youth from Military Families

Prevalence of Mental Health Problems among Military
Personnel
 Post deployment 20% of active duty and 42% of reservists
needed mental health treatment (not identify prior to
deployment) (Lamberg, 2008)*
 Reservists, National Guard and younger active duty service
members with combat related exposure increased risk for new
onset of heavy drinking, binge drinking and alcohol-related
problems (Jacobson et al., 2009)
 Lack of confidentiality may deter soldiers from accessing SUD
related treatment (Milliken, Auchterlonie & Hoge 2007)*
 Referrals to SUD treatment dramatically lower compared to
MH treatment*
www.nccp.org
Child/Youth Survivors of Abuse, Neglect &
Sexual Violence

Maine: 33% females and 67% males: a trauma related
diagnosis or were involved in child welfare due to
traumatic event (Yoe, Russell, Ryder, Perez and Boustead 2005)

50% female & 70 male rape survivors raped prior to
age 18 (Tjaden, P and Thoennes 2006)
 20% Females
 50% Males
 Raped by age 12
www.nccp.org
Children Who Experienced Abuse,
Neglect or Sexual Violence
www.nccp.org
www.nccp.org
www.nccp.org
Disabled Children & Youth at Higher Risk

More likely to be abused
(Sullivan & Knutson, 1998)
 physically (1.5 times)
 sexually (2.2 times)

Deaf children & youth higher risks
(Sullivan & Knutson, 1998)
www.nccp.org
High Prevalence of Trauma Exposure in
Juvenile Justice

Over 90 % in juvenile detention in a large urban
county have been exposed to at least one traumatic
event & nearly 60% have experienced 6 or more
traumatic events. (Abram et al, 2004)

11 % of youth in JJ were diagnosed with PTSD upon
clinical assessment. (Abram et al, 2004)
www.nccp.org
What the Data Shows School-age Youth in
Juvenile Detention
Males
Females
Any MH
disorder
Any SUD
disorder
Anxiety
disorder
ADHD
Any
Disrupt.
disorder
Affect.
disorder
65.5
73.8
50.7
46.8
21.3
30.8
16.6
21.4
41.4
45.6
18.7
27.7
Prevalence Behavioral Health Disorders of Youth in Detention by Gender (%)
NB: Approx. 90% of youth in JJ are males.
Source: Teplin, L., Abram, K., McClelland, G. M., Dulcan, M., & Washburn, J. J. (2006). Psychiatric
Disorders of Youth in Detention. Juvenile Justice Bulletin (April 2006), 1-16.
www.nccp.org
What Data Shows: School-age Youth Who
Experience Cumulative Trauma

Overall cumulative exposure to childhood trauma
= 82.5

Males were:
 3.3 x more likely than females to experience intentional or
“assaultive” violence (e.g. being raped, mugged, held up
or threatened with weapon)
 2.2 x more likely than females to experience other injury
or trauma
Source: Breslau, N., Wilcox, H. C., Storr, C. L., Lucia, V. C., & James, A. (2004). Trauma Exposure and PostTraumatic Stress Disorder: A Study of Youths in Urban America. Journal of Urban Health, 81(4), 531-544.
www.nccp.org
Children who experienced trauma from natural
and man-made disasters

Of Katrina survivors who were parents:
(Abramson & Garfield, 2006)
 Nearly 50% reported their children had new
emotional/behavioral problems
 Nearly 50% reported that they “never or only sometimes felt
safe”

Of all returning vets from Afghanistan & Iraq, those
of transition-age (18-25), were the most likely to
develop PTSD (Seal, Miner, Sen, & Marmar, 2007)*

Overall PTSD rates among veterans of OEF/OIF 4X
higher than community samples*
www.nccp.org
Youth with Substance Use Disorders
at High Risk

3-4 times higher risk for
PTSD (1)

Multiple exposures to
trauma predicted
developing SUD (2)

Youth with co-occurring
PTSD & SUD lower levels
of functioning (1)

SUD associated with
community violence,
interpersonal violence, child
maltreatment and self harm (3)

SUD can serve as mechanism
for self addressing trauma (3)

SUD impedes effective trauma
treatment (4)
1) Giaconia et al., 2000; 2) Giaconia et al., 1995; 3) Kilpatrick et al., 2003; 4) Jaycox, Ebener,
Damesek, & Becker, 2004; Riggs, 2003.
www.nccp.org
Children of Homeless Families & Runaway
Youth

Two-fifths of the homeless population in the United
States is made up of families (Bassuk et al, 2005).
Their homelessness puts them at increased risk for
other trauma, including physical and sexual violence,
emotional abuse and intense anxiety and uncertainty.

Almost two-thirds of homeless and runaway youth
living on the street have witnessed violence and
between 15-51 percent have been physically or
sexually assaulted (Kipke et al, 1997).
www.nccp.org
www.nccp.org
www.nccp.org
Children at Risk of Suicide

Three groups with a greater risk:
 American Indian/Alaska Native children and youth
 due to the historical trauma and current deprivation and
trauma
 64 % of all the completed suicide are committed by this
group nationally, 17.6/100,000 versus 10.4/100,000
(Middlebrook et al, 2005)
www.nccp.org
Children at Risk of Suicide

Adolescent Latinas
 A higher risk for suicide than Latino boys (15 % versus 7.8%)
and non-Latino boys and girls (Keaton et al, 2006).
 Among girls, Latinas attempted suicide 50-60% more than
African-American and white female adolescents (The
NHSDA report, 2003).
www.nccp.org
Children at Risk of Suicide

Gay, Lesbian, Bisexual, Transgendered and
Questioning Youth (GLBTQ)
 Between 1.7 and 2 times more likely than their non-gay and
lesbian peers to have suicidal thought (Russell & Joyner,
2001)
 More than 2.5 times more likely to attempt suicide than their
non-gay peers (Russell & Joyner, 2001)
www.nccp.org
Secondary/Vicarious Trauma among Providers

Impacts their ability as
caregivers (Bober et al., 2005)

Leads to higher rates of
turnover (Van Hook, 2008)

Provider with self care
strategies included these
in tx, led to lower levels
secondary trauma &
reduced turnover (Gordon,
2005)
www.nccp.org
Strategies to Reduce Vicarious Trauma
(Osofsky, Putnam & Lederman, 2008)

Smaller Caseloads

Self-care

Improve supervision of front-line workers

Access to mh services

Impart information on secondary trauma
www.nccp.org
Long-term Effects of Trauma

Negative Impact on Brain Development

Academic and Social Problems

Chronic Illness, Morbidity and Mortality

Intergenerational Impact
www.nccp.org
Current Service and Policy Challenges
www.nccp.org
Current Policy and Service Responses
Characterized by:

Failure to routinely screen and treat for trauma

Lack of traction to use proven effective treatment
strategies

Use treatment practices and environments that retraumatize
 Seclusion & Restraint
 Boot Camp
 Peer or Staff Abuse

Insufficient Attention to Vicarious/Secondary Trauma
www.nccp.org
Failure to Routinely Screen and Treat

Information on child trauma rarely received
according to some studies (Taylor et al., 2005; Hansen,
Hasselbrock & Tworkowski, 2002)
 84% of agencies reported in one study no/or extremely
limited information on child/youth trauma history

Much of emerging knowledge on trauma fails to
make it into daily practice (Taylor et al., 2005)
 33% of agencies report did not train staff to assess trauma
 Less than 50% reported training their staff on EBP for
children and youth with exposure to trauma
www.nccp.org
State Policies and Practices that Re-traumatize
www.nccp.org
GAO (2007) report on Abuse in State-sponsored
institutions: RTFs, boot-camps, wilderness camps

33 states with over 1600 staff involved in incidences of
abuse of children and youth in 2005

10 investigated deaths within RTFs (one case in
Texas) revealed common threads
 Untrained and inexperienced staff
 Lack of adequate nourishment in pursuit of “tough love”
philosophy/strategies
 Reckless/negligent operating procedures
www.nccp.org
SAMHSA Policy on Seclusion and Restraint
www.nccp.org
Other Public Policies Can Serve to Expose Children/Youth
to Trauma or Re-traumatize

Immigration Reform

Restrictive Housing Policies

Disaster Response Plans
Photo: P. Pereira, The Standard Times
www.nccp.org
Immigration Policies and Trauma

12 million undocumented workers in the US

Estimates 5 million children have at least one parent
undocumented

60% of these children are US-born citizens

Over 1.6 million immigration related arrests

Impact on children: Urban Institute/La Raza study
 506 children; impact on attending school, accessing resources,
getting different caring arrangements (Capps, et al. 2007)
 Children whose parents deported, arrested or detain in MN,
CO, TX, NE,IA (NCCP analysis, 2006)
www.nccp.org
Source: http://www.ice.gov/pi/news/factsheets/worksite.htm
www.nccp.org
Unaddressed Challenges

Funding Restrictions that Impeded Care and
Sustainable Treatment

Limited Support for Prevention & Early Intervention

Workforce problems: Inadequacy in Supply and
Quality
www.nccp.org
Identifying Best Practices: Key Elements
Services

Standardized Screening
and Assessments

Evidence-Based
Interventions

Culturally-Based
Strategies

Family and Youth
Engagement and
Support
Infrastructure

Training

Policies to Eliminate/
Reduce Seclusion &
Restraint

Financial Strategies

Culturally Competent
Policies

State Disaster-Related
Plans for MH services
www.nccp.org
Best Practices: Selected Screening & Assessment Tools









Acute Stress Checklist
Child Dissociative Checklist
Child Post-traumatic Stress
Reaction Index
Child PTSD Symptom Scale
Child Stress Disorder Checklist
Child’s Reaction to Trauma
Event Scale
Children’s Impact of Traumatic
Event Scale
Children’s PTSD Inventory
Children’s PTSD Interview







Children’s Sexual Behavior
Inventory
Clinician Administered PTSD
Scale
DISC (PTSD Module)
Lifetime Incidence Traumatic
Events
Los Angeles Symptoms
Checklist
Trauma Symptom Checklist
(Young Children/Children)
When Bad Things Happen
www.nccp.org
Selected Evidence-based Interventions

Parent Child Interaction Therapy aka Honoring
Children, Making Relations (Bigfoot)

Trauma-Focused CBT aka Honoring Children, Mending
the Circle (Bigfoot)

Cognitive Behavioral Interventions for Trauma in
Schools

Dialectical Behavior Therapy

Trauma Recovery and Empowerment for
Adolescents

Seeking Safety for Adolescents
www.nccp.org
Case Studies (NY, ND, ME)
www.nccp.org
North County Children’s Clinic (NCCC): New York

Watertown, NY

10th Mtn Division avg
deployment OEF/OEF 5x

Target Population- Families
(Children) of Military Personnel

27,000 residents (16,000
active duty military –
60% deployed)

4 school-based health centers provide over 2000 mental
health visits per year to children and families
www.nccp.org
North Country Children’s Clinic, New York
Strengths



Positive School Relations
Clinically sound
programming
Collaboration with the
Military HMO
Challenges





Military reimbursement for psy.
health care inadequate
Sustainable program funding
Magnitude of needs exceed
capacity
Gaps in the continuum of care
TriCare two-tier system;
disallows some PCTs for e.g.
family conflict and child maltx;
no coverage intensive commty tx
www.nccp.org
Quote from Family Member
We receive our medical care at the -- Ambulatory Health Clinic.
We took our son there in June and expressed our concerns for
his mental health. The Doctor wrote a referral for a child
psychologist in our town. That doctor had a 3 month waiting list
to get on the waiting list for an appointment. By now school had
started and we were having nights where he stayed up all night
crying, wanting his father to come home. If I did get him to
sleep, he woke up crying. It became a struggle even to get him
to go to school, he saw no use in going to school if that meant
growing up without his father. He had also started losing
interest in church, and cub scouts, two things that he usually
loves. He did not want to leave the house at all……
With the help of the school-based clinic I was able to start
helping my son cope with the deployment……
www.nccp.org
Medicine Moon Initiative-North Dakota

State-Tribal Initiative with
6 tribes

Built upon System of Care
Sacred Child Project

Strong training component
draws on cultural strengths
and lessons learned from
historical trauma
“Ours is a way of teaching parents that children are sacred”
Courtesy: Deb Painte, MMI
www.nccp.org
Medicine Moon Initiative-ND
Strengths

Culturally competent

Wraparound

Agreement with the
state to bill directly for
Medicaid

Challenges

Lack of sufficient
psychiatric or behavioral
resources to meet the
most acute needs

Lack of funding
Focus on both current
and historical trauma
www.nccp.org
Thrive: Trauma-informed System of Care,
Maine

Care delivery through
trauma-lens

Age 0-12

Service philosophy:
“What has happened to
this family” not, “What is
wrong with this family”
www.nccp.org
Thrive: Trauma-informed System of Care,
Maine
Strengths






System of care focused on
strength, engaging whole
family
Universal screening
Promotion of effective
trauma specific treatments
Staff Training
Use of trauma sensitive
assessments
Quality assurance
Challenges




On-going provider buy-in,
territorial issues pose
obstacles to collaboration
Medicaid managed care
curve-out
Struggles with substantive
inclusion of all relevant
agencies
Sustainable financial and
programmatic efficacy
www.nccp.org
Literature Review & Analysis of publicly available
data: Main Data Sources

Jennings, Ann. (2004). Blueprint for Action. Building
Trauma-Informed Mental Health Service Systems:
State Accomplishments, Activities and Resources.
September 2004.
http://www.annafoundation.org/articles.html

State block grant applications. 2004-2007

SAMHSA Grant Awards - State Summaries FY
2005/2006

Personal Interviews with selected state officials
www.nccp.org
Services: Standardized Screening and
Assessments

Most states offer some form of screening and
assessment.

In nearly 60 percent of states and territories
(data available on 46 states) universal or selective
screenings and assessments are being conducted.
In many cases the scope is limited.
www.nccp.org
Services: Evidence-Based Interventions

In less than 20 percent of states which provide
screenings and assessments, the screening and
assessment tools are evidence-based.

More than 50 percent of states provide evidencebased treatment/services; however, the scope is
mostly limited.
www.nccp.org
Services: Culturally-Based Strategies

About 30 % of states have culturally competent,
trauma informed or focused treatment/services.
www.nccp.org
Infrastructure: Training

Many states have developed training strategies of
varying depth to increase the clinical and support
capacity of those who deliver services to children,
youth and their families who have been exposed to
trauma.
 Nearly 40 percent of states (data available for 38 states)
report training on trauma-informed/specific evidence-based
practices.
 A small proportion of this training focuses on cultural
groups, gender or families.
www.nccp.org
Infrastructure: Training (cont’d)

While not widespread some best practices in training
in states include:
 Strategies those aimed at developing trauma specialists as in
Oklahoma
 System-wide or discipline-wide training like in Connecticut,
Maine, Nevada, New York, Oklahoma, Illinois and
Washington
 Trauma-related training that meet the conditions for state
clinician certification as in Wyoming
 Embedding a trauma focus in statewide evidence-based
training dissemination center in New York
www.nccp.org
Infrastructure: Policies to Eliminate/Reduce
Seclusion & Restraint

At least twenty states have implemented laws,
regulations or policies designed to reduce and
ultimately eliminate the use of seclusion and
restraint. Five of these states have implemented
strategies with far-reaching impact.
www.nccp.org
Infrastructure: Financial Strategies

A number of state legislatures have also appropriated
funding for specific trauma-related initiatives.

Other state leaders have expanded the Medicaid
benefit set to reimburse evidence-based trauma
treatments, to facilitate trauma-specific treatments
through billing and to fund specific clinicians.

Generally absent are any state specific strategies to
use the focus on information technology to create a
more trauma-informed system.
www.nccp.org
Infrastructure: Culturally Competent Policies

8 states reported have culturally competent,
trauma-focused policies.








Alaska
Connecticut
Illinois
New York
Oklahoma
South Carolina
Vermont
Washington
www.nccp.org
Highlights of State Responses: Illinois & Oklahoma
Illinois




Legislation requiring trauma
informed services
State plan for child welfare
includes public health
framework
Workforce development
Use of Effective Treatment
Strategies
Oklahoma




Trauma strategies heavily
workforce development
centered
Promotes cross systems
collaboration
Full-time state level trauma
coordinator
Evaluates and provides TA to
contractors based on Jennings
checklist of administrative
practices and services
www.nccp.org
Key Elements of Success

Leadership Support

Funding
 State
• Child Trauma Counseling
Lessons Learned

Standards for Trauma
Informed Care

Standards/Core
Competencies for Trauma
Informed Care

Communication is essential

Develop a common
language for trauma.

Transformation takes time.
 Federal
• Co-occurring Initiative
• Cross Training Initiative
• Transformation Initiative
• National Child Traumatic
Stress Initiative

Full time coordinator

Collaboration
Courtesy: Julie Young, OK
www.nccp.org
What did NCCP Survey Questions
on Trauma Add?
www.nccp.org
Systematic Screening or Intervention for Trauma
or Suicide Risk (Children and/or their Parents)

40 states report systematic screening or treatment for
trauma or suicide risk

13 states did not respond or systematic screen/treat

Common state efforts
 12 reported screening for trauma/suicide risk (4 reported using
Columbia Teen Screen)
 10 states reported providing training on validated tools such as on
TF-CBT; Applied Suicide Intervention Skills Training (ASIST);
Question, Persuade & Refer (QPR); and, crisis/suicide prevention
and intervention
 7 states report using funds like Garrett Smith funds for prevention
www.nccp.org
Plan to Deliver Mental Health Services and
Supports in Times of Disaster or Emergency

34 states reported that they had a specific plan

17 states reported that they did not have a plan

2 states did not respond
Designated Individual in CMH charged with service
coordination in the case of disaster/emergency

24 states reported they had a designated individual

8 states reported that they did not (in case of 3 for
MH not specifically child mh)

17 missing/NA
www.nccp.org
Types of Responses from States on MH Services
for Children in State Emergency Plan

Each regional coordinator has a designated emergency
satellite phone

Regional (10) disaster management teams

A system of trained and coordinated crisis counseling
staff and networks

A network ready to respond of volunteers and
professionals

“All hazards” leadership team

A MOU with community behavioral health centers to
coordinate, organize and mobilize during any crisis
www.nccp.org
Policy Recommendations
www.nccp.org
All federal, tribal, state and local policies
should reflect a trauma-informed perspective

Important factors:
 Developmentally appropriate
 Culturally & Linguistically Competent
 Encompass public health framework
 Engage children, youth and their families in healing.
 Fiscally-responsive
 Collaborative
 Accountable
 Support infrastructural development
 Competency-based training
 Address vicarious trauma
www.nccp.org
Policies should support/reinforce:

Delivery systems that identify and implement
strategies to prevent trauma, increase capacity for
early intervention and intervention and provide
comprehensive treatment

Strategies designed to prevent and eliminate
practices that cause trauma or re-traumatize

Core components of best practices in traumainformed care: prevention, developmentally
appropriate, empirically supported strategies,
cultural and linguistic competence and family and
youth engagement
www.nccp.org
Trauma-informed related policies must
include/ensure:

Funding that is supportive of care and that
adequately reimburses for effective strategies

Funding is contingent upon elimination harmful
practices that re-traumatize

Investment in strategies to ensure workforce
competency in effective strategies

Provision of incentives for care delivered in
community-based settings like schools and child care
settings in addition to health care settings
www.nccp.org
For More Information, Contact:
Dr. Janice Cooper
cooper@nccp.org
Or Visit NCCP web site
www.nccp.org
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