Where the Rubber Hits the Road: Strategies for Implementing and - - PowerPoint PPT Presentation

Where the Rubber Hits the Road:

Strategies for Implementing and Sustaining Trauma-Informed Child Welfare Practice Erika Tullberg, MPA, MPH Bonnie Kerker, PhD

NYU Child Study Center

Georgia Boothe, LMSW

Children’s Aid Society

June 7, 2017

Today’s Agenda

• Trauma-informed child welfare practice
• The Atlas Project
• Starting the work
• Measuring the impact
• Sustainability

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Trauma-Informed Child Welfare Practice

Why Trauma-Informed Child Welfare Practice?

• High incidence of trauma among children and families in

the child welfare system

• >19% of youth in foster care have clinically significant post-traumatic

stress symptoms (Kolko et al., 2010)

• Foster care alumni have higher rates of PTSD compared to the general

population (21% vs. 4.5%) (Pecora et al., 2006)

• Impact of trauma on child health and development, adult

health

• Impact of trauma on child welfare outcomes

4

Essential Elements of Trauma-Informed Child Welfare Practice

• 1. Maximize physical and psychological safety for children

and families

• 2. Identify trauma-related needs of children and families
• 3. Enhance child well-being and resilience
• 4. Enhance family well-being and resilience
• 5. Enhance the well-being and resilience of those working

in the system

• 6. Partner with youth and families
• 7. Partner with agencies and systems that interact with

children and families

National Child Traumatic Stress Network

Using Trauma-Informed Child Welfare Practice to Improve Placement Stability Breakthrough Series Collaborative

• 1. Trauma-informed mental health assessment

(including screening)

• 2. Case planning and management
• 3. Trauma-informed services
• 4. Knowledge-building and developing practice
• 5. Cross-system partnerships and system collaboration

National Child Traumatic Stress Network

Child Welfare Traumameter

• 1. Recruitment and Training
• 2. Trauma Screening
• 3. Decision-making/Services Planning
• 4. Clinical Services
• 5. Support and Supervision
• 6. Working with Children and Families
• 7. Cultural Responsiveness

ACYF “Trauma” Projects

To meet the complex special needs of children and youth in foster care, child welfare systems must:

• Have universal screening for the early identification of children and

youth with behavioral and mental health needs;

• Provide universal and periodic functional assessment of the social-

emotional strengths and difficulties of a child and parenting capabilities using; and

• Ensure access to effective treatments and services that are aligned

with the assessed behavioral and mental health needs of children and youth with behavioral and mental health needs.

Administration on Children, Youth and Families

Atlas Project Elements

Staff and foster parent consultation and training

mental health screening mental health assessment treatment decision- making mental health treatment

Organizational planning Foster care-mental health provider partnerships

Mental Health Screening and Assessment

• Pediatric Symptom Checklist
• Looks at attention, internalizing and externalizing behavior
• Child Stress Disorders Checklist
• Looks at trauma exposure and symptoms

Both tools:

• Have shorter

versions

• Have youth and
• bserver versions
• Are available in

Spanish

Child Ecology Check-In

Looks at child’s emotional and behavioral dysregulation, the stability of caretakers, foster care agency and larger service system

Intervention for Environmental Risk

highest score for ANY environmental item

Intervention for Child’s Symptoms

highest score for ANY symptom item Low need (1 or 2) Moderate need (3) High need (4 or 5) Low need (1 or 2)

No intervention (bucket 6) Social intervention (bucket 5)

Moderate need (3)

Regular trauma intervention (bucket 2)

High need (4 or 5)

Safety-focused trauma intervention (bucket 1)

Trauma Systems Therapy

Child Social Environment

Assess child’s tendency to shift into SIM states Increase child’s capacity to stay regulated even when confronted by cat hair Assess the social environment’s capacity to help & protect the child Increase the social environment’s capacity to support the child’s regulation

Trauma Systems Therapy

• Team-based model
• Grounded in foster care and mental health program

partnership

• “Therapy” includes what child welfare staff and

foster parents do

Trauma Systems Therapy… Moving from speculation to KNOWING

Moments Survival in the Moment pattern

Trauma Systems Therapy… Moving from speculation to KNOWING

pattern

Safe & healthy relationships

Addressing Secondary Trauma

• Looking at secondary

trauma experienced by staff across the agency

• Collecting data on

people’s perceptions of:

• Supervisors’ trauma-related

practice

• Secondary trauma-related

skills

• Secondary trauma

identification and support

Our supervisors and administrators identify when their staff are suffering from STS and provide effective support and guidance to them

2 4 6 8 10 12 14 16 18 Mostly Sometimes Rarely

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Starting the Work

Can our agency take this on?

• Financial and time-related resources
• Staff strengths and weaknesses
• Organizational capacity

Impact on scope of project and ramping up schedule

Potential Barriers and Facilitators

• Staff turnover
• Time limitations
• Initiative fatigue
• Integrate tools/processes into

existing practice

• Replace activities when

possible, instead of adding on

• Flexibility re scope, timing

Staff Attrition:

October 2016-March 2017

Position # of Staff # who left # positions that were vacant 1+ month % Attrition Social worker 6 5 2 83% Socio- Therapist 7 2 29% Supervisor 2

• 0%

Potential Barriers and Facilitators

Acknowledge the impact of trauma on children, families, staff

• Increases engagement, success of

interventions

• Increases trauma exposure,

related stress may make staff more rigid, fall back into old patterns

Planning Process

• Plan BEFORE implementation
• Involve all levels of staff
• Identify how new processes will be integrated into

existing processes

• Balancing existing demands while shifting practice
• Account for billable time
• Create infrastructure for sustainability from the

beginning

• Training
• Day-to-day leadership

Culture Change

• How does an agency’s existing culture facilitate or get

in the way of trauma-informed practice?

• How can this be effectively be harnessed and/or addressed

during the implementation process?

• How can the adoption of

trauma-informed practices help drive positive culture change?

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Measuring the Impact

Why is this important?

• Important to know if we’re doing what

we wanted to do

• Important to know how we can do it

more effectively

• Important to know if we are achieving our goals
• Important to know what would help us achieve our goals
• Important to show funders that this work is worth their

continued support

• Important to show us that this work is worth our effort!!

Align with Agency Priorities

• Helps to increase staff and

leadership buy-in

• Reduces burden of data

collection

• Helps people see the
• utcomes of the work

Data Collection

• Use administrative data whenever possible
• Lateral moves, step-ups, time in care, hospitalizations
• For symptom-level data, primary collection is often

necessary

• Comparison Groups
• Benefits of collecting qualitative data
• Can inform the implementation process
• Can capture more subtle changes in practice
• IRB approvals

Atlas Implementation Study:

Foster Parent Focus Groups

• Implemented annually with foster parents at each

Atlas agency

• Aimed at informing Atlas development and

monitoring the relationship between foster staff and parents over time

• Used a semi-structured guide to

conduct the groups, and qualitative methods were used to identify themes in the data

Foster Parent Focus Group Domains

• Relationships and communication with foster care

agency staff

• Tools and training
• Clinical care

Foster Parent Focus Group Results:

An Example

• Lack of communication with

foster care staff was a concern among most agencies’ foster parents – highly dependent on the individual worker

• In one follow-up focus group,

foster parents were less critical than the first about individual staff members and were more likely to attribute the problems they faced to structural issues in the agency.

Atlas Implementation Study:

Agency Leadership Interviews

• Conducted with 2-3 leaders per agency
• Conducted towards the end of the first year of

implementation, and annually when possible

• Aimed at understanding the main barriers and challenges

to successfully implementing Atlas

• An interview guide was used

Agency Leadership Interview Guide

• Expectations (are they being met?)
• Challenges in implementation
• Helpful parts of planning
• Training
• Weekly consultations

Agency Leadership Interview Results

• Communication about procedures

and expectations were not always clear

• Too much paperwork
• Trainings contained too much

information and lacked opportunity to practice new skills

• Lauded Atlas staff for dedication and

responsiveness

• Saw the benefits of the screening and

assessment tools

• Saw improvements in coordination among

staff and between agencies, staff’s clinical skills and ability of staff to address trauma

Agency Leadership Interview Results:

Changes Made

Communication about procedures and expectations were not always clear Too much paperwork Trainings contained too much information and lacked opportunity to practice new skills Sharpened and refined communication More flexibility in paperwork completion Separated out trainings

• ver time; included more

role plays in training

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Sustainability

Planning for Sustainability

• Maintain engagement of senior leadership

throughout implementation

• Identify a champion with decision-making authority

to drive day-to-day work

• Identify training capacity
• Don’t depend on sole individuals
• Challenge – don’t have the luxury of

duplicative staff

Last Thoughts

• To be successful and sustained, trauma-

informed interventions need to be integrated into ongoing program activities, not added on top

• Whatever challenges your program is having now, they will likely

influence the implementation process – plan ahead!

• Use data to inform implementation and make necessary

adjustments along the way

• Trauma-informed interventions are a necessary, but not sufficient,

part of trauma-informed child welfare practice

• How is trauma knowledge reflected in staff’s day-to-day work with

children and parents?

• What additional skills and support do your staff and foster parents

need? do your supervisors and administrators need?

Contact Information

Georgia Boothe, LMSW gboothe@childrensaidsociety.org Bonnie Kerker, PhD Bonnie.Kerker@nyumc.org Erika Tullberg, MPA, MPH Erika.Tullberg@nyumc.org

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Thank you!