When the Twig is Bent:
An Integrated Approach to Children In
Foster Care
William Holmes MD
Medical Director for Foster Car...
Objectives
• Discuss overview and awareness of trauma
and PTSD in the foster care population.
• Discuss Cenpatico’s approa...
The State of the Union
• 8.3 Mil kids lived with at least one parent dependent upon
alcohol or drugs in a 2007 survey
• In...
What is PTSD
• According to the National Institute of Mental
Health, PTSD is an anxiety disorder that may
develop followin...
PTSD and Children in Foster Care
• PTSD rate varies by exposure type
• One study of foster care children, found PTSD for
6...
PTSD and Children in Foster Care
• Another study found PTSD symptoms in 19.2% of
child welfare investigated kids placed in...
It sure leaves a lasting impact
Throughout life children exposed to trauma / PTSD:
• More substance use problems and DV
• ...
Another View
The ACE Study: Adverse Childhood Events
Kaiser Permanente’s Dept of Preventative Med.
Access to 58,000 Medica...
ACE Score Impacts
18,000 Kaiser volunteers, 22% reported being sexually abused as
children (aveerageage in study=55)
•More...
ACE Score Impacts
ACE Study Impact Examples
•A child with 4 ACEs was 390% more likely to have COPD
• A male child with ACE...
Adverse Childhood Experiences (ACE) Study Felitti, VJ, Anda, RF, et. al. Jrnl of Prev. Med 1998
Adverse Childhood Events
u...
MH Needs of Children in Foster Care
• In Sept. 2011, there were approximately 400,540
children in foster care nationwide
•...
Issues of Med in Foster Care: Why
Important?
• There is strong evidence of high use of
psychotropic med use in foster care...
Psychotropic Medications (PMs)
and Foster Care
• Studies of PMs in foster care are out of date and
often geographically sp...
Psychotropic Medications and
Foster Care
• Youth in foster care with Medicaid get 3 times the
Psychotropic Medications (PM...
Use of Medication in Foster Care:
Responses
• Importance of quality evaluation /assessment
(e.g. does hyperactive behavior...
PMUR - Psychotropic Medication
Utilization Review
• Goal: Improved use of appropriate medication
treatment
• Elements of P...
PMUR - Psychotropic Medication
Utilization Review
• Results (TX specific right now, just beginning
to use in other states)...
Developed by: Texas Department of Family and Protective Services and
The University of Texas at Austin College of Pharmacy...
Attention to a National Problem
A National Response
• The Fostering Connections to Success and
Increasing Adoptions Act of...
Not Just a Mental Health Problem
“The overrepresentation of people with
SMI or Co-Occurring Disorder (COD )in
the criminal...
Mental Health Meets Criminal Justice
• Prevalence of (SMI) in the crim. justice system is 3-6
times the rate in general U....
The Hope of System Collaboration
• Violence and trauma exposure is not an automatic lifelong ticket
to dysfunction
• The s...
What Is Trauma Awareness?
• Trauma results from adverse life experiences that overwhelm
an individual’s capacity to cope a...
What is Trauma-Informed
“When a human service program takes the step to
become trauma-informed, every part of its
organiza...
Trauma Specific Treatments
• There are numerous child and adolescent treatment
interventions with strong evidence base of ...
Non- Pharmacological
Interventions
A few names you may hear: Range Birth to 21
– Trauma-Focused Cognitive Behavioral Thera...
Non- Pharmacological
Interventions
Some Resources:
• SAMHSA National Registry of Evidence Based Programs and
practices www...
Becoming Trauma Aware in
Criminal Justice
• “there is consensus that high percentages of justice-
involved women and men h...
How Being Trauma-Informed Improves
Criminal Justice Responses
• Create and awareness and understanding of the
impact of tr...
Trauma Informed Policing
• Being aware when intervening and children
are present of what they see, hear and
experience
• C...
Screening and Assessment
• Protective services, L.E. and MH can co-train,
respond together when appropriate or it is
know ...
Responding at the Scene
• We understand that the mission of LE at the
point of intervention is a specific one and has
diff...
Helping Children at the Scene
• Ask where Children are –check if hurt, safe
• Describe your role in simple terms
• Speak a...
Helping Children at the Scene
• Reassure that what is happening with adults is
NOT their fault
• Explain to children why a...
Helpful Responses for Children
• Addressing kids on their level ? Get in the ROLES
• Relaxed manner
• Open posture (no fol...
Follow-up Can Support Resiliency
• On occasion children have visited precincts,
fire stations or met with responders in ot...
Who Helps the Helper?
-Secondary Traumatic Stress and Burnout Among Law
Enforcement Investigators Exposed to Disturbing Me...
William Holmes MD
wholmes@cenpatico.com
Roy Van Tassell, MS LPC
rvantassell@cenpatico.com
Thank You for Your Participation!
Tue vs   centpatico - van tassell
Tue vs   centpatico - van tassell
Tue vs   centpatico - van tassell
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    1. 1. When the Twig is Bent: An Integrated Approach to Children In Foster Care William Holmes MD Medical Director for Foster Care Cenpatico Roy VanTassellMS LPC Director Trauma Evidence-Based Interventions Cenpatico
    2. 2. Objectives • Discuss overview and awareness of trauma and PTSD in the foster care population. • Discuss Cenpatico’s approach to trauma focused treatment for kids in foster care • Discuss use and overuse of psychotropic medications for children in foster care • Gain an understanding of how medication use, exposure to parent substance use and trauma may affect future Rx Medication misuse
    3. 3. The State of the Union • 8.3 Mil kids lived with at least one parent dependent upon alcohol or drugs in a 2007 survey • In U.S. someone dies of drug OD every 19 minutes • Since 1999 Rx painkiller scripts have quadrupled • 6.1 Mil Americans abused Rx drugs in 2011 (down from 2010) • But number of deaths from Rx drugs doubled since 1999 • Rx deaths are more than those for heroin and coke combined • Drug OD deaths now exceed motor vehicle deaths in 29 states Sources: Trust for America’s Health; childwelfare.gov; National Survey on Drug Use and Health; CNN
    4. 4. What is PTSD • According to the National Institute of Mental Health, PTSD is an anxiety disorder that may develop following an individual’s experiencing or witnessing of a traumatic event, where the natural “fight or flight” response is damaged or altered. Although no longer in danger, the individual may feel stressed or intense fear following a situation in which they or another person experienced a threat to their life or incurred severe injury • [Now in DSM-5 Diagnosis includes indirect exposure and fits children under 6] Hamblen & Barnett, 2009
    5. 5. PTSD and Children in Foster Care • PTSD rate varies by exposure type • One study of foster care children, found PTSD for 60% of CSA kids, 42% of physically abused kids • Also 18% of those w/neither PA or SA still had PTSD, perhaps due to DV, community violence, or other exposures. • A study of kids ages 6-8 entering foster care found that one out of three met criteria for PTSD Dubnerand Motta 1999, Marsenich, 2002, Dale et. al., 1999.
    6. 6. PTSD and Children in Foster Care • Another study found PTSD symptoms in 19.2% of child welfare investigated kids placed in foster care • Over 21% of foster care alumni suffer from PTSD, a rate higher than U.S. war veterans • About 48% of children/youth in foster care have emotional or behavioral problems and 63% are victims of neglect Kolko et. al., 2010, Pecoraet al., 2005, Casey Family Programs, 2011
    7. 7. It sure leaves a lasting impact Throughout life children exposed to trauma / PTSD: • More substance use problems and DV • Use more mental health services (Inpt, OP, Res Tx) • Less likely to complete secondary or advanced education • More trouble attaining and holding stable employment • More disrupted –less trusting relationships • More problems with criminal justice system • More verbally, physically abusive to their others/own children • Experience more homelessness • Longer the exposure, worse the outcomes • More life long physical health care services • On average will die 20 years younger
    8. 8. Another View The ACE Study: Adverse Childhood Events Kaiser Permanente’s Dept of Preventative Med. Access to 58,000 Medical Psychological and Bio-Social member evaluations per yr. 18,000 volunteers, studied for 8 categories of childhood abuse / household dysfunction Abuse: Recurrent Physical, Emotional and Sexual Abuse Household [Family] Dysfunction: Someone in prison Mother treated violently Alcoholic or drug abuser One bio-parent lost for any reason Someone chronically depressed, mentally ill or suicidal
    9. 9. ACE Score Impacts 18,000 Kaiser volunteers, 22% reported being sexually abused as children (aveerageage in study=55) •More than half had one or more ACEs •One in 4 had 3 categories (25%) •One in 16 had 4 categories (6.2%) •Having one ACE = 80% likelihood of exposure to another
    10. 10. ACE Score Impacts ACE Study Impact Examples •A child with 4 ACEs was 390% more likely to have COPD • A male child with ACE of 6 has a 4,600% increased risk of adult IV drug use • Child with ACE of 4 or more was 460% more likely to suffer clinical depression • An ACE of 4 had a 1,220% increase in suicide attempts over 0 ACE group Felitti, V. The Relationship of Adverse Childhood Experiences to Adult Health: Turning Gold Into Lead www.acestudy.org
    11. 11. Adverse Childhood Experiences (ACE) Study Felitti, VJ, Anda, RF, et. al. Jrnl of Prev. Med 1998 Adverse Childhood Events underlie the Top 10 causes of death in the U.S. Ave 19 yr shorter lifespan 6 ACES = Ave Death age 60
    12. 12. MH Needs of Children in Foster Care • In Sept. 2011, there were approximately 400,540 children in foster care nationwide • 23% of maltreated kids age 17 and under have behavior problems requiring clinical treatment 3x rate of the general population • In a study of foster youth ages 14 and 17, 63% met criteria for at least one mental health diagnosis. • Kids in FC make up 3% of those under 18 with Medicaid, but receive 32% of the behavioral services for that age group U.S. Children’s Bureau, 2012, ACF 2012 Oversight of Psychotropic Medication for Children in Foster Care;
    13. 13. Issues of Med in Foster Care: Why Important? • There is strong evidence of high use of psychotropic med use in foster care • Texas experience with this… • Emotional and behavioral care needs for children in Foster care • Are medications helpful? Needed for kids in FC? • Naturally, increased prescribing may lead to increased use and potential for diversion of meds and misuse / abuse
    14. 14. Psychotropic Medications (PMs) and Foster Care • Studies of PMs in foster care are out of date and often geographically specific (within & between states) • Studied rates varied from 13%-52% of kids in care • PM use affected by age, gender, behavior, placement – Age: (more PMs and more types as kids age) – Gender: (3x more males vs. female) – Behavior (internalized vs. externalized) – Placement type (more restrictive = more PMs) ACF: Oversight of Psychotropic Medication for Children in Foster Care; Title IV-B Health Care Oversight & Coordination Plan 2012
    15. 15. Psychotropic Medications and Foster Care • Youth in foster care with Medicaid get 3 times the Psychotropic Medications (PMs) of other Medicaid qualified youth • The same study found 41% got three different classes of PMs almost 16% got 4 classes • 22% got 2 or more meds in same PM class regardless of diagnosis • Yet these children have significant mental health and behavioral treatment needs Zito, et. al. Pediatrics, 2008
    16. 16. Use of Medication in Foster Care: Responses • Importance of quality evaluation /assessment (e.g. does hyperactive behavior mean ADHD?) • Increased awareness of EBTs and education about trauma is essential • Problems with availability / access to EBTs for some children • QI programs focus on med use and management
    17. 17. PMUR - Psychotropic Medication Utilization Review • Goal: Improved use of appropriate medication treatment • Elements of PMUR: – Pharmacy data – Parameters – Review of clinical information – Contact with prescribers
    18. 18. PMUR - Psychotropic Medication Utilization Review • Results (TX specific right now, just beginning to use in other states) • Future goals: – Connecting correct meds with given diagnosis – Monitoring medication compliance – Monitoring / evaluating use of non-medication intervention effectiveness
    19. 19. Developed by: Texas Department of Family and Protective Services and The University of Texas at Austin College of Pharmacy with review and input provided by: ™Federation of Texas Psychiatry Texas Pediatric Society ™Texas Academy of Family Physicians Texas Medical Association And Rutgers University—Center for Education and Research on Mental Therapeutics September 2013 A Collaborative Texas Initiative
    20. 20. Attention to a National Problem A National Response • The Fostering Connections to Success and Increasing Adoptions Act of 2008 requires all states to increase their oversight of the health and mental health of foster care children, including initial and follow up health assessments to determine whether a child needs additional help (e.g. specialized trauma services) The Fostering Connections to Success and Increasing Adoptions Act of 2008 (Public Law (P.L.) 110-351) amended title IV-B, subpart 1 of the Social Security act
    21. 21. Not Just a Mental Health Problem “The overrepresentation of people with SMI or Co-Occurring Disorder (COD )in the criminal justice system has a significant impact on the recovery path of these individuals, creates stress for their families, and has an effect on public safety and government spending.” Blandford, A. &Osher, F. (2012). A Checklist for Implementing Evidence- Based Practices and Programs (EBPs) for Justice-Involved Adults with Behavioral Health Disorders. Delmar, NY: SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation.
    22. 22. Mental Health Meets Criminal Justice • Prevalence of (SMI) in the crim. justice system is 3-6 times the rate in general U.S. population • A study of over 20k adults in 5 jails found 14.5 % of male inmates, 31% of female met SMI criteria • Finding suggests more than 2mil. bookings of a person with SMI occur annually. • Of 17% of jailed with SMI, estimated 72% had a co- occurring substance use disorder. • 59 percent of state prisoners with mental illnesses had a co-occurring drug and/or alcohol problem
    23. 23. The Hope of System Collaboration • Violence and trauma exposure is not an automatic lifelong ticket to dysfunction • The single biggest factor in what helps kids is having a supportive, believing, consistent, nurturing care-giver and safe place in the community • There are very effective evidenced-basedcommunity programs, responses and treatments that have been clinically demonstrated to provide healing from exposure to violence and abuse for adults and children • There are effective action steps for prevention which everyone can help foster in any community, the cycles can be broken
    24. 24. What Is Trauma Awareness? • Trauma results from adverse life experiences that overwhelm an individual’s capacity to cope and to adapt positively • “Traumatic events produce profound and lasting changes in physiological arousal, emotion, cognition, and memory…may sever these normally integrated functions from one another” • It’s “lasting impact represents a combination of the event and the subjective thoughts and feelings it engenders”. • An event becomes traumatic when its adverse effect produces feelings of helplessness and lack of control, and thoughts that one’s survival may possibly be in danger. “Stress becomes trauma when the intensity of frightening events becomes unmanageable to the point of threatening physical and psychological integrity” (Van derKolk, 1996, Judith Herman, 1992, Lieberman & Van Horn, 2008)
    25. 25. What is Trauma-Informed “When a human service program takes the step to become trauma-informed, every part of its organization, management, and service delivery system is assessed and potentially modified to include a basic understanding of how trauma affects the life of an individual seeking services. “Trauma-informed organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization”. SAMHSA National Center On Trauma Informed Care
    26. 26. Trauma Specific Treatments • There are numerous child and adolescent treatment interventions with strong evidence base of effectiveness • Models range from birth to 21 some with or w/o parent • For individual, group, family, early childhood and incarcerated youth. • A range of community based and parent education and support interventions, those with evidence should be first line choices • The earlier child needs can be identified the earlier intervention can occur
    27. 27. Non- Pharmacological Interventions A few names you may hear: Range Birth to 21 – Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) – Alternatives for Families Cognitive Behavioral Therapy – Child Parent Psychotherapy (CPP) – Cognitive Behavioral Intervention for Trauma in School – Parent Child Interaction Therapy (PCIT) – Child and Family Traumatic Stress Intervention (CF-TSI) – Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS) – Trauma Affect Regulation: Guidelines for Education and Therapy Adolescent (TARGET-A)
    28. 28. Non- Pharmacological Interventions Some Resources: • SAMHSA National Registry of Evidence Based Programs and practices www.nrepp.samhsa.gov • National Child Traumatic Stress Network’s Empirically Supported Treatments and Promising Practices http://www.nctsnet.org/resources/topics/treatments-that- work/promising-practices • Evidence Based Practice Facts Sheets: Gains Center for Behavioral Health and Justice Transformation http://gainscenter.samhsa.gov/topical_resources/ebps.asp • Office of Juvenile Justice and Delinquency Prevention Model Programs Guide: http://www.ojjdp.gov/MPG
    29. 29. Becoming Trauma Aware in Criminal Justice • “there is consensus that high percentages of justice- involved women and men have experienced serious trauma throughout their lifetime. • The reverberating effect of trauma experiences can challenge a person’s capacity for recovery and pose significant barriers to accessing services, often resulting in an increased risk of coming into contact with the criminal justice system “ Policy Research Associates
    30. 30. How Being Trauma-Informed Improves Criminal Justice Responses • Create and awareness and understanding of the impact of trauma • Create an awareness of the impact of trauma on behavior, • Develop trauma-informed responses. • Provide strategies for developing and implementing trauma-informed policies. See more at: http://gainscenter.samhsa.gov/trauma/trauma_training.asp http://www.prainc.com/how-being-trauma-informed-improves-criminal-justice- responses/#sthash.UF8vLzq2.dpuf
    31. 31. Trauma Informed Policing • Being aware when intervening and children are present of what they see, hear and experience • Children key off of adult, care givers even impaired ones are child’s psychological safe base • Threats to caregivers will threaten child’s sense of safety, vulnerability
    32. 32. Screening and Assessment • Protective services, L.E. and MH can co-train, respond together when appropriate or it is know that children will be present • Every child brought into care or whose parents are identified as having substance use issues should be screened / assessed (shelters?) • Children who receive immediate preventive interventions show fewer short and long term symptoms / negative effects
    33. 33. Responding at the Scene • We understand that the mission of LE at the point of intervention is a specific one and has different priorities e.g. secure the scene / safety, etc. • But where possible and as soon as possible attend to the needs of children present, be aware of what they see, especially involving caregivers
    34. 34. Helping Children at the Scene • Ask where Children are –check if hurt, safe • Describe your role in simple terms • Speak at their level (kneeling, sitting, squating) • Try not to talk badly about parent in front of child • Keep kids with known adults when possible • Don’t say “everything will be OK” or make promises you can’t keep
    35. 35. Helping Children at the Scene • Reassure that what is happening with adults is NOT their fault • Explain to children why any use of force was necessary • Provide parent or other caregiver with information about safety, resources as appropriate
    36. 36. Helpful Responses for Children • Addressing kids on their level ? Get in the ROLES • Relaxed manner • Open posture (no folded arms or hands on hips) • Lean towards slightly w/ upper body (on level) • Eye contact (direct but not piercing, warm) • Space between you (note how close, not allowing them to feel trapped, but blocking distressful visual scenes is helpful)
    37. 37. Follow-up Can Support Resiliency • On occasion children have visited precincts, fire stations or met with responders in other settings (schools community settings) after the scene to restore connections reduce fear and avoidance • Helps to underscore task of safety at time of intervention and what occurred as necessary to get people help keep everyone safe
    38. 38. Who Helps the Helper? -Secondary Traumatic Stress and Burnout Among Law Enforcement Investigators Exposed to Disturbing Media Images Lisa M. Perez &Jeremy Jones &David R. Englert&Daniel Sachau,J Police Crim Psych (2010) 25:113–124 -Contamination of Cop: Secondary Traumatic Stress of Officers Responding to Civilian Suicides (From Suicide and Law Enforcement, P 337-355, 2001, Donald C. Sheehan and Janet I. Warren, eds. -- See NCJ-193528) Author(s): John Nicoletti ; Sally Spencer-Thomas, 2001 Nat. Criminal Justice Reference Service -The Cause and Effect of Secondary Traumatic Stress Written by Federal Employee Defense Services on 19 May 2011. Posted in The Spotlight FED AGENT .COM -Vicarious Traumatization and Spirituality in Law Enforcement FBI Law Enforcement Bulletin , July 2011 Vicarious Traumatization *Greater attention being given in last few years to Secondary Traumatic Stress for law enforcement
    39. 39. William Holmes MD wholmes@cenpatico.com Roy Van Tassell, MS LPC rvantassell@cenpatico.com Thank You for Your Participation!

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