"From Hurricane to Home" by Dr. Doug.Walker

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"From Hurricane to Home" by Dr. Doug.Walker

  1. 1. From Hurricane to Home: Evolving Trauma Treatment with Students and Families Douglas W. Walker, PhD Clinical Director Mercy Family Center Project Fleur-de-lis
  2. 2. Objectives • 1) Participants will be able to identify the rationale and programmatic challenges in creating this multi- stepped approach to addressing student’s mental health needs in the aftermath of a natural disaster. • 2) Participants will be able to identify the types and trends of psychological and educational problems of over 1,000 students who have been identified as needing intensive “third-tier” mental health services in the New Orleans community over the past three years via Project Fleur-de-lis’ weekly clinical triage.
  3. 3. TM
  4. 4. Background: Project Fleur-de-lis
  5. 5. Fleur-de-lis: Flower of light
  6. 6. Project Fleur-de-lis Project Fleur-de-lis™ is a comprehensive mental health care program for New Orleans area students designed as an intermediate and long-term school-based mental health service model for children who have been exposed to traumatic events as a result of natural and man-made disasters.
  7. 7. Best Practice: Stepped Care Approach to Mental Health Intervention • Multi-tiered levels of care • Pro-active focus is on addressing symptoms before they interfere with child’s educational or social emotional functioning • Focus is upon working with child with emotional/behavioral issues in a “non-clinical” intervention model • Utilize evidence-based treatment models and identified “best practice” in the field of child trauma
  8. 8. • Established in 1992 as a Sisters of Mercy Outreach Ministry • Managed by Sisters of Mercy Health System • Provides outpatient psychological and psychiatry services for children and adolescents • Offices in Mandeville, Metairie and Algiers • NCQA Certified • Non-profit, 501 (c) (3) organization • Project Fleur-de-lis is owned and managed by Mercy Family Center Mercy Family Center
  9. 9. School Participation • 64 participating schools • 26,000 children under project’s umbrella of care • Serving the Parishes of Orleans, Jefferson, St. John, St. Charles, St. Tammany, Washington and Plaquemines
  10. 10. Continued Success Project Fleur-de-lis is the largest school based mental health program in the Greater New Orleans Area Princeton University – Woodrow Wilson School of Public and International Affairs. (January 2007). Coping with Katrina: Mental health services in New Orleans.
  11. 11. Collaborative Partners • American Red Cross • RAND Health • Louisiana Public Health Institute • Catholic Charities – Archdiocese of New Orleans • Tulane University – Department of Social Work & Psychology • LA-YES • Morehouse School of Medicine's Regional Coordinating Center for Hurricane Response (RCC) • Louisiana Rural Trauma Services Center – LSUHSC • All Participating Schools; counselors, social workers, administrators, teachers, families
  12. 12. Dual Programming Tier Three: Community-Based Intervention (TF-CBT) Tier Two: Classroom-Based Intervention (CBITS) Tier One: School-Based Intervention (CBI) Trauma Specific Programming School-Wide Issues: Collective Issues of Response and Recovery Classroom – Community Consultation (C3): Triage Child Specific Issues for possible referral into Community Community Based Interventions: Psychology, Psychiatry, Social Work School-Based Identification of All Mental Health / Learning Issues
  13. 13. History & Timeline for Project Fleur-de-lis
  14. 14. August 2005 Monday Tuesday Wednesday Thursday Friday Saturday Sunday 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Hurricane Katrina
  15. 15. January 2006 Monday Tuesday Wednesday Thursday Friday Saturday Sunday 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 CCANO and Mercy Family Center form counselor team and divide 73 Archdiocesan schools among them for initial contact and needs assessment Because of the team’s success they are soon referred as “THE AWESOME SIX”
  16. 16. Needs Assessment • 6 counselors divided among 73 schools to collect data • Obtained information to determine school’s interest in services and/or interventions, need for a school counselor, % of devastation to school, families, & community
  17. 17. March 2006 Monday Tuesday Wednesday Thursday Friday Saturday Sunday 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Proposal to LPHI for Funding to Support ERS Development and Implementation Classroom Based Intervention© Training by Save the Children
  18. 18. Stepped Trauma Pathway Enables schools to reach all children exposed to a traumatic event and triage them “up” to higher, more appropriate levels of trauma intervention if needed
  19. 19. Stepped-Care Approach Tier One: School-Based Intervention (CBI)
  20. 20. Classroom Based Intervention (CBI®) Robert Macy, Ph.D. Boston Center for Trauma Psychology Trauma Informed, Developmentally Specificity, & Ethnocultural Specificity Evidence Based Methodological Framework
  21. 21. July 2006 Monday Tuesday Wednesday Thursday Friday Saturday Sunday 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Training: Cognitive Behavioral Intervention for Trauma in Schools (CBITS)
  22. 22. Stepped-Care Approach Tier Two: Classroom-Based Intervention (CBITS) Tier One: School-Based Intervention (CBI)
  23. 23. Cognitive-Behavioral Intervention for Trauma in Schools (CBITS) Lisa Jaycox, Ph.D. RAND Corporation Identified as a Promising Practice by SAMSHA
  24. 24. August 2006 Monday Tuesday Wednesday Thursday Friday Saturday Sunday 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Training: Trauma Focused – Cognitive Behavioral Therapy Training NCTSN Learning Collaborative Electronic Records System becomes fully operational
  25. 25. Stepped-Care Approach Tier Three: Community-Based Intervention (TF-CBT) Tier Two: Classroom-Based Intervention (CBITS) Tier One: School-Based Intervention (CBI)
  26. 26. Trauma Focused- Cognitive Behavioral Therapy (TF-CBT) Judith A. Cohen, M.D. Anthony Mannarino, Ph.D. Center for Traumatic Stress in Children & Adolescents Allegheny General Hospital, Pittsburgh, PA Esther Deblinger, M.D. CARES Institute University of Medicine & Dentistry of New Jersey School of Osteopathic Medicine Stratford , NJ Identified as a Model Program by SAMHSA
  27. 27. September 2006 Monday Tuesday Wednesday Thursday Friday Saturday Sunday 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 First C3 weekly staff meeting
  28. 28. Dual Programming School-Wide Issues: Collective Issues of Response and Recovery Classroom – Community Consultation (C3): Triage Child Specific Issues for possible referral into Community Community Based Interventions: Psychology, Psychiatry, Social Work School-Based Identification of All Mental Health / Learning Issues
  29. 29. Classroom - Community Consultation (C3) Enables schools and communities to identify children with all types of mental health and/or learning issues and triage them to appropriate care in the community
  30. 30. C3 School-Wide Issues Brought to C3 by school counselors. School-wide issues and concerns addressed by peer consultation and shared community resources Classroom – Community Consultation (C3) Weekly consultation meetings with school-based counselors to discuss students that may be in need of community based services. Goal is to support counselor interventions with students in schools to avoid decrease in adaptive functioning. Rely on Electronic Records System maintained by counselors and PFDL™ staff to promote continuity of care and quality improvement initiatives Community Based Interventions Psychiatry, Psychology, Psycho-educational Assessments, Wrap-Around Services
  31. 31. What We Have Learned
  32. 32. Hurricane Assessment Instrument: Summer of 2007 Survey based upon approximately 2,000 registered students summer 2007. Currently have over 4,000 registered students in ERS system.
  33. 33. Hurricane Assessment Instrument: Neighborhood Destroyed 56% 44% Intact Neighborhood Destroyed
  34. 34. Hurricane Assessment Instrument: Witnessed Injury or Death During Storm 97% 3% Intact Witnessed Injury of Death
  35. 35. Hurricane Assessment Instrument: Separated from Parent/Caregiver 83% 17% Family Together Separated from Parent/Caregiver
  36. 36. Hurricane Assessment Instrument: Family or Friend Injured 94% 6% Healthy Injured
  37. 37. Hurricane Assessment Instrument: Pet Lost/Dead 81% 19% - Pet Lost/Dead
  38. 38. Hurricane Assessment Instrument: Trapped During Storm 95% 5% - Trapped During Storm
  39. 39. Hurricane Assessment Instrument: Displaced From Home During Storm 24% 76% - Displaced During Storm
  40. 40. Hurricane Assessment Instrument: Past Major Trauma 82% 18% - Past Major Trauma
  41. 41. Hurricane Assessment Instrument: Home Badly Damaged 60% 40% - Home Badly Damaged
  42. 42. Hurricane Assessment Instrument: Belongings Destroyed 62% 38% - Belongings Destroyed
  43. 43. Number of Students Triaged Via C3
  44. 44. C3 Results 250 18 539 10 0 100 200 300 400 500 600 2006-2007 2007-2008 Number of Children Referred Number of Children Not Referred
  45. 45. C3 Results Three-Year Totals 250 18 539 10 412 31 0 100 200 300 400 500 600 2006-2007 2007-2008 2008-2009 as of 3/12/09 Number of Children Referred Number of Children Not Referred
  46. 46. C3 Results Third-Year Projected* 250 18 539 10 572* 39 0 100 200 300 400 500 600 2006-2007 2007-2008 2008-2009 as of 3/12/09 Number of Children Referred Number of Children Not Referred
  47. 47. Pediatric Symptom Checklist • Utilized as one of multiple screening devices used during C3 meetings • Includes all types of signs and symptoms that occur in school age children
  48. 48. Developmental Trauma Disorder • DSM-V criteria will include: – Exposure – Affective and physiological dysregulation – Attention and Behavioral dysregulation – Self and Relational dysregulation PTSD is an adult diagnosis that does not capture developmental impairments in emotional regulation, attention, cognition, perception and interpersonal relationships van der Kolk, B. (March 19, 2009). Closing Plenary. NCTSN All Network Conference, Orlando.
  49. 49. 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Distracted easily School grades dropping Has trouble concentrating Fidgety, unable to sit Feels sad, unhappy Less interested in school Is irritable, angry Has trouble with teacher Is down on him or herself Does not listen to rules Pediatric Symptom Checklist: Top Ten Symptoms 2006-2007
  50. 50. 0% 10% 20% 30% 40% 50% 60% 70% Has trouble concentrating Distracted easily School grades dropping Fidgety, unable to sit Daydreams too much Feels sad, unhappy Less interested in school Does not listen to rules Is irritable, angry Worries a lot Pediatric Symptom Checklist: Top Ten Symptoms 2007-2008
  51. 51. C3 Referral Types and Trends
  52. 52. C3 Community Triage: By Type 2006-2007 School Year 43% 7% 7% 43% Psycho-Educational Evaluation Therapy Psychiatry No Referral Necessary
  53. 53. C3 Community Triage: By Type 2007-2008 School Year 53% 8% 2% 1% 36% Psycho-Educational Evaluation Therapy Psychiatry No Referral Necessary Case Management
  54. 54. C3 Referrals: Followed Through with Services 2006-2007 School Year 58% 42% Followed Through with services Did Not Follow Through with services
  55. 55. C3 Referrals: Followed Through with Services 2007-2008 School Year 68% 32% Followed Through with services Did Not Follow Through with services
  56. 56. Combined 2006-2007 Triage by Month (268 total) 0 10 20 30 40 50 S O N D J F M A M J J A No Referral Necessary Psychiatry Therapy Psycho- Educational Evaluation
  57. 57. Combined 2007-2008 Triage by Month (549 total) 0 10 20 30 40 50 60 70 80 90 S O N D J F M A M J J A Case Management No Referral Necessary Psychiatry Therapy Psycho- Educational Evaluation
  58. 58. Autumn 2008 (143) 0 10 20 30 40 50 60 70 80 90 100 110 120 130 S O N D Case Management No Referral Necessary Psychiatry Therapy Psycho- Educational Evaluation
  59. 59. Significant Increase September to October 2008 • Only 2 C³ meetings in September (9/19/08 & 9/26/08) – 9/5 meeting cancelled because we were evacuated for Hurricane Gustav – 9/12 meeting cancelled due to extreme weather from Hurricane Ike • October numbers above include 5 C³ meetings (10/3, 10/10, 10/17, 10/24, & 10/31)
  60. 60. What We Have Accomplished
  61. 61. Free Care Via C3 $700,000 675 Children Have Received No Cost Outpatient Mental Health Care Since 9/1/06
  62. 62. Trauma Trends September 1, 2006 to Present All New!!
  63. 63. 70 124 76 0 20 40 60 80 100 120 140 2006 – 2007 2007-2008 2008-2009* Total Trauma Referrals by Year *To date.
  64. 64. 89 71 44 32 11 10 9 4 2 0 10 20 30 40 50 60 70 80 90 100 Hurricane Death/Illness of Relative/Close Friend Divorce/Separation Domestic Violence Incarceration Parent Sexual Abuse Death of Parent Physical/Illness/Self Community Violence Types of Trauma Referrals September 2006 to Present
  65. 65. 0 2 4 6 8 10 12 9 11 1 3 5 7 10 12 2 4 9 11 1 2006 – 2007 2007-2008 2008-2009 Referrals for Trauma Treatment by Year & Month: Hurricane
  66. 66. 0 1 2 3 4 5 6 7 8 9 10 9 11 1 3 5 7 10 12 2 4 9 11 1 2006 – 2007 2007-2008 2008-2009 Referrals for Trauma Treatment by Year & Month: Divorce / Separation
  67. 67. 0 1 2 3 4 5 6 7 8 9 10 9 11 1 3 5 7 10 12 2 4 9 11 1 2006 – 2007 2007-2008 2008-2009 Referrals for Trauma Treatment by Year & Month: Incarceration of Parent
  68. 68. 0 1 2 3 4 5 6 7 8 9 10 9 11 1 3 5 7 10 12 2 4 9 11 1 2006 – 2007 2007-2008 2008-2009 Referrals for Trauma Treatment by Year & Month: Death of Parent
  69. 69. 0 1 2 3 4 5 6 7 8 9 10 9 11 1 3 5 7 10 12 2 4 9 11 1 2006 – 2007 2007-2008 2008-2009 Referrals for Trauma Treatment by Year & Month: Death/Illness of Relative or Close Friend
  70. 70. 0 1 2 3 4 5 6 7 8 9 10 9 11 1 3 5 7 10 12 2 4 9 11 1 2006 – 2007 2007-2008 2008-2009 Referrals for Trauma Treatment by Year & Month: Community Violence
  71. 71. 0 1 2 3 4 5 6 7 8 9 10 9 11 1 3 5 7 10 12 2 4 9 11 1 2006 – 2007 2007-2008 2008-2009 Referrals for Trauma Treatment by Year & Month: Domestic Violence
  72. 72. 0 1 2 3 4 5 6 7 8 9 10 9 11 1 3 5 7 10 12 2 4 9 11 1 2006 – 2007 2007-2008 2008-2009 Referrals for Trauma Treatment by Year & Month: Physical Illness/Injury Student
  73. 73. 0 1 2 3 4 5 6 7 8 9 10 9 11 1 3 5 7 10 12 2 4 9 11 1 2006 – 2007 2007-2008 2008-2009 Referrals for Trauma Treatment by Year & Month: Sexual Abuse
  74. 74. Percentage Referrals for Trauma Treatment / Total Trauma Referrals by Year
  75. 75. 70 124 76 0 20 40 60 80 100 120 140 2006 – 2007 2007-2008 2008-2009* Total Trauma Referrals by Year *To date.
  76. 76. 89 71 44 32 11 10 9 4 2 0 10 20 30 40 50 60 70 80 90 100 Hurricane Death/Illness of Relative/Close Friend Divorce/Separation Domestic Violence Incarceration Parent Sexual Abuse Death of Parent Physical/Illness/Self Community Violence Types of Trauma Referrals September 2006 to Present
  77. 77. 44 34 21 0 10 20 30 40 50 60 70 80 90 100 2006 – 2007 2007-2008 2008-2009 Percentage Referrals for Hurricane Trauma Treatment / Total Trauma Referrals by Year Percentage%
  78. 78. 16 17 16 0 10 20 30 40 50 60 70 80 90 100 2006 – 2007 2007-2008 2008-2009 Percentage Referrals for Divorce / Separation Trauma Treatment / Total Trauma Referrals by Year Percentage%
  79. 79. 4 1 10 0 10 20 30 40 50 60 70 80 90 100 2006 – 2007 2007-2008 2008-2009 Percentage Referrals for Incarceration Trauma Treatment / Total Trauma Referrals by Year Percentage%
  80. 80. 10 0 00 10 20 30 40 50 60 70 80 90 100 2006 – 2007 2007-2008 2008-2009 Percentage Referrals for Death of Parent Trauma Treatment / Total Trauma Referrals by Year Percentage%
  81. 81. 20 28 29 0 10 20 30 40 50 60 70 80 90 100 2006 – 2007 2007-2008 2008-2009 Percentage Referrals for Death/Illness of Relative or Close Friend Trauma Treatment / Total Trauma Referrals by Year Percentage%
  82. 82. 0 2 00 10 20 30 40 50 60 70 80 90 100 2006 – 2007 2007-2008 2008-2009 Percentage Referrals for Community Violence Trauma Treatment / Total Trauma Referrals by Year Percentage%
  83. 83. 3 15 14 0 10 20 30 40 50 60 70 80 90 100 2006 – 2007 2007-2008 2008-2009 Percentage Referrals for Domestic Violence Trauma Treatment / Total Trauma Referrals by Year Percentage%
  84. 84. 1 1 3 0 10 20 30 40 50 60 70 80 90 100 2006 – 2007 2007-2008 2008-2009 Percentage Referrals for Physical Illness/Injury Student Trauma Treatment / Total Trauma Referrals by Year Percentage%
  85. 85. 1 2 8 0 10 20 30 40 50 60 70 80 90 100 2006 – 2007 2007-2008 2008-2009 Percentage Referrals for Sexual Abuse Trauma Treatment / Total Trauma Referrals by Year Percentage%
  86. 86. Future Directions • Adding and dropping schools. Maintain 65 schools • Continue to add schools who seek our program • Additional care managers • Expand third-tier preferred provider list • Plan implementation of Stepped Trauma Pathway post future evacuation
  87. 87. Future Directions • Add trauma informed evidence-based treatments (i.e., Psychological First Aid for Schools) • Add Child Advocacy and Family Law representation to C3 meetings • Offer C3 expertise via telehealth to other programs/regions
  88. 88. Future Directions • Establish CBITS Learning Community in New Orleans – June 11-12 – Then offer training spring/fall each year – Support school counselors in screening and implementation – Consistent peer consultation throughout school year
  89. 89. Future Directions Compile data from three years of program into comprehensive paper for publication
  90. 90. Future Expansion • Adapt program to meet the needs of other communities along the Gulf Coast • Become intermediate and long-term mental health response of choice to future disasters through membership in NCTSN
  91. 91. Special Thanks to: Kate Gegenheimer Mimi Pecot John Hill Laura Danna Jayme Bensel Sharon Heno Beth Cooney
  92. 92. Douglas W. Walker, PhD Clinical Director – Mercy Family Center Project Director – Project Fleur-de-lis dwalker1@mercyfamilycenter.com
  93. 93. TM TM

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