Download Community-Based Interventions for Children

Community Based
Interventions In Two Parts:
Systems Of Care And
Approaches To Recovery From
Psychological Trauma
Lenore B. Behar, PhD, Director
Child & Family Program Strategies
Durham, North Carolina
Presentation for
Mississippi Institute on
School Health, Wellness
and Safety
The Super Conference
September 27-29, 2006
Philadelphia, Mississippi
For Bibliography & Slides
Go to: www.lenorebehar.com
See: Presentations
Community Based Interventions In Two Parts:
Systems Of Care And Approaches To
Recovery From Psychological Trauma
Mississippi Super Conference,September 2006
Definitions
Children:
The term “children” includes all
people eligible for System of Care
services, as defined by the
State.
Two Paths for Children
Exposed to Trauma
• System of Care as a Mode of
Service Delivery for Children with
Serious Emotional Problems
• Trauma Focused Interventions,
• usually Individual or Family
Therapies
Converging Paths for Children
Exposed to Trauma
 Since 1985, System of Care
has been federal policy for
children with serious emotional
disturbances, and their families
 Since 1993, System of Care has
been state policy in Mississippi
The Focus of System of Care
in Mississippi
To provide community based care
and decrease the use of
inappropriate out-of-home
placements by using pooled
resources from mental health,
education, child welfare, and
Medicaid for children with SED
How Mississippi SOC Evolved
• legislatively mandated services—one of
the first in the country
• mechanisms to review service quality
• policy guidance from the State
• state and community level interagency
teams for children who are difficult to
serve—multi-agency assessment and
planning teams (MAP)
• teams include agencies and parents
Support from the Family
Organization
• Mississippi Families as Allies for
Children's Mental Health (MSFAA)
established in 1990
• one of the first family-run, family
focused organizations in the country
• provided ongoing support to System of
Care development
System of Care Principles
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Child centered, individualized
Family focused
Community based
Comprehensive
Culturally competent
Accountable/evidence based
Coordinated across agencies
Requires care management
Why Do We Need SOC?
• Need collective expertise
• Need unified approach to child
and family
• Need to use all the resources
available to child and family
It Is Rocket Science!!
What is the Population for
the System of Care?
The definition is clear:
• Children with serious/severe emotional
disturbances and their families
• Children and families who need the
services of multiple agencies, or who
need multiple services
What is SED?
An emotional/behavioral disorder
diagnosed by a qualified
professional that:
• Requires services of several
agencies
• Significantly impairs functioning
• Is anticipated to continue for a
significant amount of time
Role of Agencies
• Identify children needing services
• Identify services needed by the
child and family
• Coordinate services within agency
• Coordinate services across
agencies
• Use a case manager, if needed
How to Access SOC/MAP
• Refer through your agency
representative to the MAP
Team
• Refer directly to the MAP
Team leader
• Refer through community
mental health center
Demonstration Sites
• 1999-2006, Children of Mississippi
and their Parents Accessing
Strength Based Services
(COMPASS) in Hinds County
• 2006-2012, the Pinebelt System of
Care in Forrest, Lamar and Marion
Counties
Acceptance of System of
Care
• Surgeon General’s Report, 2000
• Report of the President’s New
Freedom Commission, 2003
• Over $100 million annual funding by
Congress through the Center for
Mental Health Services, SAMHSA
• Lawsuit settlements in several states
• State statutes and policies
Relevance to Children Exposed
to Trauma
• 20 years of study of system of care
issues has clarified the value of
context of services
• Studies of clinical effectiveness of
services for children exposed to
trauma have evolved separately
• These two paths are merging for
improved services to children and
families
Definitions
Trauma
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Physical Abuse and Neglect
Sexual Abuse
Traumatic Grief
Domestic Violence
Community and School Violence
National Child Traumatic Stress Network, 2006
Definitions
Trauma
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Complex Trauma (multiple trauma)
Medical Trauma
Refugee and War Zone Trauma
Natural Disasters
Terrorism
Two Groups of Children
• Group 1: Children exposed to
trauma who exhibit symptoms
requiring treatment; show the
potential for PTSD (about 20%)
• Group 2: Children exposed to
trauma who will recover without
treatment (about 80%)
Description of the Groups
Both may show the same
symptoms initially
• Group 1: Symptoms increase;
children do not recover with
initial intervention
• Group 2: Shows resilience,
recovery
System of Care for Group 1
They meet the definition of serious
or severe disturbance:
• The disorder interferes with daily
functioning (sleep, school,
interactions, thinking)
• It is projected to be long term,
without treatment
• Long-term effects without
treatment can be damaging
SOC Principles Should Apply
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Child centered, individualized
Strengths based
Family focused
Community based
Comprehensive; formal and informal
Culturally competent
Accountable/evidence based
Coordinated across agencies
Requires care management
Evidence Based Services for
Group 1
• Include:
– Cognitive Behavioral Therapy
– Eye Movement Desensitization
and Reprocessing (EMDR)
– Trauma Focused Individual,
Family and Group Treatment
Online Course in
Trauma Focused CBT
www.musc.edu/tfcbt
Importance of Trauma
Practices in Systems of Care
Children exposed to trauma
• Had higher service costs
• Used more high-end
services, including:
psychiatric hospitalization,
residential treatment,and
crisis intervention services
at higher cost
Yoe, Burns et al, 2004
Importance of Trauma
Practices in Systems of Care
• Used more Case Management
services at higher cost; and
• Used more outpatient-clinical
and medication management
services at higher cost
Importance of Trauma Practices
in Systems of Care
Groups were the same in
service use and costs in
• Substance Abuse Tx
• Home-Based Family Services
• Day Treatment
• Community Support Services
• Behavioral Health Pharmacy
• In-Home Services
Group 2, Why Intervene?
• To alleviate traumatic stress
reactions
• To provide comfort
• To (possibly) prevent longerterm, more serious reactions
• To identify those who need
more intensive interventions
SOC Principles for Group 2
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Not child centered, not individualized
Strengths based
Family involved
Community based
Comprehensive, only informal services
Culturally competent
Accountable/evidence based
Coordinated across agencies
Does not require care management
Community Based
• Interventions delivered in the
child’s “community”
– With peers
– In school or other group setting
– Involves child’s helpers-parents,
teachers, shelter aides
– Uses indigenous assistants
Strengths Based
• Focuses on stabilization
• Corrects misperceptions
• Emphasizes maintaining
psychological control--coping
• Emphasizes support systems
• Focuses on health and selfcare
Family Focused
• Parents involved in planning
• Parents involved in learning
how to cope
• Parents involved in ongoing
support of children
Impact of Trauma on Schools
Events of past 16 years:
• Desert Storm—the first war fought
on television
• Oklahoma City bombing—news
coverage
• School shootings
• September 11, 2001
• Hurricane Katrina
Marlene Wong, 2006
Crisis & Emergency Plan
for Schools
Mental Health Component
www.ed.gov/emergencyplan
Mitigation and Prevention
• Identify possible disasters
• Identify potential hazards/
barriers to a good response
transportation routes
factories/other highly
populated areas
Preparation
Develop an emergency response plan;
consider emotional responses
• Establish relationships with mental
health professionals
• Develop protocols for response
• Train staff in psychological first aid
• Establish back-up systems
• Practice, practice, practice
Response
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Assess level of exposure
Identify those most at risk
Provide support/first aid
Provide timely information/media
messages
• Identify those who need longerterm intervention and arrange it
Recovery
• Address long-term needs through
interventions using coping
strategies
• Address long-term needs through
referral to community or inschool specialists
• Plan for anniversaries
Actions for Schools
• Recognize children are
vulnerable to many kinds of
trauma through direct or
indirect exposure
• Central point for community—
50% of people involved with
school
Ensure Internal Coordination
• Establish who is in charge
• Establish roles for each entity
school safety personnel
resource officers
school counselors/psych./sw
school health
teachers
Group 2: Evidence Based
Services/Promising Practices
• Psychological First-Aid
• Post Trauma Stress
Management
• Classroom-Based Interventions
or Group Interventions
National Center for PTSD, 2005, Macy, Behar, et al 2005, Macy,
2006
Trauma Response Teams
Examples of Effective Programs
• Center for Trauma Psychology
– Community
– Classroom
• Community Policing Project (Yale)
• Community Stress Prevention
Centre (Israel)
Center for Trauma
Psychology-Community
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Intensively trained volunteers
Follow a clear protocol
Establish contacts in communities
Provide Psychological First
Aid/Post Traumatic Stress
Management
Informal evidence of effectiveness
Center for Trauma
Psychology--Classroom
• Uses classroom based coping
groups
• Trains teachers
• Involves parents
• Used also by Save the Children
Most evidence of effectiveness
Community Policing Project
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Highly trained staff
Train police to handle child cases
Ride along with police
Provide team interventions—
psychologists & police together
Informal evidence of effectiveness
Community Stress
Prevention Centre (Israel)
• Trains child caregivers, parents,
teachers, first responders
• Provides back-up
• Experienced in international relief
Informal evidence of
effectiveness—theory based
Resources at
www.nctsnet.org
For
• Educators
• General Public
• Juvenile Justice Professionals
• Media
• Mental Health/Medical Professionals
• Parents and Caregivers
• Policy Makers