COULD TRAUMA-INFORMED CARE INCREASE THE GRADUATION RATES OF URBAN YOUTH AS IT HAS FOR A GROUP OF DELINQUENT

YOUTH IN RESIDENTIAL CARE? (WE THINK IT CAN)

Joseph Lavoritano, MA, M.Ed., NCSPExecutive Director, Saint Gabriel’s System

James J. Black, Ph.D.Director of Mental Health Programs, Saint Gabriel’s System

Martha Tavantzis, M.S.W., L.C.S.W. Director of Treatment, Saint Gabriel’s Hall

Presentation at Eastern University January 18, 2012

TODAY’S AGENDA

DESCRIPTION OF SAINT GABRIEL’S SYSTEM

DEVELOPMENTAL TRAUMA

MAPPING DATA OF PHILADELPHIA VIOLENCE AND POVERTY

EFFECTS OF PROLONGED EXPOSURE STRESS AND TRAUMA ON THE DEVELOPING BRAIN

TODAY’S AGENDA

ACES STUDY

SANCTUARY MODEL OF TRAUMA-INFORMED CARE

TRAUMA-FOCUSED CBT AND TRAUMA ART NARRATIVE THERAPY

COMMUNITY MEETING

TODAY’S AGENDA

DATA: POSTIVE OUTCOMES

TAKE-AWAYS

SAINT GABRIEL’S SYSTEM 500-600 youth in care on any given day

Serves both delinquent and dependent youth

180 youth in residential care in Audubon, PA (Saint Gabriel’s Hall--SGH)

230 youth in three day-treatment programs in Philadelphia and Bensalem, PA (De La Salle In Towne, De La Salle Vocational, Brother Rousseau Academy)

SAINT GABRIEL’S SYSTEM 95 youth in group homes (dependent

and delinquent RTF’s) at St. Francis/St. Joseph

60 female youth in the St. Vincent group homes (dependent)

The youth we will be discussing today are the Saint Gabriel’s Hall youth

SAINT GABRIEL’S HALL

184 YOUTH (MALE)

EIGHT “REGULAR

RESIDENTIAL” UNITS

(16 BEDS EACH)

TWO DRUG AND ALCOHOL

UNITS(16 BEDS

EACH)

24 BED FARM-BASED

PROGRAM (MITCHELL

HALL)

DEVELOPMENTAL TRAUMA

WHAT IS IT?

WHY IS IT

IMPORTANT

?

HOWEVER, UNFORTUNATELY, A NUMBER EXPERIENCE AN OPPOSITE

FATE, SUFFERING SERIOUS TRAUMAS—EVERYTHING FROM

ABUSE AND NEGLECT TO CHRONIC COMMUNITY AND FAMILIAL VIOLENCE,

AND CAREGIVERS IMPAIRED BY ILLNESS, SUBSTANCE ABUSE AND

THEIR OWN MENTAL HEALTH ISSUES

MANY CHILDREN GO THROUGH CHILDHOOD WITH

FEW MAJOR UPSETS…

LITERATURE SUPPORTS A STRONG LINK BETWEEN POVERTY, TRAUMA AND BRAIN DEVELOPMENT

Dannlowski et al. (2012). Limbic Scars: Long-Term Consequences of Childhood Maltreatment Revealed by Functional and Structural Magnetic Resonance Imaging. Biological Psychiatry, 71(4), 286-293.

McCrory, E., De Brito, S. A., & Viding, E.(2011). The impact of childhood maltreatment: A review of neurobiological and genetic factors. Frontiers in Psychiatry. 2:48. Epub 2011 Jul 28.

Evans, G. and Schamberg, M. (2009) Childhood poverty, chronic stress, and adult working memory. By Gary W. Evans and Michelle A. Schamberg.  Proceedings of the National Academy of Sciences, Vol. 106 No. 13.

DEVELOPMENTAL TRAUMA DISORDER

Developmental TraumaDisorder will not make it into the DSM-5, but there was serious consideration to have it included to capture life for these children who have histories of exposure to multiple chronic traumas usually of an interpersonal nature.

“Developmental Trauma Disorder” (van der Kolk, 2005) which is

characterized by the presence of:

psychic conflicts central nervous system alterations distorted images of social life chronic stress a vulnerability to stress-related illnesses warped moral values rage a profound loss of trust, and loss of a sense of security. (NASP Communique, 2010)

WHILE PTSD IS A GOOD DEFINTION FOR ACUTE TRAUMA IN ADULTS…

IT DOES NOT APPLY WELL TO CHILDREN AND YOUTH WHO

HAVE EXPERIENCED PERVASIVE AND CHRONIC

EXPOSURE TO LOSS, VIOLENCE, NEGLECT AND

ABUSE

DUE TO A CHILD’S DEVELOPING BRAIN, TRAUMA HAS A MUCH MORE PERVASIVE AND LONG-TERM INFLUENCE ON SELF- CONCEPT AND ABILITY TO SELF-REGULATE THAN CAN BE EXPLAINED BY PTSD

VIOLENCE IN PHILADELPHIA, 2010

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

306

1608

8483

Homicide

Shootings

Assaults

Philadelphia

United States Attorney's Office Eastern District of PA

2011 – 324 homicides

2012-- 331 homicides

THE BRAIN AND TRAUMA• WHAT TRIGGERS IT – senses pick up a threat – loud noise, a scary sight, a creepy feeling – the information travels two different routes through the brain

A . THE SHORT CUT- When startled the fear center, amygdala, sends all points bulletin and triggers the classic fear response:

• STRESS-HARMONE BOOST

• Cortisol

• RACING HEART

• FIGHT, FLIGHT ON FRIGHT

• DIGESTIVE SHUTDOWN

B. THE HIGH ROAD – Conscious mind kicks in and some sensory information bypasses the amygdala and is routed to the thalamus, processing hub of sensory cues and then the cortex for analysis of the raw data. This signals a continued fear alert or may signal the amygdala to have the body stop alert.

• Due to the violence and trauma that was evident in the neighborhoods we were seeing new behaviors

 • Youth were hypervigilant and showed an inability to distinguish real threats from benign actions. • Brain research was saying continued exposure to violence, poverty and trauma resulted in poor pre-frontal cortex development. We were witnessing youth who had a limited or no ability to control their emotions who moved rapidly to a fight or flight response to any perceived threat

What is Trauma & Chronic Stress?

Trauma is an overwhelming event that causes intense feelings of fear, helplessness or horror. There are many different kinds of trauma, and not everyone responds the same way.

Chronic Stress is an overwhelming external element that impacts a person’s sense of daily safety.

Largest study of its kind ever, almost 18,000 subjects

Examined the health and social effects of adverse childhood experiences over

the lifespan

Majority of participants were 50 or older (62%), were white (77%) and had

attended college (72%).

The Adverse Childhood Experiences (ACE Study)

10 categories of experience up to 18 years old

• emotional, physical, or sexual

CHILD ABUSE

• emotional or physical

CHILDHOOD NEGLECT

• domestic violence• substance abuse (alcohol or drugs)• mental illness• parental discord• Crime (imprisonment)

GROWING UP WITH:

Add up the # of categories = ACEs score = trauma dose

WHAT DO WE MEAN BY ADVERSE CHILDHOOD EXPERIENCES?

ACES EXCERCISE

ACE Score

Only one-third had a zero ACE score

One in four had ACE score of 2 or more

One in six had an ACE score of 4 or more

One in nine had an ACE score of 5 or more

ASPP Workshop Attendees’ACE Score

had a 0 ACE Score

had ACE score of 2 or more

had an ACE score of 4 or more

had an ACE score of 5 or more

ACE StudyStrong, graded relation to childhood

adversitySmoking Attempted suicide

COPD Revictimization

Heart Disease Teen pregnancy

Diabetes Fractures

Obesity Promiscuity

Hepatitis Sexually transmitted disease

Alcoholism Poor job performance

Other substance abuse

Poor self-rated health

Depression Violent relationships

When a person experiences a traumatic event, some sort of Loss is experienced. When a loss is experienced, a person

may feel overwhelming emotions. These overwhelming

emotions lead often lead to unsafe behavior. This unsafe

behavior has consequences on a person’s future.

Understanding trauma is not just about acquiring knowledge.

It’s about changing the way you view the

world.

It’s Just Common Sense That.. People avoid things that scare them People avoid pain If somebody hurts you, you get away from

them We can tell who can be trusted and who

can’t People learn from their experience Parents love their children You don’t hurt people you love People remember anything that is really

terrible

But traumatized children frequently..

Put themselves in situations of danger Hurt themselves Get into and stay in relationships with hurtful

people Are frequently unable to discern who is to be

trusted Don’t seem to learn from experience Have been hurt by people who were supposed

to love them Frequently hurt the people they love the most Don’t remember the worse experiences of

their lives

The Heart of Trauma TheorySickness vs. Injury Model

Changing the fundamental question from:

“What's wrong with you?" to

"What's happened to you?“

Foderaro, 1991

Injury ModelWhat’s happened to you?

Includes physical, psychological, social, and moral forms of injury

Includes deprivation, neglect, and developmental insult

Implies rehabilitation process that is mutual, long-term: Requires active collaborative relationship between helper and injured party

Removes stigma and shame Provides understandable shared framework Increase in compassion, increase in

expectations

S.E.L.F.

•Safety: Physical, Psychological, Social, Moral

•Emotions: Handling feelings without becoming self/other destructive

•Loss: Feeling grief and dealing with personal losses, preparing for change

•Future: Re-establishing the capacity for choice

S

L

EF

How do people heal?

Autobiography in Five Chaptersby Portia Nelson

I walk down the streetThere is a deep hole in the

sidewalkI fall inI am lost . . . I am helplessIt isn't my fault.It takes forever to find a way out.

I walk down the same street,There is a deep hole in the

sidewalk,I pretend I don't see it.I fall in again.I can't believe I am in the same

place.But it isn't my fault.It still takes a long time

to get out.

I walk down the same street.There is a deep hole in the

sidewalk.I see it is there.I still fall in . . . it's a habit.My eyes are open.I know where I am.It is my fault.I get out immediately.

44

I walk down the same street.There is a deep hole in the

sidewalk.I walk around it.

I walk down a different street.

Saint Gabriel’s Hall was awarded a 3-year

grant that began in Fiscal Year 2008/2009

to implement the Sanctuary Model of

Trauma-Informed Care

The goal of treatment is CHANGE.

If children do not make substantial and positive changes then treatment

is not working!

If treatment isn’t working maybe it’s US and our systems of care that are

the problems, not the children.

• The operating system is the foundation software for the computer.

• The programs that allow you to do various things are application software.

A master program that controls a computer's basic functions and allows other programs to

run on a computer IF they are compatible with that operating system.

WHAT IS AN OPERATING SYSTEM?

SANCTUARY IS THE NEW OPERATING SYSTEM

SO, DO WE HAVE TO GET ALL NEW APPLICATIONS?

TRAUMA-FOCUSED COGNITIVE BEHAVIORAL THERAPY (TF-CBT)

Evidence-Based

Specifically Targets Trauma

State Grant—7 Therapists

Free 10 Credit Course at www.musc.edu/tfcbt

TRAUMA ART NARRATIVE THERAPY (TANT)

Developed by Dr. Lyndra Bills

Research Underway with LIU to Establish Evidence-Based Status

All SGH Therapists Trained (Arts Skills Not Necessary!)

Process Speaks to Non-Verbal Part of Brain, Specific Event-A Scene

Trauma Symptom Checklist for Children (TSCC)

Developed by Dr. John Briere in 1989

54 Self-report Items, 2 validity scales and 6 clinical scales, and 4 subscales

Normed by age and gender on over 3000 children and youth

Strong validity and reliability, easy to administer and score

COMMUNITY MEETING

HOW ARE YOU FEELING TODAY?—CONNECTS YOU TO YOUR FEELINGS

WHAT IS YOUR GOAL FOR TODAY?—CONNECTS YOU TO THE FUTURE

WHO CAN HELP YOU WITH THAT? –CONNECTS YOU TO COMMUNITY

POSITIVE OUTCOMES

Does it work?

Positive Outcomes in

Program

Graduation Rates

SymptomsVocational

Certifications

Psychiatric Hospitalizatio

ns

60 % of youth 17 years old or older graduate from Saint Gabriel’s Hall with a High School Diploma or Equivalency.

GRADUATION RATES

Fiscal Year # of Graduates

Percentage

FY 08/09 28 of 70 40%

FY 09/10 39 of 89 44%

FY 10/11 52 of 104 50%

FY 11/12 68 OF 113 60%

Number of SGH Graduates by Fiscal YearSAINT GABRIEL’S HALL GRADUATES

24

35

44

56

82

73

0

10

20

30

40

50

60

70

80

90

06/ 07 07/ 08 08/ 09 09/ 10 10/ 11 11/ 12

Number of SGS Graduates by Fiscal Year

Analysis of Variance on Pre- and Post-Test TSCC scores (N=117) reveal:

Decreased Depression scores (p = .000)

Decreased Post-Traumatic Stress scores (p = .002)

Dissociation (p = .039)

SGS Industry Certificates by Year

14

132

239

267

0

50

100

150

200

250

300

2008-2009 2009-2010 2010-2011 2011-2012

PSYCHIATRIC HOSPITALIZATIONS BY FISCAL YEAR

67

1

4 4

10

1

2

3

4

5

6

7

8

FY07 FY08 FY09 FY10 FY11 FY12

PsychiatricHospitalizations

POSITIVE OUTCOMES

Does it work?

Positive Outcomes

Post Discharge

Counseling

Attendance

Rearrests

School Attendanc

e

RATE OF ATTENDANCE IN COUNSELING POST DISCHARGE

(N=683)

25%(127)15%

(72)

60%

(297)

0

10

20

30

40

50

60

70

>75% 50% -75% <50%

12% (20)

0

20

40

60

80

100

120

07/08 08/09 09/10 10/11 11/12

Not Rearrested

Rearrested

86%(128)

14%(21)

71%(49)

29%(20)

88%(172)

12%(24)

81%(157)

88%(148)

19%(36)

REARREST BY YEAR DURING THE PERIOD OF REINTEGRATION (3-6 MONTHS)(N=775)

RATE OF SCHOOL ATTENDANCE(N=427)

19%(84)

19%(80)

62%

(263)

0

10

20

30

40

50

60

70

> 75% 50% -75% < 50%

Saint Gabriel’s Hall Finishes #1

Among CBH-Funded RTF Providers!

Several Outcomes Led to this First-Place Finish according to CBH’s most recent Provider

Profile ReportMost Notably:

Less than 1% of youth FTA’d to another RTF

0% of youth FTA’d to psychiatric inpatient services

60% of youth attend a follow-up outpatient appointment within 30 days of discharge

Saint Gabriel’s Hall is Sanctuary Certified and Utilizes Master’s Level Therapists Trained in Trauma-Focused Cognitive Behavioral Therapy—Both Sanctuary and TF-CBT are Evidence-Based!

POSITIVE OUTCOMES AND EVIDENCE-BASED PROGRAMMING: A WINNING COMBINATION!

TAKEAWAYS

DEVELOPMENTAL TRAUMA IS REAL AND DISPROPORTIONATELY AFFECTS KIDS FROM POOR NEIGHBORHOODS

PROLONGED EXPOSURE TO STRESS AND TRAUMA HAS A DELETERIOUS EFFECT ON THE DEVELOPING BRAIN

MOVING FROM A “SICKNESS MODEL” TO AN “INJURY MODEL” OF TRAUMA-INFORMED CARE HAS HAD A POSITIVE IMPACT ON OUTCOMES FOR THE YOUTH IN SAINT GABRIEL’S SYSTEM