trauma informed care & graduation rates (joseph lavoritano)
DESCRIPTION
Developmental trauma is real, and disproportionately affects children 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 the St. Gabriel's system.TRANSCRIPT
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