CONNECTING THE DOTS: Safety, Permanency, and Well-being

1. CONNECTING THE DOTS: Safety, Permanency, and Well-being Bryan Samuels, Executive DirectorChapin Hall Center for Children University of Chicago

2. 25% Decline in Caseloads 2002-2011 Data Source: Adoption and Foster Care Analysis and Reporting System, U.S. Department of Health and Human Services

3. Average Lifetime Cost of Maltreatment is $210,000 X. Fang et al., 2012

4. Factors Contributing to Poor Outcomes Stress Genetics Dysfunctional Family Environmental Infections Substance Abuse Biological Adverse Childhood Experiences Community Violence Prenatal Damage Psychological Abuse Trauma Neglect

5. Understanding Adverse Childhood Experiences • The landmark study of Adverse Childhood Experiences (ACEs) links negative early experiences to poor physical health outcomes, including obesity, heart disease, stroke, cancer, liver disease, etc. • There is a linear relationship between the number of ACEs experienced and the likelihood of poor health outcomes.

6. Emotional, and Social Capacities Are Inextricably Intertwined Within the Architecture of the Brain Maltreatment during early childhood can cause vital regions of the brain that lead to a variety of physical, emotional, cognitive, and mental health problems. Maltreatment results in difficulties regulating emotional reactions, rage, dissociation, changes in perception of self and others, and changes in understanding and interpreting events. Siegel, DJ. (2001). Toward an interpersonal neurobiology of the developing mind: Attachment relationships, “mindsight,” and neural integration. Infant Mental Health. 22(1-2):67. Terr, LC. (1991). Acute responses to external events and Posttraumatic stress disorders. In Lewis, M (Ed.). Child and adolescent psychiatry: a comprehensive textbook New Haven, CT: Williams & Wilkins.

7. Maltreatment is powerful in shaping brain architecture and actually changes the chemistry in brain cells.

8. Maltreatment & Complex Trauma • Refers to children’s experiences of multiple traumatic events that occur within the caregiving system – the social environment that is supposed to be the source of safety and stability in a child’s life. • Typically, complex trauma exposure refers to the simultaneous or sequential occurrences of child maltreatment—including emotional abuse and neglect, sexual abuse, physical abuse, and witnessing domestic violence—that are chronic and begin in early childhood. • Moreover, the initial traumatic experiences (e.g., parental neglect and emotional abuse) and the resulting emotional dysregulation, loss of a safe base, loss of direction, and inability to detect or respond to danger cues, often lead to subsequent trauma exposure (e.g., physical and sexual abuse, or community violence).”

9. Impact of Trauma on Brain Development Traumatic Stress NEUTRAL START Adapted from: Family Policy Council. (2007). The High Cost of Adverse Childhood Experiences (PPT). Olympia, WA: Author.

10. Connecting the Dots to Stress at Home

11. Connecting the Dots to Stress at Home

12. Connecting the Dots of Early Experiences Alter Gene Expression Extensive scientific research has shown that the healthy development dependson how much and when certain genes are expressed in the cells of these systems. Research has shown that environmental factors and early experiences have the power to impact whether genes are turned "on" or "off"—essentially whether and when genes are activated to do certain tasks.

13. Connecting the Dots to Poor Outcomes Among Children Known to Child Welfare Dolan, M., Casanueva, C., Smith, K., & Ringeisen, H. (2011). NSCAW Child Well-Being Spotlight: Children Placed Outside the Home and Children Who Remain In-Home after a Maltreatment Investigation Have Similar and Extensive Service Needs. OPRE Report #2012-32, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

14. Connecting the Dots to Relational Skills and Social-Emotional Problems

15. “There is no doubt that children in harm’s way should be removed from a dangerous situation. However, simply moving a child out of immediate danger does not in itself reverse or eliminate the way that he or she has learned to be fearful. The child’s memory retains those learned links, and such thoughts and memories are sufficient to elicit ongoing fear and make a child anxious.” National Scientific Council on the Developing Child (2010). Persistent Fear and Anxiety Can Affect Young Children’s Learning and Development: Working Paper No. 9. Retrieved fromwww.developingchild.harvard.edu (emphasis added) “Traditional child welfare approaches to maltreatment focus largely on physical injury, the relative risk of recurrent harm, and questions of child custody, in conjunction with a criminal justice orientation. In contrast, when viewed through a child development lens, the abuse or neglect of young children should be evaluated and treated as a matter of child health and development within the context of a family relationship crisis, which requires sophisticated expertise in both early childhood and adult mental health.” •  National Scientific Council on the Developing Child (2004). Young Children Develop in an Environment of Relationships: Working Paper No. 1. Retrieved from www.developingchild.harvard.edu (emphasis added)

16. Safety & Permanency are Necessary but not Sufficient to Ensure Well-Being Bellamy, J. (2008). Behavioral problems following reunification of children in long-term foster care. Children and Youth Services Review. 30:216. Fechter-Leggett, MO & O’Brien, K. (2010). The effects of kinship care on adult mental heath outcomes of alumni of foster care. Children and Youth Services Review. 32(2):206. Simmel, C.; et al. (2007). Adopted youths psychosocial functioning: A longitudinal perspective. Child and Family Social Work. 12(4):336.

17. Chaffee Programs Yield Poor Outcomes Koball, Heather, et al. (2011). Synthesis of Research and Resources to Support At-Risk Youth, OPRE Report # OPRE 2011-22, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

18. Abusive or Neglectful Parenting • Insecure Attachments & Emotional Dysregulation Pathway to Poor Outcomes for Children and Youth • Maladaptive Coping Strategies • Poor Social Functioning, Disturbed Peer Relationships Poor Outcomes • Psychological Distress

19. Connecting the Dots to Executive Function Executive function and self-regulation skills successfully, both individuals and society experience lifelong benefits. • School Achievement—Executive function skills help children remember and follow multi-step instructions, avoid distractions, control rash responses, adjust when rules change, persist at problem solving, and manage long-term assignments. • PositiveBehaviors—Executive functions help children develop skills of teamwork, leadership, decision-making, working toward goals, critical thinking, adaptability, and being aware of our own emotions as well as those of others. • Good Health—Executive function skills help people make more positive choices about nutrition and exercise; to resist pressure to take risks, try drugs, or have unprotected sex; and to be more conscious of safety for ourselves and our children. Having good executive function primes our biological systems and coping skills to respond well to stress. • Successful Work—Executive function skills increase our potential for economic success because we are better organized, able to solve problems that require planning, and prepared to adjust to changing circumstances.

20. Integrating Safety, Permanency, and Well-being • Cognitive Functioning • Physical Health and Development • Emotional/ Behavioral Functioning • Social Functioning The framework identifies four basic domains of well being: (a) cognitive functioning, (b) physical health and development, (c) behavioral/emotional functioning, and (d) social functioning. Within each domain, the characteristics of healthy functioning related directly to how children and youth navigate their daily lives: how they engage in relationships, cope with challenges, and handle responsibilities. Environmental Supports Personal Characteristics Developmental Stage

21. Screening, Functional Assessment & Progress Monitoring • “Functional assessment—assessment of multiple aspects of a child’s social-emotional functioning (Bracken, Keith, & Walker, 1998)—involves sets of measures that account for the major domains of well-being.” • “Child welfare systems often use assessment as a point-in-time diagnostic activity to determine if a child has a particular set of symptoms or requires a specific intervention. Functional assessment, however, can be used to measure improvementin skill and competencies that contribute to well-being and allows for on-going monitoring of children’s progress towards functional outcomes.” • “Rather than using a “one size fits all” assessment for children and youth in foster care, systems serving children receiving child welfare services should have an array of assessment tools available. This allows systems to appropriately evaluate functioning across the domains of social-emotional well-being for children across age groups (O’Brien, 2011) and accounting for the trauma- and mental health-related challenges faced by children and youth who have experienced abuse or neglect.” Valid and reliable mental and behavioral health and developmental screening and assessment tools should be used to understand the impact of maltreatment on vulnerable children and youth. • TRAUMA SCREENING • Child and Adolescent Needs and Strengths (CANS) Trauma Version • Childhood Trauma Questionnaire (CTQ) • Pediatric Emotional Distress Scale (PEDS) • FUNCTIONAL ASSESSMENT • Strengths and Difficulties Questionnaire (SDQ) • Child Behavior Checklist (CBCL), the Social Skills Rating Scale (SSRS) • Emotional Quotient Inventory Youth Version (EQ-i:YV) Two Days in May - Ohio

22. Time to Stop Counting Service “It is common for child welfare systems to gauge their success based on whether or not services are being delivered. One way to focus attention on well-being is to measure how young people are doing behaviorally, socially, and emotionally and track whether or not they are improving in these areas as they receive services” (ACYF-CB-IM-12-04). Measuring Services How many children received…? How many hours of training were delivered? What percent of children got…? Measuring Outcomes Are trauma symptoms reduced? Did services increase relationship skills? Do children have healthier coping strategies?

23. De-Scaling What Doesn’t Work, Scaling Up What Does De-scaling what doesn’t work Investing in what does INEFFECTIVE APPROACHES RESEARCH-BASED APPROACHES

24. Intervention Must be Strong Enough to Meet Complex Profiles ** * ** * *p<.001, **p<.0001 Scheeringa, M. and Gonzales, R.. Clinical treatment approaches to trauma. Tulane University School of Medicine. (April 15, 2013 presentation to at the CWLA Neuroscience and Child Maltreatment Conference).

25. Matching Populations, Outcomes, & Approaches: IV-E Waiver Examples • Population • Screening& Assessment • EBIs • Outcomes • Children, 8-17 • - UCLA PTSD Index • - Strengths & Difficulties Questionnaire • - Child & Adolescent Needs & Strengths • Trauma-Focused Cognitive Behavioral Therapy • - Behavior problems • - PTS symptoms • - Depression • - Delinquency/Drugs- Peer problems- Family cohesion • Children, 13-17 • - Strengths & Difficulties Questionnaire • - Child & Adolescent Needs & Strengths • Multisystemic Therapy • Children, 2-7 • - Trauma Symptoms Checklist for Young Children- Infant Toddler Emotional Assessment • - CBCL • Parent-Child Interaction Therapy • - Conduct disorders • - Parent distress • - Parent-child interaction

26. Connecting the Dots to Child Welfare Practices

27. Connecting the Dots of Promising Practices To promote emotional, social, cognitive, and physical development broadly, promising practices including a range of strength building strategies that: Reduce stress in children’s lives, both by addressing its source and helping them learn how to cope with it in the company of competent, calming adults; Foster social connectionand open-ended creative play, supported by adults; Incorporate vigorous physical exercise into daily activities, which has been shown to positively affect stress levels, social skills, and brain development; Increase the complexity of skills step-by-step by finding each child’s “zone” of being challenged but not frustrated; and Include repeated practice of skills over time by setting up opportunities for children to learn in the presence of supportive mentors and peers.

28. Connecting Dots of Promising Practices Focus on Relationships—Children develop in an environment of relationships. This starts in the home and extends to caregivers, teachers, medical and human services professionals, foster parents, and peers. Children are more likely to build effective executive function skills if the important adults in their lives are able to: • Supporttheir efforts; • Modelthe skills; • Engagein activities in which they practice the skills; • Providea consistent, reliable presence that young children can trust; • Guidethem from complete dependence on adults to gradual independence; and • Protectthem from chaos, violence, and chronic adversity, because toxic stress caused by these environments disrupts the brain circuits required for executive functioning and triggers impulsive, “act-now-think-later” behavior.

29. Connecting the Dots To Well-being • Focus on child & family behavior, skills competencies, outcomes • Build capacity for more intensive EBP/RBIs • Monitor progress for improved child/youth functioning • Promoting • Well-being • Change practice to address trauma • Actively promote healthy relationships • Take developmental approaches

30. PROMOTING WELL-BEING ACROSS THE U.S. Partnerships to Demonstrate the Effectiveness of Supportive Housing for Families in the Child Welfare System Permanency Innovations Initiative Regional Partnership Grants to Increase Well-Being and Improve Permanency Outcomes for Children Affected by Substance Abuse Working with Children’s Bureau for Title IV-E Child Welfare Demonstration Projects, for FY 2013 Title IV-E Child Welfare Demonstration Projects, Approved in FY 2012

31. Illinois’ Child Welfare Population 1990 to 2003 51,000 20,848

32. Re-Defining Success: Focusing on Well-being • Redesign performance-based contracting to emphasize well-being outcomes in addition to permanency. • Implement new placement system to keep children in the same school they attended prior to substitute care. • Implement comprehensive assessment. • Re-design transitional living and independent living programs to prepare youth for transition to adulthood. • Creat a child location unit that tracks all youth who run away. • Introduce evidence-based services to address trauma. • Establish a common outcome measures for residential treatment and group homes.

33. RE-DEFINING SUCCESS: STATE OF ILLINIOS • Reduced caseload ratios in public and private sectors form 20 cases per worker to 14 cases per worker. • Reduced disproportionate representation of African American children in child welfare system declined from 69.3% to 60%. • Decreased number of youth “on run” decreased by 40% and number of days “on run” decreased by 50%. • Decreased late child protection investigations by 60%. • Reduced distance between home of origin and foster care placement reduced from 20 miles to 7.8 using new school placement strategy. • Reduced time in residential treatment by 20%. • Decreased child welfare population declined from 23,500 to16,500 statewide.

34. QUESTIONS?

35. Healing and Recovery SOCIAL AND EMOTIONAL WELL-BEING FOR CHILDREN, YOUTH, AND FAMILIES Assessment drives individualized treatment plan with evidence-based interventions Systematic approaches to teaching coping skills and social skills Nurturing environments provide security and promote positive outcomes Supportive, responsive relationships promote healing and recovery and reinforce growing social and emotional skills Systems and policies promote and sustain screening, assessment, the use of evidence-based interventions, progress monitoring, and continuous quality improvement Adapted from the Technical Assistance Center on Social Emotional Intervention for Children and the Center on the Social and Emotional Foundations for Early Learning

36. Achieving Better Outcomes context: therapeutic, responsive & supportive settings & relationships Validated Screening Case Planning for Safety, Permanency, and Well-being Outcomes: Safety, Permanency, Well-Being Evidence-based/informed Intervention(s) Clinical Assessment Functional Assessment Progress Monitoring social-emotional functioning

37. Evidence-Based Interventions

38. Evidence-Based Interventions

39. Connecting the Dots to Brain Science • While the healthy body can restore itself quickly after a stressful incident (running for a late bus, facing an important examination), this is not the case with long term stress overload. • Chronic (toxic) stress causes the brain to secrete an excess of hormones, such as cortisol. Excessive secretion of cortisol interferes with memory, retention, focus, and learning. • As a result of experiencing extreme traumatic stress over time, the part of the brain responsible for learning new things—can become damaged. • An overload of stress can cause an imbalance in the functioning of the brain’s hemispheres. • When we are excessively depressed, anxious, and  stressed, the right hemisphere becomes dominant. This interferes with cognition, self-regulation, and the ability to focus and remember. IL CFP Early Childhood