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Trauma-Informed Care for Children

The Sanctuary Model in Pennsylvania

In 2006, Department of Public Welfare urged child residential providers to move toward reducing or eliminating the use of restraints. A kick-off event was held to roll out the “Alternatives to Coercive Techniques” project, and 12 forums were held across the state where discussions included topics such as organizational change, leadership, specific skills for de-escalating conflict and incident debriefing, data collection, and youth and family involvement. The forums were designed to help providers to understand the vision for building a restraint-free system and gain their support for creating that vision.

The number one request at these forums was for training, specifically on trauma-informed care. In response to that request, two all-day trainings were held with Sandra Bloom, a nationally-known expert on trauma-informed care and the creator of the Sanctuary Model. As a result of the forums and recommendations, the Sanctuary Model was brought to Pennsylvania. The Sanctuary Model is about organizational change, and is a three-year process that starts with a diagnostic evaluation and a five-day training for agency leadership. Agency leaders are required to attend five days of intensive training, develop a multidisciplinary core team within their agency, participate in on-site and telephone consultation as well as consortium calls and booster trainings. These steps support the process of change in an organization to a trauma-informed culture. Preliminary data from implementation of the Sanctuary Model in other states show positive results, including a decrease in the use of restraints, less staff turnover, and better outcomes for children and youth.

The Department had limited funding to implement the Sanctuary Model in Pennsylvania, and developed a request for participation with some basic requirements: participating facilities had to have more than 50 beds, the chief executive officer and/or the chief operating officer had to attend the five-day training, and facilities had to agree to collect and submit data that would help evaluate the effectiveness of the program. Twenty-nine agencies are now implementing the Sanctuary Model in their treatment programs.

Residential Programs Accredited as Certified Sanctuary Programs
Congratulations to the following residential programs that have been awarded accreditation as certified Sanctuary ® Programs by The Sanctuary Institute of the Andrus Children’s Center:

Abraxas Academy, Morgantown
Bethany Children’s Home, Womelsdorf
The Bradley Center, Pittsburgh
Children’s Home of Reading, Reading
Children's Home of York, York
Children’s Service Center—Bridgeview Residential Treatment Center, Wilkes-Barre
Devereux, Brandywine
Gannondale, Erie
Glade Run Lutheran Services, Zelienople
Harborcreek Youth Services, Inc., Harborcreek
Holy Family Institute, Pittsburgh
Mars Home for Youth, Mars
North Central Secure Treatment Unit - Girl's Program, Danville
Perseus House, Erie
Philhaven, Mt. Gretna
Presbyterian Children’s Village, Rosemont
Sarah Reed Children’s Center, Erie
St. Gabriel’s Hall, Audubon
Silver Springs - Martin Luther Schools, Plymouth Meeting
South Mountain Secure Treatment Unit, South Mountain
VisionQuest Academy at Franklin, Hudmont
VisionQuest Academy at Franklin, South Penn
Wordsworth, Philadelphia
York Detention Center, York

This accreditation is awarded to agencies that demonstrate excellence in their organizational and clinical practices through implementation of the Sanctuary Model. These programs join Pace School in Pittsburgh in being the only certified sites in Pennsylvania.  Other sites will soon join these residential programs in being certified by The Sanctuary Institute, as part of the Department of Public Welfare’s Sanctuary pilot project

Accreditation through The Sanctuary Institute means that an organization has demonstrated a sustained commitment to nonviolence, emotional intelligence, social learning, shared governance, open communication, social responsibility, growth and change.  This is evidenced in the following outcomes:

  • The ability to provide evidence supported treatment to people who have experienced trauma
  • The utilization of a shared language for talking about injury and healing, that is accessible to staff, clients and families
  • Emotional and social learning as part of the educational approach
  • An organizational approach to treatment that is uniform in all areas of the agency
  • Lower direct care turnover rates for staff
  • Higher staff satisfaction reports
  • A reduction in incidents of violence and aggression
  • Improved clinical and educational outcomes
  • Reduced symptoms related to trauma
  • Increased discharges to lower levels of care
  • Improved collaboration among employees

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Trauma-Focused Cognitive Behavioral Therapy Training

Sanctuary Residential Facilities Receive Trauma-Focused Training
Fourteen residential treatment providers that are already implementing the Sanctuary Model are participating in a training program in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT).

Master’s level therapists from the 14 residential treatment facilities complete a free 10-hour online course, participate in two days of regional training, participate in consultation conference calls twice a month for a year, and collect fidelity data and pre-post outcome instruments for participating children.

Trauma-Focused Cognitive Behavioral Therapy is an evidence-based treatment to address behavioral, emotional, and other issues related to trauma experienced by children and youth, such as child abuse and domestic violence. Components include education about the impact of trauma and skills to re-regulate emotions, behavior, and cognition. When TF-CBT is integrated into the environment of a treatment facility, there are a number of potential benefits: resolution of trauma symptoms, including decreased aggression, property destruction and self-injurious behavior; increase in safety for children and staff; less need for restraint and seclusion; more opportunities for personal growth and positive interactions; and shortened length of stay and fewer readmissions.

Residential treatment facilities that participating in the TF-CBT training:
Southeast
Devereux Beneto Center
St. Gabriel’s Hall
Carson Valley Children’s Aid
Presbyterian Children's Village
Silver Springs–Martin Luther School

Northeast/Central
Children’s Home of York
Children’s Home of Reading
Shawnee Academy
Children’s Service Center-Bridge View RTF

West
Perseus House
Sarah Reed Children’s Center
Harborcreek Youth Services
Glade Run Lutheran Services
Bradley Center
Mars Home for Youth

CASSP Newsletter, “Making Residential Treatment More Effective,” March 2009

CASSP Newsletter, “Trauma and Attachment Disorders,” June 2014

Resources and Research in Trauma-Informed Care

Trauma-Focused Cognitive Behavioral Therapy for Children Affected by Sexual Abuse and Trauma, from the Child Welfare Information Gateway, August 2012

Creating Trauma-Information Child-Serving Systems, February 2012 webinar from the National Technical Assistance Center for Children’s Mental Health; features the work of the National Child Traumatic Stress Network to help systems become more trauma-informed.

The Poverty Clinic: Can a stressful childhood make you a sick adult? Article on how childhood trauma affects childhood health, New Yorker, March 21, 2011.

Helping Children and Youth Who Have Experienced Traumatic Events, 2011 short report released for Children’s Mental Health Awareness Day

Trauma Faced by Children of Military Families: What Every Policymaker Should Know, National Center for Children in Poverty, May 2010.

Strategies and Practices to Eliminate the Use of Unnecessary Restraints, Department of Public Welfare bulletin, effective June 21, 2010

Prone Restraints in Children’s Facilities, Department of Public Welfare bulletin, effective June 21, 2010

Core Competencies for Alternatives to Coercive Techniques (ACT)

Responding to Childhood Trauma: The Promise and Practice of Trauma Informed Care, by Dr. Gordon R. Hodas.

The Silver Springs Model of Trauma Recovery and Resiliency for Children and Adolescents. Used by permission.

Living Sanctuary: Creating Trauma-Informed Systems That Promote Recovery, by Sandra Bloom, M.D. Used by permission of Sandra Bloom.

Early Experiences Can Alter Gene Expression and Affect Long-Term Development, National Scientific Council on the Developing Child, 2010.

Excessive Stress Disrupts the Architecture of the Developing Brain, National Scientific Council on the Developing Child, 2005.

The Impact of Early Adversity on Children’s Development, National Scientific Council on the Developing Child.

Recognizing and Addressing Trauma in Infants, Young Children, and Their Families, Best Practice Tutorial from the Center on Early Childhood Mental Health Consultation (Tutorial #6)

Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services, July 2008. Prepared for the Substance Abuse and Mental Health Services Administration by the National Center for Trauma-Informed Care as a follow-up to the session on trauma-informed services presented by Terry Cline, Ph.D., SAMHSA Administrator, during the meeting of the National Association of State Mental Health Program Administrators in July 2008 in Nashville, Tennessee.

Cognitive Behavioral Therapy Proven to Benefit Symptomatic Children and Adolescents Following a Traumatic Event: The US Task Force on Community Preventive Services recommends individual cognitive behavior therapy and group cognitive behavior therapy to reduce psychological harm to youth who show psychological symptoms following exposure to traumatic events. The Task Force recommendation and related findings are published in the September 2008 issue of the American Journal of Preventive Medicine. Abstract of article

Bloom, S. (2005). The Sanctuary Model of organizational change for children's residential treatment. Therapeutic Community: The International Journal for Therapeutic and Supportive Organizations, 26(1), 65-81. This paper offers a good overview of the Sanctuary Model, highlighting the role of leadership and the need for culture change in order to create a therapeutic community. Specific elements of the Model, to be implemented by staff, are described.

Mahoney, K., Ford, J., Ko, S., Siegfried, C. (2004). Trauma-focused interventions for youth in the juvenile justice center. Washington, DC : Juvenile Justice Working Group of the National Child Traumatic Stress Network, www.NCTSNet.org. Many children and youth in juvenile justice facilities have experienced trauma and maltreatment, and it is essential that their trauma-related needs be recognized and addressed. The authors discuss the importance of pretreatment assessment, trauma-focused interventions, treatment of co-occurring disorders, and family based interventions with this population.

Perry, B (2000). Traumatized children: How childhood trauma influences brain development. Journal of the California Alliance for the Mentally Ill. 11(1): 48-51. Starting with a clinical vignette, Perry describes changes in brain structure and neurobiology that occur in children subjected to trauma, and how this may influence the child's functioning. The Child Trauma Academy website has many related articles.

Perry, B (1994) The effects of traumatic events on children – Materials for caregivers. Child Trauma Academy: www.ChildTrauma.org. This review article by Perry discusses the body's alarm state in response to traumatic threat, and then describes the core symptoms of PTSD (re-experiencing, avoidance, and hyperarousal) in lay language. The final section describes the range of symptomatic outcomes for children subjected to severe trauma.

Hennessey, M., et al (2004). Trauma among girls in the juvenile justice system. Washington, DC: Juvenile Justice Working Group of the National Child Traumatic Stress Network, www.NCTSNet.org. Data from many sources indicate that females in the juvenile justice system are highly likely to have experienced trauma, especially direct victimization. These individuals are at high risk of substance use, involvement in violent activity, further victimization, and development of mental health problems. Ensuring safety in care is essential. In addition, gender-specific programming is needed.

Rivard, J., Bloom, S., McCorkle, D., Abramowitz, R. (2005). Preliminary results of a study examining the implementation and effects of a trauma recovery framework for youths in residential treatment. Therapeutic Community: The International Journal for Therapeutic and Supportive Organizations, 26(1), 1-12. Outcomes related to treatment environment and youth coping were monitored in this study comparing implementation of the Sanctuary Model in residential treatment units with other units that did not implement the Model. Among the findings was an increase in: safety for staff and clients, help and support within the community, open expression of feelings, and self-sufficiency and independence in decision-making.

Annotated Bibliography on Alternatives to Seclusion and Restraint prepared by Gordon R. Hodas, MD, Statewide Child Psychiatric Consultant to OMHSAS

"Empowering Direct Care Workers Who Work with Children and Youth in Residential Treatment," by Gordon R. Hodas, MD

From the US Centers for Disease Control and Prevention’s Guide to Community Preventive Services: Cognitive Behavioral Therapy Proven to Benefit Symptomatic Children and Adolescents Following a Traumatic Event

The US Task Force on Community Preventive Services recommends individual cognitive behavior therapy and group cognitive behavior therapy to reduce psychological harm to youth who show psychological symptoms following exposure to traumatic events. The Task Force recommendation and related findings are published in the September 2008 issue of the American Journal of Preventive Medicine.

Every day, children witness, hear about, or directly experience traumatic events. These can be single or repeated events, on an individual or a mass scale (e.g., a homicide versus a plane crash); they can be natural or manmade (e.g., a tsunami versus a bombing); and they can be intentional or unintentional (e.g., rape versus severe illness). Before this review was conducted, many professionals who work with youth who have been exposed to trauma did not know whether the therapies they used were effective.

The Task Force—a non-federal volunteer group of public health and prevention experts appointed by the Director of the Centers for Disease Control and Prevention (CDC)— assessed Community Guide systematic reviews of 7 interventions to reduce psychological harm (e.g., depression, post-traumatic stress disorder) to youth following exposure to a traumatic event. The Task Force based its findings on systematic reviews conducted by CDC’s Community Guide staff in collaboration with federal and non-federal experts in research, practice, and policy.

Based on their assessment of the evidence of effectiveness of these interventions, the Task Force recommended two interventions on the basis of strong evidence, and found insufficient evidence to determine the effectiveness of five others. Note that “Insufficient Evidence” does not mean that the intervention does not work, only that there is not yet enough evidence to determine whether or not it is effective.

Interventions designed to reduce psychological harm among youth who have experienced, witnessed, or otherwise been exposed to a traumatic event:

  1. Recommended:
    • Individual cognitive behavior therapy
    • Group cognitive behavior therapy
  2. Insufficient Evidence:
    • Play therapy
    • Art therapy
    • Psychological debriefing
    • Psychodynamic therapy
    • Pharmaceutical therapy

Learn more about this systematic review and then check out the full article: Wethington, H., Hahn, R.A., Fuqua-Whitley, D., & Sipe, T.A., et al. (2008). The effectiveness of interventions to reduce psychological harm from traumatic events among children and adolescents: A systematic review. American Journal of Preventive Medicine, 35 (3), 287-313. Click here for an abstract of the article and how to obtain the full text. Contact:  Robert A. Hahn, PhD, CDC: 404-498-0958

 

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Trauma-Informed Care for Adults

Cross-Systems Collaboration Committee

Cross-systems Collaboration Committee was created in the summer of 2004 with the primary goals of ending violence in the lives of persons with disabilities and promoting full access to victims’ services, wellness, and recovery. The committee is chaired by the Disability Rights Network of Pennsylvania (DRN) and the Pennsylvania Coalition Against Rape (PCAR). Other partners include Pennsylvania Mental Health Consumers’ Association (PMHCA), Pennsylvania Coalition Against Domestic Violence (PCADV), Pennsylvania Office of Mental Health and Substance Abuse Services (OMHSAS), Pennsylvania Office of Developmental Programs (ODP), The Institute on Disabilities at Temple University, Pennsylvania Commission on Crime and Delinquency (PCCD), The Arc of Pennsylvania, Sexual Assault Resource and Counseling Center (SARCC), Lebanon County, and Drexel University College of Medicine Behavioral Healthcare Education.

The mission of the cross system collaboration is to foster, encourage, support, and advocate for cross-systems communication, training, and the provision of attitudinally and physically accessible direct care services on all levels; promote a coordinated, statewide, trauma-informed communication network between individual victims, survivors, and service entities; and promote and enhance trauma-informed training and services.

Project Illumination

Project Illumination is a statewide collaboration to promote awareness of sexual violence towards people with disabilities. It uses a cross- system approach through partnerships to promote awareness and understand the impact of sexual violence on people with disabilities. The partners include The Arc of Pennsylvania, Institute on Disabilities at Temple University, Pennsylvania Coalition Against Rape, Disabilities Rights Network of PA, and Office of Mental Health and Substance Abuse.

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