Organizations across the Midwest that are integrating trauma-informed practices based on adverse childhood experiences research are like freckles amassing into a suntan, says Elena Quintana.
“It’s spreading,” says the executive director of the Institute of Public Safety and Social Justice at Adler University in Chicago, who estimates that about 100 organizations have integrated trauma-informed and resilience-building practices based on research in adverse childhood experiences. “You want there to be total coverage within practice and policy. We’re not there yet, but those spots are getting bigger.“
Restraints and seclusion
One of those spots is SaintA in West Allis, WI, that provides foster care, education and mental health services for children and families. The organization serves about 5,000 people daily across a wide array of services, the largest of which is child welfare case management in Milwaukee County, where SaintA serves about 1,400 children daily.
Ann Leinfelder Grove, executive vice president and a 25-year veteran of SaintA, says her organization began moving toward trauma-informed care about eight years ago.
“We were looking at the question of how to reduce the use of physical restraints within one of our programs,” she says. The State of Wisconsin had encouraged a change in the use of physical intervention and seclusion to manage troubled youth, which SaintA does through its residential treatment program, which serves 40 children at any one time, as well as supervised visitation family services programming.
“It started as a simple work group,” Leinfelder Grove recalls of SaintA’s initial efforts, “and ended up with a quest to how to learn more about what was out there that could help us reshape our practices.”
SaintA staff members met with childhood trauma experts Drs. Bruce Perry, senior fellow at ChildTrauma Academy in Houston, and Robert Anda, one of the co-authors of the CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study.
The ACE Study began in 1995 with 17,000 Kaiser Permanente members who volunteered to participate in research on the long-term effects of ACEs. The data, first published in 1998, revealed the remarkable prevalence of ACEs, and the direct link between childhood adversity and the adult onset of chronic disease, mental illness, violence and being a victim of violence.
Research explains the link by showing how the toxic stress of trauma harms the structure and function of children’s developing brains, how it embeds in our bodies, and how its epigenetic consequences can impact succeeding generations. Ongoing research and programming is demonstrating that building resilience can help people overcome their traumatic and adverse pasts, and change systems to stop traumatizing already traumatized people.
Learning about the ACE Study and the effects of trauma on a child’s development left “a core group of us energized,” and the effort moved from looking only at restraints to “a paradigm shift for how we looked at all of our service delivery,” Leinfelder Grove says.
SaintA became one of several flagship demonstration sites for Perry’s Neurosequential Model of Therapeutics (NMT) and all staff “from the receptionist to the CEO” were trained in early brain development and related science.
With the help of Anda and Laura Porter—who co-founded research, education and consulting firm ACE Interface with Anda, SaintA helped cement a perspective shift from “what’s wrong with you to what’s happened to you,” when dealing with troubled youth, “an appreciation of their life history as it shapes their current circumstance,” Leinfelder Grove says.
SaintA staffers have gained considerable understanding of how to help children and youth who have experienced adversity regulate themselves, which “often takes the form of rhythmic, repetitive activities that calm the brain,” she says.
Staff members also focus on the importance of relationship-building as a foundation of success, and how attachments early in life and healthy, supportive, safe relationships serve as the foundation for success in life—and how healing needs to occur among those whose healthy relationships have been fewer and further between, she says.
Staff and foster parents also focus on their own capacity. “We spend a lot of emphasis on work-life balance, and wellness, and creating a healthy and supportive organizational culture for our employees,” says Leinfelder Grove. “We teach our parents and foster parents and caregivers those concepts, and we guard against compassion fatigue and vicarious trauma.”
In the five years following the paradigm shift, SaintA experienced a 46 percent decrease in critical behavioral incidents (including those that resulted in property damage), a 61 percent decrease in the use of physical restraints, and a 28 percent improvement in behavior on the Child and Adolescent Functional Assessment Scale (CAFAS), a multidimensional measure of functional impairment. Along the way, the number of people served by organization’s residential treatment program jumped 69 percent.
The organization has also developed a model called Seven Essential Ingredients, in which they translated what they learned into easy-to-understand language. They’ve trained close to 15,000 people, including outside schools and community-based agencies, and have been inundated with requests for training.
“When we started out with the restraint question, we never envisioned we would be consulting around the country and talking with other organizations about what it means to be trauma-informed,” she says, adding that restraints are now used “only as a last resort, when the risk of the child’s behavior is greater than the risk of the use of restraint.” Documentation and debriefing are required in such cases.
“Coincidentally, but maybe not entirely, we’ve grown from a $10-$11 million nonprofit to about $37 million” over the past eight years, she says. “The more important number is that we’re serving about 5,000 people each day, which is easily more than four-fold from when we were just beginning this work.”
ACEs in education
ACEs and trauma-informed concepts have become more prevalent at Adler in recent years as well, Elena Quintana says. The university trains “community psychologists” based on the philosophies of Alfred Adler, who “advanced the revolutionary idea that responsible practitioners must advocate to change the social conditions that affect community health and well-being,” according to its web site.
“A lot of Adlerian psychology is about the social determinants of mental health,” Quintana says. “What are the things that happen
in the world that foster mental health, or deteriorate mental health? ACEs are such an important part of that, that we have put that into our orientation. And students are so grateful for that. I can’t tell you how many social work graduates or psychology graduates who say, ‘I never got exposed to this.’”
Students who want to deepen their understanding of trauma and ACEs can take the traumatic stress psychology concentration in the doctorate of psychology program, which “offers students specialized knowledge and training to provide therapy and assessment services for individuals with symptoms of traumatic stress, including people who have experienced combat, disasters, accidents or life-threatening illness, or interpersonal violence.”
Another option is the master’s in art therapy program, of which the school’s web site says: “Art therapists are counselors trained to help people through art—as they cope with stress, traumatic experiences, or challenging relationships, and work toward personal insight and fulfillment.” And Quintana notes that Adler’s Community Health Services Division, which provides contracted services to undeserved populations, trains all mental health service provider in trauma- and ACEs-informed care.
As part of her work, Quintana develops trauma-informed alternatives to detention and evaluates organizations’ restorative justice efforts. “Restorative justice [which emphasizes repairing conflict between two people, often after one harms another in some way] is hugely important in terms of helping communities find a way back from perpetrating trauma against people.”
Quintana believes that emotional regulation is “the next great frontier” of ACEs and trauma-informed research. “We’re getting clues from epigenetics; we’re getting clues from neurobiology” about what causes and how to address emotional dysfunction, she says. “Neurobiology gives us insight on what kinds of treatments…can help the process of developing connections that are damaged. Additionally, epigenetics shows us that when things happen in our lifetimes, they can have significant and direct effects on our children or their children. What is not known is what can be done in this lifetime to assist in emotional regulation for our descendants.”
Quintana believes research in this area is still developing. “I don’t think anybody’s totally hit the nail on the head, but we’re getting closer,” she says. “I don’t think anyone says, ‘This is the key to recovering or developing an ability to emotionally regulate for those who are challenged with traumatic memory and experience.’ It seems there are lots of things that contribute differently for different people and we pick up clues to those things based on science.”
Nevertheless, the juvenile justice and criminal justice fields are already moving further away from the myth of the “super predator” that held sway in the politically charged crime-wave years of the 1980s and 1990s, Quintana says. “We brought up all these kids in this [atmosphere],” she says. “That hurt so many people. We are now in a mode of being ready to reclaim our youth.”
That’s because—or perhaps the result of—shifts in the political winds, Quintana says. “Politicians are so worried about how they will appear if they’re ‘soft on crime,’ ” she says. But locking everyone up is so expensive that people “are thinking about how smart it is, and how right it is, to form more caring communities. Interestingly, the right thing is also the cheaper thing. There’s less human toll, and less economic cost. It’s better for the young people, but also better for the workers in the system, to interact in a more humane way.”
For example, Quintana says, the per-person rate for Cook County’s temporary juvenile detention center is more than $600 per day.
“There is no greater negative investment made to the tune of billions of dollars annually [nationwide] than what we invest in the juvenile justice system,” she says. She cites the recent work of journalist Nell Bernstein, author of “Burning Down the House”: “There is no greater predictor of who will go into the adult prison system than looking at who has served time as a juvenile.
“If, instead, you offer mentoring, counseling to help strengthen the family, advocacy and support for getting back into school [and] succeeding in school, and employment training, you will do all of these things in community for much cheaper than it costs to diminish a young person’s future,” Quintana adds. “You could provide all the services I listed for multiple young people in community for a fraction of that [$600] cost.”
“Lemonade for Life”
The University of Kansas Center for Public Partnerships and Research has worked to build resilience and keep young people on track toward success by piloting the Lemonade for Life training program, in partnership with the Iowa Department of Public Health, with 25 family support professionals—home visitors, parent educators, family support workers and those that provide supervision to them in both states, says the center’s director, Jackie Counts. The center has been trying to develop a methodology for family therapists and social workers to know when to delve into ACEs and trauma.
The pilot began in July 2014 and finished in October, Counts says, and a preliminary review of the results has shown that all participants were female, 82 percent were between the ages of 26 and 45, and none reported lower than a bachelor’s degree in education.
Nearly all (94 percent) said they understood how early experiences influence the course of a person’s life, but all disagreed that a child’s high ACE score would stop them from making positive decisions in life, and all knew where to refer someone struggling with ACEs. Nearly all (88 percent) said their own experience with ACEs impacts how they interact with clients, and 70 percent said they had the ability to make others excited about their future.
“When is the right time?” she says about how those working with families decide when and how to talk about ACEs. “Do you have the right relationship with the family? Is the family in a good place that day? A script that might work for you may not work for me—it really has to be within your own style and your own word choice, just to get people more comfortable and not have a canned script. This has to be a natural thing and has to be authentic.”
“What we learned from doing the training in pilot [mode] was that people need to practice it and try it out, and it depends on their comfort level with their own ACEs,” she says. “A lot of people thought it was intrusive.”
The center provides one-day trainings for family support professionals with the prerequisite that they are generally familiar with ACEs research. The Lemonade for Life program does not cover why ACEs are important but assumes that knowledge, Counts says.
“We talk a lot about knowing your own [ACE] score, how you introduce it, how you put it in perspective, how you in your own life have taken bad situations and turned them around,” she says. “They work on a resiliency plan, with ways to work on small goals, and practice that with families.”
The program includes a “coaching call” 30 to 45 days afterward for “people in the training to come together and say, ‘that worked’ or ‘that didn’t work,’ ” Counts says. “We’re all trying to figure this out together. … We’ve gotten really good feedback from the practitioners who have used it. They say families who they’ve been working with for a long time, a little light bulb goes on and they say, ‘That’s why this is so hard!’ It’s a benign way of offering a little bit different understanding of your past.”
“You can’t rewrite the beginning of your story, but you can write the end,” Counts says, summing up the philosophy of the Lemonade for Life program.
The center and its Iowa partner has been working to spread Lemonade for Life to other populations, Counts says. They already have trained community-based child abuse prevention program staff in Iowa, and they have garnered interest from people in the employment and training, and faith-based communities. There is a training planned at the National Parents as Teachers conference in November.
Trauma 101, 201 and a ‘radical’ project
Illinois DCFS also has been training staff and foster parents on trauma-related issues beginning with Trauma 101 since 2007. In 2009, they rolled out Trauma 201 that “promoted not only a better understanding of complex trauma but also trauma-informed casework practices for families,” says Kimberly Mann, project director at the Illinois Department of Children and Family Services.
The overall thrust was to give caseworkers specific strategies and skills for each phase in the life of a family’s case, she says, and more than 25,000 staff and foster parents have participated in the trauma trainings.
“The primary finding is that the field has a better understanding of the lasting effects of early adversity,” says Mann, an associate professor of social work at Chicago State University. “We emphasize that current behavior may be a result of these [past traumatic] experiences.”
In July 2013, Cook County DCFS undertook a “radical” project involving 900 families with identified trauma needs and children under the age of four. Half receive new services and half are in a control group, which receives “business as usual” services predating the initiative. The intervention group is screened for trauma experiences across 13 areas and is provided “developmentally appropriate, trauma-informed, rigorous” interventions, Mann says.
Infants and toddlers assessed to be at the highest risk and their caregivers receive the Child Parent Psychotherapy treatment model, in which a therapist works to strengthen the relationship and restore the child’s sense of safety, attachment and social and emotional development. Those at moderate or lower levels of risk of being derailed by their ACEs receive the Nurturing Parenting Program, a home-based intervention that teaches alternative methods of discipline, empathy and nurturing skills, as well as appropriate developmental expectations.
A third-party evaluation of the intervention group is tracking reductions in trauma symptoms, improved child and parent functioning, improved child well being and increased permanency and reunification rates. The evaluation will end in September 2018, and a report is due out by March 2019.
“At some point in time, when you think broadly about what we have learned from ACES—it’s much more vast than just trauma—it’s the way we all need to be moving, identifying a need and then trying to address it,” Mann says. “This initiative is a fairly substantial beginning toward making a promising impact on very young children.”
Midwest summits keep ACEs talk going
These and other organizations that have or are working to adopt ACEs- and trauma-informed practices were among the 140 attendees at the second annual Midwest Regional Summit on Adverse Childhood Experiences, held last month in Chicago.
Conference organizer Margie Schaps, executive director of the Health and Medicine Policy Research Group, estimates these attendees were among “hundreds” of organizations throughout the Midwest that have or are working toward adopting ACEs and trauma-informed practices and principles.
Leinfelder Grove says “definitely hundreds, more likely thousands” of organizations throughout the region are using trauma-informed care, while Quintana has a more conservative estimate of about 100.
“The extent to which this understanding is embedded into the policies and practices varies widely,” says Quintana. “Our big challenge is that many, many people hear about ACEs. Few people know how to translate that into life-improving action steps, although I do think that the networking that is happening across states is really helping cross-pollination efforts that lead to policies that are informed and that work well.”
Midwest Regional Summit attendees say the material presented and networking opportunities at the conference have only deepened their knowledge base—and their resolve to face down trauma and ACEs and build resilience. Leinfelder Grove says SaintA co-hosted the first annual Midwest ACEs Summit in 2014, a one-day event that drew about 150 people.
“We had a commitment to keeping the conversation ongoing,” she says. Those who spoke about implementing ACEs- and trauma-informed practices “are great champions for all of us, making sure we’re keeping up with the latest information about ACEs, the research and the movement, so to speak. And with the networking, you can get so much information listening to how others are taking the science and implementing it in their circles and their systems.”
Mann, who served on the conference planning committee, says DCFS has been educating personnel around trauma-informed practices for “several years now.” She finds it “exciting that people well beyond mental health and child welfare are getting involved in” ACEs- and trauma-informed practices.
“It was just so very rich having people across [sectors],” she says. “We tend to get very near-sighted around the work we’re doing in our particular systems.”