Home for the Holidays?

Our guest blogger is “Dr. Aby,” the in-house clinical psycholigist for the DC Child & Family Services Agency.

xmastrauma2

By Dr. Abyssinia Washington

It’s that special time of the year again.  The time of year where images of lovingly decorated trees, back-to-back holiday parties, family photos for the year-end holiday card and the joy of buying the perfect gift for loved ones rule the day.

Around the globe and here in America, this image of the holidays may differ based on cultural, religious or social beliefs and norms, but for the most part, these three words are supposed to dominate the mood of the season: JOY, LOVE, PEACE.

Our expectations of what the holidays should look and feel like are powerful and rooted in our early childhood experiences in our homes, schools, communities and places of worship.  Our culture also builds expectations around celebration, sharing and abundance associated with this season; but in reality, these expectations may be in stark contrast to memories that remind us of the realities of who and what may be missing from our lives.

Our professional lives in the child welfare field expose us to families who struggle tremendously with providing safety, nurturing or material support all year long.  For many children we interact with, there will be no going home for the holidays.  The pain and loneliness of separation from home and family may feel worse at times when we perceive others as having a picture perfect holiday.  It’s important to acknowledge that the high expectations of the holiday season may be a trigger for many of us who are experiencing a range of different losses or struggles.

Below are tips from “Helping Young People in Foster Care Through the Holidays.”

1. Prepare the foster youth in your care for the holidays in your home

Have a discussion with the young person about your family’s holiday customs. Do you celebrate over multiple days, or is there one “main” celebration? Are there religious customs? Will gifts be exchanged? What should they wear? Who will they meet? What preparations need to be done in advance? Will there be visitors to the home? Will they be taken on visits to the homes of other family or friends? And in all of these events, will your youth be expected to participate? Knowing what to expect will help to decrease anxiety around the holidays. Avoid surprises and you will decrease seasonal tensions.

xmastrauma3

2. Prepare friends and family before you visit

Let people know in advance about new family members in your home. Surprising a host or hostess at the door with a “new” foster youth may set up an awkward situation — such as a scramble to set an extra place at the table — making the young person feel like an imposition right from the start of the visit. Your preparation of friends should help cut down on awkward but reasonable questions such as “who are you?” or “where did you come from?”

3. Remember confidentiality

You may receive well intended but prying questions from those you visit over the holidays. If your young person is new to your home, it is natural that family members ask questions about your youth’s background. Understand that questions are generally not meant to be insensitive or rude, but simply come from a place of not knowing much about foster care. Think in advance about how to answer these questions while maintaining your youth’s confidentiality. Use the opportunity to educate interested family and friends. Discuss with your young person how they would like to be introduced and what is appropriate to share about their history with your family and friends. (Remember, they have no obligation to reveal their past.)

4. Arrange meeting your family in advance, if possible

The hustle and bustle of the holidays can make it particularly chaotic for your young person to participate in your family traditions. Anxiety may run high for young people already, and the stress of meeting your relatives may be a lot to deal with. If possible, you can arrange a casual “meeting” in advance of “main events.” If it is not possible or practical to meet beforehand, make a list of names of some of the people they’ll meet and their connection to you. You can also encourage a quick call from relatives you plan to visit to deliver a personal message of “we are excited to meet you” so that your youth knows they will be welcome.

5. Have extra presents ready to help offset differences

It should not be expected that all relatives purchase presents for your youth. Be prepared with other small gifts and for those family members that express concern over not having brought a gift, offer one of your “backups” for them to place under the tree. Extra presents may be addressed “from Santa,” even for older youth, to help offset a larger number of gifts other children may receive at the same time. Children often keep count of the number of gifts received (right or wrong) and use it to compare with other kids, so sometimes quantity is important.

6. Facilitate visits with loved ones

The holidays can be a busy time for everyone including foster parents and caseworkers. But it is especially important during this time of year to help your young person arrange for visits with loved ones. Don’t allow busy schedules to mean the postponement of these important visits. Try to get permission for your youth to make phone calls to relatives. If long distance charges are an issue, ask if calls can be placed from the foster care agency or provide a local business or individual to “donate” by allowing the use of their phone. A youth may wish to extend holiday wishes to relatives and friends from an old neighborhood, but may need your help getting phone numbers together. Use the opportunity to help the youth develop their own address book.

7. Help them make sure their loved ones are okay

Young people may worry that their family members are struggling through the holidays. If homelessness has been a regular issue, the winter season may bring cold weather and extreme hardship. Your youth may experience guilt if they feel a loved one is struggling while they are living in comfort. Knowing that a biological parent or sibling has shelter from the cold or has their other basic needs met may ease a young person’s mind through the always emotional holidays.

8. Extend an invitation

If it is safe and allowed by your foster care agency, consider extending an invitation to siblings or bioparents through the holidays. It need not be an invitation to your “main” holiday event; consider a “special” dinner for your youth to celebrate with their loved ones. If this not possible to do within your home, consider arranging a visit at a local restaurant.

Extending an invitation to their loved ones need not signal to a young person that you support their bio-family’s lifestyle or choices — rather it tells a young person that you respect their wish to stay connected to family. You will also send a message to the youth that they aren’t being put in a position to “choose” your family over their bio-family and that it is possible to have a relationship with all the people they care about.

9. Understand and encourage your youth’s own traditions and beliefs

Encourage discussion about the holiday traditions your young person experienced prior to being in foster care, or even celebrations they liked while living with other foster families. Incorporate the traditions the youth cherishes into your own family celebration, if possible. Use the opportunity to investigate the youth’s culture and research customary traditions. If the young person holds a religious belief different from yours, or if their family did, check into the traditions customarily surrounding those beliefs.

xmastrauma

10. Assist in purchasing or making holiday gifts or in sending cards to their family and friends

Allow young people to purchase small gifts for their relatives, or help them craft homemade gifts. Help send holiday cards to those that they want to stay connected with. The list of people that your youth wishes to send cards and gifts to should be left completely to the youth, although precautions may be taken to ensure safety (for example, a return address may be left off the package, or use the address of the foster care agency) and compliance with any court orders.

11. Understand if they pull away

Despite your best efforts, a young person may simply withdraw during the holidays. Understand that this detachment most likely is not intended to be an insult or a reflection of how they feel about you, but rather is their own coping mechanism. Allow for “downtime” during the holidays that will allow the youth some time to themselves if they need it (although some youth would prefer to stay busy to keep their mind off other things — you will need to make a decision based on your knowledge of the young person). Be sure to fit in one-on-one time, personal time for your youth and you to talk through what they are feeling during this emotional and often confusing time of year.

12. Call youth who formerly lived with you

The holidays can be a particularly tough time for youth who have recently aged out of foster care. They may not have people to visit or a place to go for the holidays. In addition, young people commonly struggle financially when they first leave foster care. A single phone call may lift their spirits and signal that you continue to care for them and treasure their friendship. Be sure to include these youth on your own holiday card list. A small token gift or gift basket of homemade holiday goodies may be especially appreciated.

Click here for more tips.

Dr. Abyssinia Washington, M. Ed and Psy.D, is the Trauma and Healing Implementation Specialist for the Trauma Grant at the DC Child and Family Services Agency.

Washington-Area Pediatricians Start to Tackle Trauma

CFSA doctor

by Marie Morilus-Black

As part of a District-wide effort to address trauma, local pediatricians are doing their part by actively seeking opportunities to identify mental health concerns, including those that are trauma related, in their patients through the Mental Health Screening in Primary Care Learning Collaborative said Dr. Lee Beers, medical director for Municipal and Regional Affairs of the Child Health Advocacy Institute at Children’s National Health System.

Guest blogger: Dr. Lee Beers

In addition to mCFSA, traumaental health, trauma can have an impact on physical health as well.

“Many studies show that exposure to traumatic events in early childhood can increase risks for heart disease, diabetes, high blood pressure and other health conditions,” she said. “The more adverse childhood experiences you have, the greater your risks of health concerns. The impact on your physical health can also affect your ability to implement your recommended treatment.”

Pediatricians just don’t have all of the tools to address trauma and it’s something that requires community support and a community response, according to Dr. Beers. Building the necessary relationships to tackle trauma is difficult for a provider who’s seeing patients all day, but we want to help facilitate those relationships – pediatricians can be important connectors as they have regular touch points with children and families and play an important role in the system of care.

“Part of the reason that we wanted to focus on mental health in the first place is because there is this huge issue of unmet mental health needs in the city impacted by high rates of violence that complicate and aggravate mental and behavioral health issues,” said Dr. Beers. “A lot of providers were seeing that our families were struggling with mental health concerns; while the providers had some training, it was not sufficient for what they wanted.”

And even though the pediatricians haven’t formally started using Trauma Systems Therapy, the training that Washington, DC-area primary care providers have undertaken was designed to shore up their trauma-informed knowledge base.

“The primary care environment is different from some of the other environments that have longer periods of time to spend with children and families. From a time standpoint, it’s pretty important to have briefer and more efficient ways to identify concerns and connect them with the diagnostic and treatment services that they need,” said Dr. Beers.

Children’s National started hosting a nine-month learning collaborative funded by DC Behavioral Health and Health Departments in February 2014 that focused on general mental health screenings. The training ultimately expanded to 15 months in large part because the pediatricians requested even more support.  These trainings involved monthly webinar, conference calls and chart reviews.

CFSA doctor 2

“The day-to-day  work of health care is pretty different than other systems, so we’ve adopted strategies that can be integrated into our existing workflow,” Dr. Beers said of the 140 providers who have participated across the city – representing about 80 percent of the children on Medicaid. “Each practice reviewed charts to see how well they did with the mental health screenings and saw really nice improvements.”

The providers are seeing more identification and recognition of signs of trauma and are using this training as a tool to address mental health in a substantive way.

“What we’re finding is that kids are getting identified earlier by integrating mental health in a variety of ways into primary care practices,” she said. “As a result of these screenings, a lot of children are coming to the attention of behavioral health providers.”

The hope for the next stage of this work will include looking at how to pilot trauma screening over the next 12 months.

“We’re working with a lot of folks from across the city to think about how we engage in a comprehensive, citywide approach to preventing, identifying and addressing trauma,” she said. “The health care systems haven’t always been well-connected with that but are trying to become more connected so that we can all work collaboratively together.”

Dr. Lee Beers is the medical director for Municipal and Regional Affairs of the Child Health Advocacy Institute at Children’s National Health System.

Introducing Marie Morilus-Black and the July 1st Launch of Trauma Assessment Tools

By Marie Morilus-Black

Research findings indicate that 51 percent of children in foster care have experienced serious trauma. Further, somewhere between 83 and 91 percent of children living in challenging neighborhoods – where a significant portion of our in-home population resides – suffer from trauma. Often, their parents have a history of trauma that has gone untreated.

Embed from Getty Images

With those kinds of staggering statistics, it’s imperative that we focus on the trauma first. That’s why the July 1 implementation of the Child and Adolescent Functional Assessment Scale (CAFAS)® and the Preschool and Early Childhood Functional Assessment Scale (PECFAS)® functional assessment tools along with the Caregiver Strength and Barriers Assessment (CSBA) represent a powerful next step in our journey to becoming a trauma-informed public child welfare system.

These objective, third-party tools standardize the assessments and serve as indicators of what’s going on in that parents or that child’s life. They will allow us to measure and track a parent or a child’s progress in healing.

This work is important to me because all the research stresses that you have to treat the trauma first before children – and even before the entire family – can benefit from other kinds of help.

I was the State Children and Youth Services Director at the District of Columbia Department of Behavioral Health for nearly six years before joining CFSA last January.  While at DBH, I was heavily involved in partnering with CFSA to identify comprehensive screening and assessment tools that numerous organizations throughout the city could adopt.

Marie Morilus Black, trauma, child welfare, children, DC, CFSA, Child and Family ServicesThat partnership really happened in synch with my role at DBH. We implemented the assessment tool last November at DBH, an experience that served as a perfect foreshadowing and segue for my helming the newly created role of Deputy Director of the Office of Well Being at CFSA. Approximately 50 percent of the cases at DBH are also CFSA-involved. When CFSA created the Office of Well Being with all of the related components – espousing everything from behavioral health to substance abuse and education to daycare – I gravitated to how this office addressed the whole person and family. In my previous position, I focused on the children exclusively, and now I’m thrilled to naturally expand to focusing on children and families and all the related needs they have, including the service needs of the adults in their lives.

CFSA has taken a little bit more time to implement the assessment tools because the agency wanted to integrate them into our automated case management system. My experience and lessons learned implementing the assessment tool at DBH informs the work we are doing now at CFSA.

I really believe that the way that we are integrating the trauma work and the functional assessments into our case planning process not only addresses the trauma of the children but also of the parents. This approach makes us a leader in the child welfare community because we are truly building a trauma-informed child welfare system of care. We are beginning to look at how that work will then impact well-being. Currently, we are working with Chapin Hall at the University of Chicago – a research and policy center focused on a mission of improving the well-being of children and youth, families, and their communities – to develop some specific well-being indicators  we can track to ensure  we are actually achieving the outcomes  we want.

Since the last blog post, we also have the following updates:

We’ve trained nearly 3,000 staff, foster parents, members of the community and other stakeholders on trauma-informed care.

In the fall, we will start a whole new series of training for community partners and for new staff. We’re also executing a train-the-trainer model so that we will have local capacity to do the training ourselves. There is interest in training recreational staff throughout the city so that even more people who interface with kids on a daily basis become trauma knowledgeable.  I want adults who work with our kids to focus on “what happened to our kids vs. what is wrong with our kids.”

We have launched the screening instruments that will assess for trauma.

The Child Stress Disorder Checklist is a screening that we do for trauma while the Caregiver Strengths and Barriers Assessment is a screening that we give parents that includes a trauma component.

On July 1, we are launching the functional assessments that will trauma-inform our integrated case plans.

The CAFAS® and the PECFAS® tools will not only trauma-inform the integrated case plan but will also show if the plans are leading to better outcomes. We will be able to answer the question, “are our kids and parents getting better?”

We’ve conducted an evaluation following the training and have discovered some key findings.

  • 94 percent think these practices will help children and families who have experienced traumatic events.
  • 93 percent report better understanding of a child’s symptoms in the context of his or her world.
  • 83 percent see trauma-informed practice contributing to more effective, comprehensive, and individualized intervention planning for children.
  • 86 percent think trauma-informed practice is a viable way to break down barriers between service systems.

I originally wanted to be a child psychiatrist. One of my mentors asked me why, and I told her I wanted to counsel families and help improve their lives. I began to reconsider after she pointed out that they do a lot of medication therapy. While medication therapy has its place, I didn’t want that to be my first go-to solution for helping to heal families.

An internship with Crisis Services in Buffalo, NY, and interviews I conducted with psychiatrists at state psychiatric facilities underscored my mentor’s point and made me realized that a lot of that work doesn’t deal with the family treatment that I wanted to do. A paid fellowship and scholarship-funded graduate degree later, I shifted my focus and passion to social work and a career in human services.

I look forward to shepherding the great work of the trauma team and the Office of Well Being forward here at CFSA. As we continue to embed trauma best practices into the way we assist our children and youth, we look forward to offering an art class or karate class to  help our young people combat trauma versus medicating the issue or worse yet – leaving them to fight alone.

Power of Multiple Best Practices Adds Up

by Michele Rosenberg

shutterstock_128372408

Our adoption of Trauma Systems Therapy (TST) is a main driver of positive practice change in DC child welfare—and what this blog is all about. At the same time, it’s far from the only strategy we have underway to get better outcomes for children and families. I just want to give you a glimpse into three of the many best practices in our performance improvement renaissance. We’re finding that the synergy among all these new approaches is extremely powerful.

Focus on Families

The sea change taking place in DC child welfare is the shift from a system with a high child removal rate and geared primarily for foster care to a system focused on strengthening families and keeping them together. In the process, we’re taking a close look at family needs and developing a more nuanced array of community-based services. Although our first thought in becoming trauma-informed was to help child victims of abuse and neglect, we’re quickly finding that the trauma lens is invaluable in understanding and helping their parents as well.

Structuring Critical Thinking

RED (review/evaluate/direct) Teams is the best practice of bringing professionals together and structuring their critical thinking at significant points throughout the life of a case. This leads to vastly improved insights, judgment, and decisions about the difficult and delicate matters we confront in child welfare every day. We’ve found that purposefully asking trauma-informed questions during RED Teams enhances the discussion and resulting decisions.

Taking Good Care

CFSA has a major push underway to improve the well being of every child, youth, and adult we serve. TST fits perfectly with increased efforts in areas such as substance abuse treatment, educational achievement, and transitional planning for youth.

Sum Greater Than the Parts

Each of these (and all our other) major improvement strategies has its own champions and implementation body, but at the deputy director level in CFSA, we’re also paying attention to the big picture. By cross-pollenating our teams, we’ve been able to address concerns about integrating all these best practices and operationalizing them in day-to-day work. We’re working on an agency-wide model of practice improvement that will help social workers and all of us grasp the integration of these best practices and the great potential of their combined forces. I’m deep into looking for the best ways to communicate all that and will likely share more thoughts on this topic in the future. If you have ideas or suggestions about good ways to implement practice change, I look forward to hearing from you.

Healing Helpers All Over Town

by Michele Rosenberg

In 2012, the DC Department of Behavioral Health (DBH) received a federal grant to improve and strengthen the system of public mental health care in the District of Columbia. That work fits so well with CFSA’s efforts to become trauma informed! The long-standing CFSA-DBH partnership has deepened as we collaborate to improve services to those we’re serving jointly. Guest blogger (and one of my key community partners) Denise Dunbar from DBH shares her perspective on what is truly a win-win situation for users and providers.

shutterstock_109528382

Guest blogger Denise Dunbar:
DBH supports prevention and treatment of District residents with mental health and substance use disorders. We have a network of certified, community-based, private providers who increasingly use evidence-based practices.

Denise Dunbar DBH

Denise Dunbar

Focus on Children

Our work with children is especially important because half of all lifetime cases of mental disorders begin by age 14. By some estimates, as many as 14 percent to 20 percent of all children have some type of emotional or behavioral disorder.

In 2008, DBH and CFSA established the Choice Provider Network to meet the unique needs of children and youth in the foster care system. Over the years, these six providers have phased in nine specific evidence-based practices that address a range of mental and behavioral health needs for children and youth from birth to age 21.

This month, the first cohort of DBH child-serving community providers will participate in Trauma Systems Therapy (TST) training at CFSA, which will become our tenth specific evidence-based practice. DBH has been working to build a broad foundation of knowledge about trauma, and TST is a definite enhancement.

Partnership

This is just one of the many ways DBH and CFSA are collaborating. Last year, we decided we will both use the Child and Adolescent Functional Assessment Scale (CAFAS)®, which gives us common data-driven information and language for confronting children’s needs and a common basis for establishing shared well being outcome measures and identifying the best services in each case. When children have to leave home to be safe, we’re working to speed access to services by having DBH behavioral health providers participate in CFSA’s initial meetings with the family and professional team.

Some DBH clinicians have been based on site at CFSA for several years—and continue to adopt new and better ways of supporting child welfare. In the past year, they screened 86 percent of children entering or re-entering foster care, providing early identification of social/emotional and mental/behavioral issues and a clearer pathway to services. This approached proved so useful that DBH has recently added clinicians to also screen the many children and youth CFSA serves at home.

Healing

Together, CFSA and DBH are working to become trauma informed and to use best practices to meet child and youth mental and behavioral health needs. Ultimately, our shared goal is to restore healthy functioning and brighten the future for children and youth who have been through so much.

Denise Dunbar, MSW, is the mental health program manager assigned to CFSA at the DC Department of Behavioral Health, Office of Programs and Policy, Child and Youth Services Division.