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1. When the Twig is Bent:
An Integrated Approach to Children In
Foster Care
William Holmes MD
Medical Director for Foster Care Cenpatico
Roy VanTassellMS LPC
Director Trauma Evidence-Based Interventions Cenpatico

2. Objectives
• Discuss overview and awareness of trauma
and PTSD in the foster care population.
• Discuss Cenpatico’s approach to trauma
focused treatment for kids in foster care
• Discuss use and overuse of psychotropic
medications for children in foster care
• Gain an understanding of how medication use,
exposure to parent substance use and trauma
may affect future Rx Medication misuse

3. The State of the Union
• 8.3 Mil kids lived with at least one parent dependent upon
alcohol or drugs in a 2007 survey
• In U.S. someone dies of drug OD every 19 minutes
• Since 1999 Rx painkiller scripts have quadrupled
• 6.1 Mil Americans abused Rx drugs in 2011 (down from 2010)
• But number of deaths from Rx drugs doubled since 1999
• Rx deaths are more than those for heroin and coke combined
• Drug OD deaths now exceed motor vehicle deaths in 29
states
Sources: Trust for America’s Health; childwelfare.gov; National Survey on Drug Use
and Health; CNN

4. What is PTSD
• According to the National Institute of Mental
Health, PTSD is an anxiety disorder that may
develop following an individual’s experiencing or
witnessing of a traumatic event, where the natural
“fight or flight” response is damaged or altered.
Although no longer in danger, the individual may
feel stressed or intense fear following a situation in
which they or another person experienced a threat
to their life or incurred severe injury
• [Now in DSM-5 Diagnosis includes indirect
exposure and fits children under 6]
Hamblen & Barnett, 2009

5. PTSD and Children in Foster Care
• PTSD rate varies by exposure type
• One study of foster care children, found PTSD for
60% of CSA kids, 42% of physically abused kids
• Also 18% of those w/neither PA or SA still had
PTSD, perhaps due to DV, community violence, or
other exposures.
• A study of kids ages 6-8 entering foster care
found that one out of three met criteria for PTSD
Dubnerand Motta 1999, Marsenich, 2002, Dale et. al., 1999.

6. PTSD and Children in Foster Care
• Another study found PTSD symptoms in 19.2% of
child welfare investigated kids placed in foster care
• Over 21% of foster care alumni suffer from PTSD, a
rate higher than U.S. war veterans
• About 48% of children/youth in foster care have
emotional or behavioral problems and 63% are
victims of neglect
Kolko et. al., 2010, Pecoraet al., 2005, Casey Family Programs, 2011

7. It sure leaves a lasting impact
Throughout life children exposed to trauma / PTSD:
• More substance use problems and DV
• Use more mental health services (Inpt, OP, Res Tx)
• Less likely to complete secondary or advanced education
• More trouble attaining and holding stable employment
• More disrupted –less trusting relationships
• More problems with criminal justice system
• More verbally, physically abusive to their others/own children
• Experience more homelessness
• Longer the exposure, worse the outcomes
• More life long physical health care services
• On average will die 20 years younger

8. Another View
The ACE Study: Adverse Childhood Events
Kaiser Permanente’s Dept of Preventative Med.
Access to 58,000 Medical Psychological and Bio-Social member
evaluations per yr.
18,000 volunteers, studied for 8 categories of childhood abuse / household dysfunction
Abuse:
Recurrent Physical, Emotional and Sexual Abuse
Household [Family] Dysfunction:
Someone in prison
Mother treated violently
Alcoholic or drug abuser
One bio-parent lost for any reason
Someone chronically depressed, mentally ill or suicidal

9. ACE Score Impacts
18,000 Kaiser volunteers, 22% reported being sexually abused as
children (aveerageage in study=55)
•More than half had one or more ACEs
•One in 4 had 3 categories (25%)
•One in 16 had 4 categories (6.2%)
•Having one ACE = 80% likelihood of
exposure to another

10. ACE Score Impacts
ACE Study Impact Examples
•A child with 4 ACEs was 390% more likely to have COPD
• A male child with ACE of 6 has a 4,600% increased risk of
adult IV drug use
• Child with ACE of 4 or more was 460% more likely to suffer
clinical depression
• An ACE of 4 had a 1,220% increase in suicide attempts
over 0 ACE group
Felitti, V. The Relationship of Adverse Childhood Experiences to Adult Health: Turning Gold Into Lead
www.acestudy.org

11. Adverse Childhood Experiences (ACE) Study Felitti, VJ, Anda, RF, et. al. Jrnl of Prev. Med 1998
Adverse Childhood Events
underlie the Top 10 causes
of death in the U.S.
Ave 19 yr shorter lifespan
6 ACES = Ave Death age 60

14. MH Needs of Children in Foster Care
• In Sept. 2011, there were approximately 400,540
children in foster care nationwide
• 23% of maltreated kids age 17 and under have
behavior problems requiring clinical treatment 3x
rate of the general population
• In a study of foster youth ages 14 and 17, 63% met
criteria for at least one mental health diagnosis.
• Kids in FC make up 3% of those under 18 with
Medicaid, but receive 32% of the behavioral
services for that age group
U.S. Children’s Bureau, 2012, ACF 2012 Oversight of Psychotropic Medication for
Children in Foster Care;

15. Issues of Med in Foster Care: Why
Important?
• There is strong evidence of high use of
psychotropic med use in foster care
• Texas experience with this…
• Emotional and behavioral care needs for
children in Foster care
• Are medications helpful? Needed for kids in FC?
• Naturally, increased prescribing may lead to
increased use and potential for diversion of
meds and misuse / abuse

16. Psychotropic Medications (PMs)
and Foster Care
• Studies of PMs in foster care are out of date and
often geographically specific (within & between
states)
• Studied rates varied from 13%-52% of kids in care
• PM use affected by age, gender, behavior, placement
– Age: (more PMs and more types as kids age)
– Gender: (3x more males vs. female)
– Behavior (internalized vs. externalized)
– Placement type (more restrictive = more PMs)
ACF: Oversight of Psychotropic Medication for Children in Foster Care;
Title IV-B Health Care Oversight & Coordination Plan 2012

17. Psychotropic Medications and
Foster Care
• Youth in foster care with Medicaid get 3 times the
Psychotropic Medications (PMs) of other
Medicaid qualified youth
• The same study found 41% got three different
classes of PMs almost 16% got 4 classes
• 22% got 2 or more meds in same PM class
regardless of diagnosis
• Yet these children have significant mental health
and behavioral treatment needs
Zito, et. al. Pediatrics, 2008

18. Use of Medication in Foster Care:
Responses
• Importance of quality evaluation /assessment
(e.g. does hyperactive behavior mean ADHD?)
• Increased awareness of EBTs and education
about trauma is essential
• Problems with availability / access to EBTs for
some children
• QI programs focus on med use and
management

19. PMUR - Psychotropic Medication
Utilization Review
• Goal: Improved use of appropriate medication
treatment
• Elements of PMUR:
– Pharmacy data
– Parameters
– Review of clinical information
– Contact with prescribers

20. PMUR - Psychotropic Medication
Utilization Review
• Results (TX specific right now, just beginning
to use in other states)
• Future goals:
– Connecting correct meds with given diagnosis
– Monitoring medication compliance
– Monitoring / evaluating use of non-medication
intervention effectiveness

21. Developed by: Texas Department of Family and Protective Services and
The University of Texas at Austin College of Pharmacy
with review and input provided by:
™Federation of Texas Psychiatry Texas Pediatric Society
™Texas Academy of Family Physicians Texas Medical Association
And Rutgers University—Center for Education and Research on Mental Therapeutics
September 2013
A Collaborative Texas Initiative

22. Attention to a National Problem
A National Response
• The Fostering Connections to Success and
Increasing Adoptions Act of 2008 requires all
states to increase their oversight of the health
and mental health of foster care children,
including initial and follow up health
assessments to determine whether a child
needs additional help (e.g. specialized trauma
services)
The Fostering Connections to Success and Increasing Adoptions Act of 2008 (Public Law (P.L.)
110-351) amended title IV-B, subpart 1 of the Social Security act

23. Not Just a Mental Health Problem
“The overrepresentation of people with
SMI or Co-Occurring Disorder (COD )in
the criminal justice system has a
significant impact on the recovery path
of these individuals, creates stress for
their families, and has an effect on public
safety and government spending.”
Blandford, A. &Osher, F. (2012). A Checklist for Implementing Evidence-
Based Practices and Programs (EBPs) for Justice-Involved Adults with
Behavioral Health Disorders. Delmar, NY: SAMHSA’s GAINS Center for
Behavioral Health and Justice Transformation.

24. Mental Health Meets Criminal Justice
• Prevalence of (SMI) in the crim. justice system is 3-6
times the rate in general U.S. population
• A study of over 20k adults in 5 jails found 14.5 % of male
inmates, 31% of female met SMI criteria
• Finding suggests more than 2mil. bookings of a person
with SMI occur annually.
• Of 17% of jailed with SMI, estimated 72% had a co-
occurring substance use disorder.
• 59 percent of state prisoners with mental illnesses had a
co-occurring drug and/or alcohol problem

25. The Hope of System Collaboration
• Violence and trauma exposure is not an automatic lifelong ticket
to dysfunction
• The single biggest factor in what helps kids is having a
supportive, believing, consistent, nurturing care-giver and safe
place in the community
• There are very effective evidenced-basedcommunity programs,
responses and treatments that have been clinically
demonstrated to provide healing from exposure to violence and
abuse for adults and children
• There are effective action steps for prevention which everyone
can help foster in any community, the cycles can be broken

26. What Is Trauma Awareness?
• Trauma results from adverse life experiences that overwhelm
an individual’s capacity to cope and to adapt positively
• “Traumatic events produce profound and lasting changes in
physiological arousal, emotion, cognition, and memory…may
sever these normally integrated functions from one another”
• It’s “lasting impact represents a combination of the event and
the subjective thoughts and feelings it engenders”.
• An event becomes traumatic when its adverse effect
produces feelings of helplessness and lack of control, and
thoughts that one’s survival may possibly be in danger. “Stress
becomes trauma when the intensity of frightening events
becomes unmanageable to the point of threatening physical
and psychological integrity”
(Van derKolk, 1996, Judith Herman, 1992, Lieberman & Van Horn, 2008)

27. What is Trauma-Informed
“When a human service program takes the step to
become trauma-informed, every part of its
organization, management, and service delivery system
is assessed and potentially modified to include a basic
understanding of how trauma affects the life of an
individual seeking services.
“Trauma-informed organizations, programs, and services
are based on an understanding of the vulnerabilities or
triggers of trauma survivors that traditional service
delivery approaches may exacerbate, so that these
services and programs can be more supportive and
avoid re-traumatization”.
SAMHSA National Center On Trauma Informed Care

28. Trauma Specific Treatments
• There are numerous child and adolescent treatment
interventions with strong evidence base of effectiveness
• Models range from birth to 21 some with or w/o parent
• For individual, group, family, early childhood and
incarcerated youth.
• A range of community based and parent education and
support interventions, those with evidence should be first
line choices
• The earlier child needs can be identified the earlier
intervention can occur

29. Non- Pharmacological
Interventions
A few names you may hear: Range Birth to 21
– Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
– Alternatives for Families Cognitive Behavioral Therapy
– Child Parent Psychotherapy (CPP)
– Cognitive Behavioral Intervention for Trauma in School
– Parent Child Interaction Therapy (PCIT)
– Child and Family Traumatic Stress Intervention (CF-TSI)
– Structured Psychotherapy for Adolescents Responding
to Chronic Stress (SPARCS)
– Trauma Affect Regulation: Guidelines for Education and
Therapy Adolescent (TARGET-A)

30. Non- Pharmacological
Interventions
Some Resources:
• SAMHSA National Registry of Evidence Based Programs and
practices www.nrepp.samhsa.gov
• National Child Traumatic Stress Network’s Empirically
Supported Treatments and Promising Practices
http://www.nctsnet.org/resources/topics/treatments-that-
work/promising-practices
• Evidence Based Practice Facts Sheets: Gains Center for
Behavioral Health and Justice Transformation
http://gainscenter.samhsa.gov/topical_resources/ebps.asp
• Office of Juvenile Justice and Delinquency Prevention Model
Programs Guide: http://www.ojjdp.gov/MPG

31. Becoming Trauma Aware in
Criminal Justice
• “there is consensus that high percentages of justice-
involved women and men have experienced serious
trauma throughout their lifetime.
• The reverberating effect of trauma experiences can
challenge a person’s capacity for recovery and pose
significant barriers to accessing services, often
resulting in an increased risk of coming into contact
with the criminal justice system “
Policy Research Associates

32. How Being Trauma-Informed Improves
Criminal Justice Responses
• Create and awareness and understanding of the
impact of trauma
• Create an awareness of the impact of trauma on
behavior,
• Develop trauma-informed responses.
• Provide strategies for developing and
implementing trauma-informed policies.
See more at: http://gainscenter.samhsa.gov/trauma/trauma_training.asp
http://www.prainc.com/how-being-trauma-informed-improves-criminal-justice-
responses/#sthash.UF8vLzq2.dpuf

33. Trauma Informed Policing
• Being aware when intervening and children
are present of what they see, hear and
experience
• Children key off of adult, care givers even
impaired ones are child’s psychological safe
base
• Threats to caregivers will threaten child’s
sense of safety, vulnerability

34. Screening and Assessment
• Protective services, L.E. and MH can co-train,
respond together when appropriate or it is
know that children will be present
• Every child brought into care or whose parents
are identified as having substance use issues
should be screened / assessed (shelters?)
• Children who receive immediate preventive
interventions show fewer short and long term
symptoms / negative effects

35. Responding at the Scene
• We understand that the mission of LE at the
point of intervention is a specific one and has
different priorities e.g. secure the scene /
safety, etc.
• But where possible and as soon as possible
attend to the needs of children present, be
aware of what they see, especially involving
caregivers

36. Helping Children at the Scene
• Ask where Children are –check if hurt, safe
• Describe your role in simple terms
• Speak at their level (kneeling, sitting, squating)
• Try not to talk badly about parent in front of child
• Keep kids with known adults when possible
• Don’t say “everything will be OK” or make
promises you can’t keep

37. Helping Children at the Scene
• Reassure that what is happening with adults is
NOT their fault
• Explain to children why any use of force was
necessary
• Provide parent or other caregiver with
information about safety, resources as
appropriate

38. Helpful Responses for Children
• Addressing kids on their level ? Get in the ROLES
• Relaxed manner
• Open posture (no folded arms or hands on hips)
• Lean towards slightly w/ upper body (on level)
• Eye contact (direct but not piercing, warm)
• Space between you (note how close, not allowing
them to feel trapped, but blocking distressful
visual scenes is helpful)

39. Follow-up Can Support Resiliency
• On occasion children have visited precincts,
fire stations or met with responders in other
settings (schools community settings) after
the scene to restore connections reduce fear
and avoidance
• Helps to underscore task of safety at time of
intervention and what occurred as necessary
to get people help keep everyone safe

41. Who Helps the Helper?
-Secondary Traumatic Stress and Burnout Among Law
Enforcement Investigators Exposed to Disturbing Media Images
Lisa M. Perez &Jeremy Jones &David R. Englert&Daniel Sachau,J Police Crim Psych (2010) 25:113–124
-Contamination of Cop: Secondary Traumatic Stress of
Officers Responding to Civilian Suicides (From Suicide and Law
Enforcement, P 337-355, 2001, Donald C. Sheehan and Janet I. Warren, eds. -- See NCJ-193528)
Author(s): John Nicoletti ; Sally Spencer-Thomas, 2001 Nat. Criminal Justice Reference Service
-The Cause and Effect of Secondary Traumatic Stress
Written by Federal Employee Defense Services on 19 May 2011. Posted in The Spotlight FED AGENT .COM
-Vicarious Traumatization and Spirituality in Law
Enforcement FBI Law Enforcement Bulletin , July 2011 Vicarious Traumatization
*Greater attention being given in last few years to
Secondary Traumatic Stress for law
enforcement

42. William Holmes MD
wholmes@cenpatico.com
Roy Van Tassell, MS LPC
rvantassell@cenpatico.com
Thank You for Your Participation!