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Healing Families, Helping Systems: A Trauma-Informed Practice Guide for Working with Children, Youth and Families J A N UA RY 2017

Acknowledgments WRITERS

Nancy Poole, Christina Talbot and Tasnim Nathoo,

BC Centre of Excellence for Women’s Health

WORKING GROUP

Julie Adams, BC Ministry of Children and Family

Development (MCFD), Child and Youth Mental

Health Policy

Leslie Anderson, MCFD, Child Welfare Policy

Dayna Long, MCFD, Youth Forensic Psychiatric Services

Dr. Natalie Franz, MCFD, The Maples Adolescent

Treatment Centre

Janet Campbell, MCFD, Regional Child and Youth

Mental Health Coordinator, Coast Fraser Region

Karen Sam, MCFD, Aboriginal Services Branch

Terry Lejko, MCFD, Director of Practice,

Coast North Shore SDA

Kim Dooling, MCFD, Practice Consultant,

Provincial Practice Branch

Kim Hetherington, MCFD, Early Childhood

Development/Children and Youth with Special Needs

Chris Burt, Hollyburn Family Services

Ben Eaton, School District 8 (Kootenay Lake)

ADVISORY COMMITTEE

Robert Lampard, MCFD, Child and Youth Mental Health Policy

Aleksandra Stevanovic, MCFD, Child and Youth with Special Needs, Autism and Early Years Policy

Karen Bopp, MCFD, Child and Youth with Special Needs, Autism and Early Years Policy

John Yakielashek, MCFD, Director of Practice, South Island

Stephanie Mannix, MCFD, Aboriginal Policy Branch

Twila Lavender, Ministry of Education, Comprehensive School Health

Kelly Veillette, Ministry of Health, Health Services Policy and Quality Assurance Division

Christine Westland, First Nations Health Authority

Judith Wright, Victoria Child Abuse Prevention and Counselling Centre

Julie Collette, Families Organized for Recognition and Care Equality ( The F.O.R.C.E.) Society for Kids’ Mental Health

Traci Cook, The F.O.R.C.E. Society for Kids’ Mental Health

Dan Malone, Foster Parent Support Services Society

Angela Clancy, Family Support Institute of BC

THIS GUIDE IS INTENDED to guide the professional work of practitioners assisting children, youth, and families in British Columbia.

IT IS BASED ON: findings from current academic and grey literature; lessons learned from implementation in other jurisdictions; and ideas offered by practitioners from the Ministry for Children and Families in BC in web meetings held in February 2015.

AN IMPORTANT GOAL OF THE GUIDE is to build upon existing promising practices to improve support and expand relationships with families, other practitioners and other systems of care.

THIS DOCUMENT IS AVAILABLE AT gov.bc.ca/traumainformedpractice

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Contents 1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

1.1 Project Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

1.2 Intended Audience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

1.3 The Rationale for this Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

2. UNDERSTANDING TRAUMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2.1 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2.2 Trauma Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

2.3 Effects of Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

3. TRAUMA-INFORMED – DEFINITION AND PRINCIPLES. . . . . 10

3.1 What do we mean by Trauma-Informed? . . . . . . . . . . . . . . . . . . . . 10

3.2 What do we mean by Trauma-Specific? . . . . . . . . . . . . . . . . . . . . . . 11

3.3 Principles of Trauma Informed Practice . . . . . . . . . . . . . . . . . . . . . . 13

4. IMPLEMENTING TRAUMA-INFORMED APPROACHES . . . . . 15

4.1 TIP in Interactions with Children and Youth . . . . . . . . . . . . . . . . . . 16

4.2 TIP in Interactions with Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

4.3 TIP for Worker Wellness and Safety . . . . . . . . . . . . . . . . . . . . . . . . . 24

4.4 TIP at the Organizational Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

4.5 TIP at the Leadership Level – Relational System Change . . . . . 29

OVERVIEW OF GUIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

GUIDE SUMMARY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

APPENDIX 1: PRACTICAL TIP STRATEGIES FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

APPENDIX 2: TRAUMA-INFORMED PRACTICE PRINCIPLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

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1. Introduction

1.1 Project Objectives This guide is concerned with advancing understanding and action about trauma-informed approaches that support program and service delivery for/with children, youth and families. A trauma-informed approach is a system-wide approach that is distinct from, yet linked to, the delivery of trauma-specific treatments and interventions.

This guide is the result of a project of the Ministry of Children and Family Development in British Columbia with the following objectives:

• TO IDENTIFY TRAUMA-INFORMED APPROACHES to supporting children, youth and families, from the academic and non- academic literature and from the experience of those delivering child and youth services in B.C. (child protection, youth justice, child and youth mental health, children with special needs, early years services, and family, youth and children in care services and adoption services).

• TO RAISE AWARENESS among those delivering child and youth services in B.C. of evidence-informed approaches to trauma-informed service delivery.

• TO INCREASE CAPACITY amongst service providers delivering child and youth services in B.C. to better serve children, youth and families impacted by violence and trauma, and thereby improve outcomes for those engaged with these services.

1.2 Intended Audience This Trauma-informed Practice ( TIP) Guide is designed to inform the work of leaders, system planners and practitioners working with children, youth and families within the service areas of the British Columbia Ministry of Children and Family Development and Delegated Aboriginal Agencies. This document may also be relevant to those working with children, youth and families in other settings such as schools, hospitals and other community-based settings.

1.3 The Rationale for this Guide Experiences of trauma, arising from childhood abuse, neglect, witnessing violence and disrupted attachment, as well as other life experiences such as accidents, natural disasters, sudden unexpected loss, war/terrorism, cultural genocide and other life events that are out of one’s control – affect almost everyone in child and youth serving agencies. Children and their caregivers, therapists and administrators, program planners and support staff are all affected by these types of traumatic experiences, either directly or indirectly.

Trauma-informed approaches to serving children, youth and families recognize how common the experiences of trauma are, and the wide range of effects trauma can have on both short-term and long-term health and well-being. Trauma-informed approaches involve a paradigm shift to support changes in everyday practices and policies to factor in the centrality of trauma for many children, youth, and families, and our growing understanding of how to promote resilience. The overall goal of trauma- informed approaches is to develop programs, services, and environments that do not re-traumatize while also promoting coping skills and resilience.

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FURTHER READING/LINKS

• Harris, M., & Fallot, R. (2001). Using trauma theory to design service systems. San Francisco: Jossey-Bass.

• Hodas, G. (2006). Responding to childhood trauma: The promise and practice of trauma-informed care. Retrieved from Echo Parenting and Education http://ccyp.vic.gov.au/childsafetycommissioner/ downloads/calmer_classrooms.pdf

• Trauma-informed Practice Guide (2013) British Columbia Centre of Excellence for Women’s Health  and Ministry of Health, Government of British Columbia. http://bccewh. bc.ca/2014/02/trauma-informed-practice-guide/

• Truth and Reconciliation Commission of Canada: Calls to Action (2015). http://www.trc.ca/websites/trcinstitution/ File/2015/Findings/Calls_to_Action_English2.pdf

WEBSITES

• National Child Traumatic Stress Network website: www.nctsn.org

• National Center for Trauma-Informed Care website: http://www.samhsa.gov/nctic

• The Adverse Childhood Experiences (ACE) Study website: http://acestudy.org

• The National Collaborating Centre for Aboriginal Health: www.nccah-ccnsa.ca

• PHSA San’yas Indigenous Cultural Safety: http://www.sanyas.ca

The foundation of trauma-informed approaches is the wealth of research we now have on integrated, evidence-informed approaches that support brain development and resilience. Providing safety, choice, and control to individuals who have experienced trauma is the starting place and encourages us all to work in ways that can make a positive difference by reducing the short-term effects of trauma, supporting long-term healing, and creating systems of care that support staff, children, youth and families alike.

A key aspect to trauma-informed practice is that it is delivered in a culturally safe manner to people from diverse backgrounds [2, 3]. This includes cultural sensitivity toward Aboriginal peoples, refugees, immigrants, and people of different religions, ethnicities and classes, and requires a commitment to ongoing professional development in cultural agility. Current Truth and Reconciliation processes are assisting Canadians to become more aware of the devastating intergenerational impacts of residential schools and other forms of institutional

abuse on Aboriginal people’s cultural identity,

health, and parenting. Trauma-informed practice

is a component of broader healing strategies that

help address historic and intergenerational trauma

experienced by Aboriginal peoples.

Being trauma-informed is a fundamental tenet of the

Circle process outlined in the Aboriginal Policy and

Practice Framework in British Columbia (APPF) and this

guide respects and aligns with that document [3].

The APPF is a trauma-informed framework that

recognizes the importance of culturally safe

interactions with Aboriginal communities. The

APPF provides context to the historical and

intergenerational component of gathering the

Circle. This Trauma-Informed Practice Guide was

developed to align with the values and principles

outlined in the APPF, and can help to inform those

working to incorporate the APPF into their practice

with Aboriginal children, youth and families. Utilizing

these two documents in tandem will help to

strengthen culturally safe and holistic practice.

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2. Understanding Trauma

This section defines trauma, provides some data on how common it is, and briefly describes key effects of trauma on children and youth.

2.1 Definitions Trauma has been described as having three aspects: exposure to harmful and/or overwhelming event(s) or circumstances, the experience of these event(s) which will vary from individual to individual, and effects which may be adverse and long-lasting in nature [3, 4].

There are a number of dimensions of trauma, including timing of first exposure, magnitude, complexity, frequency, duration, and whether it occurs from an interpersonal or external source. Two types of trauma particularly relevant to children and youth are developmental and intergenerational trauma. Developmental trauma results from exposure to early traumatic stress (as infants, children and youth) and is related to neglect, abandonment, physical abuse or assault, sexual abuse or assault, emotional abuse, loss and separation, witnessing violence or death, repeated grief and loss, and/or coercion or betrayal [5-8]. Developmental trauma can also be related to prenatal, birth, and perinatal experiences such as experiences involving poor prenatal care, a difficult pregnancy or birth and/ or early hospitalization. Often the term complex developmental trauma is used to acknowledge the impact of multiple or chronic exposure to trauma in the caregiving relationship. Children and youth may also experience system-induced trauma through exposure to invasive medical treatments, youth incarceration or involvement in the justice system, and multiple moves in foster care.

Intergenerational trauma describes the neurobiological and/or psychological effects that can be experienced by people who have close connections with trauma survivors. Coping and adaptation patterns developed in response to trauma can be passed from one generation to the next [9]. The historical and intergenerational trauma related to colonization (past and present), the Indian residential school experience, Indian Hospitals, the ‘60s Scoop and other forms of systemic oppression experienced by Aboriginal peoples in Canada has had a devastating impact on Aboriginal families and communities [10, 11]. Manifestation of trauma is illustrated by the elevated levels of suicide, mental health issues and substance use amongst Aboriginal communities and is associated with continuing family separation, high levels of incarceration and high rates of violence against Aboriginal girls and women [12]. Involvement with institutionalized services may be triggering for some Aboriginal people, who may in turn appear disinterested or disengaged from the service. Disengagement is likely due to collective post-traumatic impacts based on a shared history of colonization and the imposition of a Western model of health than it is about the dislike of any particular worker. “Embarking on a pathway towards restorative policy and practice is impossible without understanding the shared history of colonization and the attempted destruction of Aboriginal cultures.This history continues to intergenerationally impact the lives of Aboriginal children, youth, family and communities today and continues to contribute to a climate of mistrust and divisiveness.” [3].

The workforce in systems of care serving children, youth, and families affected by trauma can also be affected. Some of the terms that have been used to describe the effects of trauma exposure in the workplace are: vicarious trauma; trauma exposure response; secondary trauma; compassion fatigue; and empathic stress. Vicarious traumatization refers to “the cumulative transformative effect on the helper working with the survivors of traumatic life events” [13]. The effects of vicarious trauma occur

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on a continuum and are influenced by the amount of traumatic information a practitioner is exposed to, the degree of support in the workplace, personal life support, and personal experiences of trauma.

Post-traumatic growth refers to the positive psychological growth some people report once they have had the opportunity to heal from their negative experience(s) [14, 15]. For example, some people report a greater appreciation for life, increased compassion and empathy for others and/ or an increased recognition in their human potential and personal strengths.

While developmental, intergenerational, historical and vicarious trauma are most relevant to this guide, there are many other forms of trauma and responses to trauma which can affect children, youth and families (as mentioned in the Rationale section above). Readers are encouraged to follow up on the links identified throughout this document for further information on types of trauma and approaches to mitigating its effects.

2.2 Trauma Prevalence Trauma arises from many forms of neglect, abuse, violence, loss, witnessing of violence and other overwhelming life events. Individuals react to and cope with these potential sources of trauma in different ways. We do not have Canadian data on prevalence for all forms of trauma, nor details on how prevalence rates vary by different subgroups of children, youth and families. The following 5 examples are drawn from available data:

• A 2008 survey of 10,000 Canadian youth revealed high rates of trauma; 21% of girls and 31% of boys reported physical abuse, while 13% of girls and 4% of boys reported sexual abuse [16].

• In the 2013 BC Adolescent Health Survey, 5% of females and 10% of males reported being physically attacked or assaulted, 13% of females and 4% of males were sexually abused, and 4% of all students who completed the survey experienced both sexual and physical abuse (6% of females; 1% of males). Students were asked to report on stress, despair, sadness, self-harm and suicide attempts. Of those youth who reported self-harm, 43% also reported using substances to “manage stress” compared

to 14% of all students who tried substances [16].

• Rates of endorsement of traumatic distress and thoughts of suicide were notable in a Canadian evaluation of youth in a concurrent disorders program, with 90% of female and 62% of male youth endorsing concerns with traumatic distress [17]. Such findings highlight the need for trauma- informed services, early identification of concerns and access to specialized interventions [18].

• In a study of the prevalence of mental disorders and mental health needs among incarcerated male and female youth in British Columbia, it was found that, when compared with males, females had significantly higher odds of presenting with substance use/dependence disorders; current suicidal ideation; sexual abuse; PTSD; and symptoms of depression and anxiety [19].

• In a review of 31 cases of critical injury or death of children in care reported to the Office of the Representative for Children and Youth in BC for the period of 2010-2011, all had experienced trauma earlier in their lives. Early traumatic experiences within their family of origin included physical abuse by a family member, sexual abuse by a family member, neglect by their family, exposure to domestic violence, and/or exposure to problematic substance use in the family [20].

GENDERED PREVALENCE OF CHILD AND YOUTH TRAUMA

The experiences and effects of trauma among children and youth are different based on sex and gender identity. Boys are more likely to experience physical assault, physical bullying, and physical threats, and are slightly more likely to have witnessed violence [21, 22]. One study found that boys reported significantly greater exposure to both interpersonal and non-interpersonal traumatic life events [24].

However, girls are more likely to experience sexual victimization, psychological and emotional abuse, internet harassment, and emotional bullying. One study found that girls were more likely than boys to have experienced sexual abuse and to report greater clinical levels of PTSD symptoms and disassociation symptoms [25].

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Rates of childhood sexual abuse are typically higher among girls (25% vs 16%) [23]. Girls in residential group care report high rates of childhood sexual abuse [24]. Rates of forced sexual activity are also higher among girls and young women, and have also been linked with trauma symptoms and antisocial behaviours [25].

CHILDREN AND YOUTH WHO ARE PARTICULARLY VULNERABLE

Children and youth are vulnerable to the negative effects of traumatic experiences due to the predictable and sequential process of brain development. Emerging research on the developing brain indicates that children who have experienced abuse and neglect in infancy and early childhood are at a greater risk for developing maladaptive behaviours and mental health problems as they get older [26].

Some children and youth are more likely to experience traumatic events than others. Vulnerable groups include: children and youth living on a low income or living with a parent with mental illness or their own unresolved trauma histories [27-29]; lesbian, gay and bisexual youth [30-34]; transgender children and transsexual children and youth, including two-spirit youth; Aboriginal children and youth [35, 36]; and children and youth with disabilities [37, 38]. For example, lesbian, gay and bisexual youth report very high rates of verbal victimization [39], as well as sexual and physical abuse and assault at school [32], and sexual orientation victimization among this sub- group has been associated with post-traumatic stress symptoms [31]. Rates of sexual and physical abuse and maltreatment (both in the home and in institutional settings) are much higher among deaf children and youth, and the communication barriers that these youth experience may prevent disclosure and/or exacerbate trauma [40]. Youth with hearing loss report greater and more severe physical abuse than other youth [41].

Trauma also appears to increase the risk for involvement in the youth justice, child welfare and foster care systems. Several studies reveal that youth involved in the justice system [41-43], youth who are

incarcerated [44] and youth in foster care [45] and child welfare systems [45, 46] report very high rates of traumatic experiences.

2.3 Effects of Trauma Our understanding of the effects of trauma on children and youth is ever expanding. A key study that has influenced our understanding and action is the Adverse Childhood Experiences Study, which linked early childhood trauma to long term health and social consequences (See http://www.acestudy. org/). Our increasing understanding of trauma is aided by our ability to link evidence of the effects related to brain functioning, with those related to the social determinants of health, and to apply both these sources of evidence in our practice and policy. This section provides a brief overview of the potential effects of trauma on children, youth and families. A key principle of trauma-informed practice is becoming aware of these effects, so that we offer welcoming, compassionate, culturally competent and safe support universally in child serving systems.

The centrality of trauma to development: For children, exposure to trauma can have a range of consequences, impacting brain development, attachment, emotional regulation, behavioural regulation, cognition, self-concept, and the progression of social development [47].

Many factors affect an individual’s trauma response: Culture, gender, age/developmental stage, temperament, personal resilience, trauma type (acute, chronic, complex, intergenerational, historical and vicarious) as well as the duration and onset will influence the way an individual responds.

Experiences of trauma can have a range of negative effects: Following a traumatic experience, the majority of children and youth will experience acute symptoms [48]. While these symptoms may decrease with time, the period of recovery is dependent on many factors including: duration and severity of trauma, emotional health, caregiver support following trauma, and previous exposure to other traumatic events [21, 48-50]. Such symptoms may include:

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Physical effects such as: • fatigue • headaches • pain • insomnia • gastrointestinal upset • exacerbation of existing health issues [48]

Emotional effects, such as: • anxiety • fear • panic • depression • feelings of helplessness [48]

Relational issues may include trust or attachment issues with caregivers, and a decrease in academic performance in school [48, 51].

Neurobiological contributions to our understanding of trauma: Traumatic experiences that take place during the critical window of the first five years of early childhood impact the brain in multiple areas and can actually change the structure and function of the developing brain, including structures involved with regulating stress and arousal [6]. Since the brain develops in a use-dependent manner, chronic activation can lead to the development of an overactive and overly reactive stress response system [52, 53]. The cortisol response in those exposed to childhood trauma is typically dysregulated, resulting in an overactive immune response which may increase their risk of stress related disorders as well as infections and chronic health issues [54, 55]. Children and youth who have experienced traumatic events may have a reduced ability to regulate emotions and poorer intellectual functioning [56]. Children who have experienced severe traumatic experiences such as neglect, may exhibit cognitive impairments and communication issues [57, 58]. These changes in brain function may continue into adulthood and be associated with heart disease, diabetes, substance use problems and other chronic health problems. It can be seen how central trauma can be to the ability to self-regulate, communicate and learn.

Acute trauma and complex trauma can have different effects:

Acute trauma refers to the response to a single traumatic event. Acute trauma may result in trust and security issues, issues regarding development of independence and autonomy, separation anxiety and temper tantrums among young children (age 0-5) [48]. Among somewhat older children, acute trauma may result in sleep disturbances, stunting in physical growth, poor concentration and lower academic performance, issues with impulse control, irritability and behavioral issues [48]. Acute stress disorder is linked to acute trauma[59]. It is similar to post- traumatic stress disorder (see below), causes significant distress or impairment, but symptoms are not as severe and recovery in functioning happens more quickly.

Complex trauma refers to the response to ongoing traumatic events, particularly by interpersonal experiences perpetrated by caregivers. Complex trauma may have more significant effects on emotional, physical and behavioral health than acute trauma [48, 56]. Among young children (age 0-5 years), complex trauma is associated with: developmental delays, trust and security issues, hyper-arousal and disassociation, issues with emotional regulation, attachment issues, temper tantrums, and severe separation anxiety [48, 54, 60]. Among older children and youth (age 6 and older), complex trauma has been associated with medical problems, sleep issues, decreased growth, learning disabilities, issues with boundaries and impulse control, apathy, low self-esteem, problems with peer relationships, oppositional behaviours, and suicidal ideation [48, 54, 61]. It is important to remember that ‘multiples matter’: repeated traumatic experiences create higher risk. It is also important to remember that traumatic events are not the only adversity that children and youth may experience: children and youth with more complex or multiple needs are more likely to have experienced multiple adversities such as parental mental

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illness and substance use challenges, poverty, family conflict, divorce, and other family and community level adversities[62]. A trauma- informed approach includes understanding how the presence of protective factors and family strengths can mitigate the risks of trauma exposure, and how their absence can increase risks.

Post-traumatic stress disorder (PTSD): Post traumatic stress disorder is a mental health disorder arising from exposure to trauma involving death or the threat of death, serious injury, or sexual violence. Not all children and youth who experience traumatic events develop post-traumatic stress disorder, but many children who experience physical or sexual abuse or who are exposed to violence develop at least some of the symptoms such as numbing, arousal, re-experiencing the traumatic event or avoidance [63].

Protective buffers: A developing fetus or child may experience traumatic or toxic stress if they are exposed to chronic threat or traumatic stress in the absence of protective buffers [64]. A protective buffer is a care provider who is attuned to the child’s distress or physiological state of “fear” and who assists the child in regulating stress. Our growing knowledge of neuroplasticity, attachment and resilience underline the importance of care providers, social workers and others who work in a trauma-informed way with children and youth.

Parents with trauma responses: When working with children and families we may notice and understand trauma responses in children, but not recognize or accept them so readily in parents. Unresolved trauma responses over time can become adaptive behaviours and reactions that we see in adults but are otherwise mislabelled or stigmatized.

TRAUMA EFFECTS ARE FREQUENTLY MISUNDERSTOOD

Trauma effects can be misunderstood by those experiencing them and by those involved in their lives, and this can contribute to re- traumatization, unhelpful interventions and a negative labelling of the behaviour (or the child) as “bad”, “angry”, or “defiant”. One common example of misunderstanding, is how multiple, small stressful events which accumulate over time can have the same effect as one single, large traumatic event [67]. It is important to remember that it is not necessarily the event(s) themselves that are traumatizing; rather, it is how one experiences the events. A hallmark of traumatic experiences is that they typically overwhelm an individual mentally, emotionally, and physically.

This stigmatization may be particularly directed to families impacted by chronic and multiple adversities, which can contribute to multi- generational challenges. This can include some Aboriginal families and communities impacted by colonization, residential school experiences and other forms of historical trauma. A parent who is in a “fight-flight or freeze response” due to how they are experiencing service delivery or workers interactions may be labelled as “avoidant and non-compliant”, having “anger management problems,” or be perceived to have “limited capacity” to understand issues or manage their behaviour. Overall, trauma- related issues such as problematic substance use, depression, anger problems, fear of intimacy or authority, hypervigilance, and emotional numbing can impact emotional regulation, and interfere with parents’ ability to make accurate assessments of risk and safety [65]. This, in turn, impacts parenting skills and disrupts family connection and stability setting up the potential for intergenerational transmission of trauma [66]. These responses need to be taken into account when Social Workers are recommending services that are part of Court Orders and/or Family Plans in child protection cases, or when teachers or other school personnel are working with families in an educational context.

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LINKS ON THE EFFECTS OF TRAUMA

• Alberta Family Wellness Initiative http://www.albertafamilywellness.org/

CENTRE ON THE DEVELOPING CHILD, HARVARD UNIVERSITY VIDEOS

• Toxic Stress: https://www.youtube. com/watch?v=rVwFkcOZHJw

• Building Adult Capabilities to Improve Child Outcomes: A Theory of Change https://www.youtube.com/watch? v=urU-a_FsS5Y

• Parenting After Trauma: Understanding Your Child's Needs https://www.healthychildren. org/English/family-life/family-dynamics/ adoption-and-foster-care/Pages/Parenting- Foster-Adoptive-Children-After-Trauma.aspx

• Science In Seconds: Epigenetics http://www.albertafamilywellness.org/ resources/video/science-seconds-epigenetics

• The Child Trauma Academy Channel on YouTube: https://www.youtube.com/ channel/UCf4ZUgIXyxRcUNLuhimA5mA

• Understanding the Effects of Maltreatment on Brain Development, Child Welfare Information Gateway: https://www.childwelfare.gov/ pubs/issue-briefs/brain-development/

UNDERSTANDING HISTORIC TRAUMA

EXPERIENCED BY ABORIGINAL PEOPLES

• Aboriginal peoples and historic trauma: The processes of intergenerational transmission: http://www.nccah-ccnsa. ca/Publications/Lists/Publications/ Attachments/142/2015_04_28_AguiarHalseth_ RPT_IntergenTraumaHistory_EN_Web.pdf

Unhealthy coping strategies: While recognizing the adverse effects of trauma, it is also important to see strengths in the adaptations that children, youth and families have employed in order to cope. Viewing child, youth and family challenges from a trauma lens helps us to avoid pathologizing the ways in which individuals cope with trauma, and to remain non-judgemental. People impacted by trauma are typically active in their resistance to distress, even if that resistance isn’t always adaptive in the long-term. For example, some youth and adults with trauma histories use psychoactive substances as a coping strategy to help self-regulate emotions, numb hyper- arousal symptoms, reduce intrusive memories, and combat feelings of helplessness and depression. However, what begins as a coping strategy can result in substance use problems and addiction [67]. Thus trauma-informed approaches support an understanding of how trauma, mental health and substance use concerns may be inter-related, and avoid narrow, stigmatizing and possibly re- traumatizing approaches Service providers working in a trauma-informed way notice the need for support and the potential for learning and growth in the face of what has happened to clients.

Summary: It is important to be aware of the effects of trauma: to understand the physiology of trauma and how traumatic experiences shape the brain; to recognize the centrality of affect-regulation (emotional management; ability to self-soothe) as foundational to interventions; and to regard coping mechanisms as adaptive and work from a strengths- based and resilience-enhancing approach [72].

The National Child Traumatic Stress Network notes that responses to trauma are complicated because they both influence and are influenced by numerous factors including personal characteristics such as age, developmental stage and temperament; gender; culture and family; life circumstances and histories. Responses to trauma and loss, therefore, encompass a wide range of reactions with varying degrees of onset, duration and intensity, which can be mitigated by preventative and protective factors. Having good self-esteem, an array of coping skills, and a positive attachment to a caregiver or caregiving system can protect against adverse trauma effects. Recognizing the signs of trauma and responding appropriately not only mitigates the effects, but enhances the resilience of children and families and those who support them. [68].

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3. Trauma-informed – Definition and Principles The experience(s) of trauma can affect many areas of health and development, and affect one’s sense of safety, trust and confidence. Systems can help or hinder a person’s recovery from trauma. Trauma-informed services begin with an accurate understanding of trauma and its impacts, and benefit recovery through an intentional and active focus on creating safety, trust, clarity, connection and inclusion. Trauma-informed services support pro-social skill development related to self- regulation and self-calming. This is achieved in practical, attuned ways at all levels of support and care, across all settings, including in specialized treatment services.

3.1 What do we mean by Trauma-Informed?

Trauma-informed practice means integrating an understanding of trauma into all levels of care, system engagement, workforce development, agency policy and interagency work.

Trauma-informed services take into account an understanding of the prevalence and effects of trauma in all aspects of service delivery, and place priority on the individual’s sense of safety, choice, empowerment and connection [69]. In interactions with children and families, trauma-informed practice is about the way of being in the relationship, more than a specific treatment strategy or method.

Trauma-informed services for children and their families and caregivers are provided in ways that:

• Recognize the universal need for children’s or young people’s physical and emotional safety;

• Build self-efficacy and positive self-regulation skills;

• Create relational and cultural safety in all aspects of trauma-informed work; and

• Engage parents and caregivers in respectful and non-traumatizing ways.

A key aspect of trauma-informed services is to create an environment where the potential for further traumatization or re-traumatization (events that reflect earlier experiences of powerlessness and loss of control) is mitigated and where service users can learn and grow at a pace that feels safe. A trauma-informed system is designed so that it does not traumatize service users or providers who did not have trauma-related impacts in the past, or re-traumatize those who do have such histories.

To support a trauma-informed approach to client interactions, trauma-informed practice must be embedded throughout all levels of the system. This requires system leadership, policies that set clear expectations for trauma-informed approaches, professional development of all staff, a focus on worker wellness, and interagency collaboration to build a trauma-informed system of care. As such, the focus of trauma-informed practice is often on changes at the system/practice level, resulting in benefits to children, youth and their families.

To ensure trauma-informed systems are culturally safe at every level of the organization, Aboriginal peoples must be represented and included in all levels of the organization. Aboriginal peoples must be present at the leadership level to ensure Aboriginal perspectives are reflected in strategic and decision-making bodies. Aboriginal knowledge must be respected and reflected in the development and design of policy and practice. Both representation and policy have direct impacts on the personal relationships built with Aboriginal peoples through service, by ensuring that culturally safe interventions and programming are being delivered to children and youth.

11TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

3.2 What do we mean by Trauma-Specific?

Trauma-specific services directly facilitate trauma recovery through specialized clinical interventions and Aboriginal traditional practices. Trauma-specific services are typically provided as a form of treatment to those who have a trauma disorder. Trauma- informed practices are broader, not dependent on disclosure, and applied universally. The following table summarizes how trauma-informed and trauma-specific interventions both differ and fit together in a system of support and treatment.

TRAUMA-INFORMED SERVICES

• Are informed about trauma, and work at the client, family, staff, agency, community and system levels from the core principles of trauma awareness, safety and trustworthiness, choice and collaboration, and building of strength and skills

• The connections between trauma and related health and relational concerns are explored in the course of work with all clients, trauma adaptations are identified, and supports and strategies offered that increase safety and support connection to services.

TRAUMA-SPECIFIC SERVICES

• Are offered in a trauma-informed environment, and are focused on treating trauma through therapeutic interventions involving practitioners with specialist skills.

• Based on a detailed assessment, are offered to clients with trauma, mental health and/or substance use concerns and who seek and consent to treatment.

Source: Trauma-informed Practice Guide (2013) British Columbia Centre of Excellence for Women’s Health and Ministry of Health, Government of British Columbia.

Why is it important to know about the difference between trauma-informed and trauma-specific?

• Everyone working in child- and youth-serving systems contributes to embedding a trauma- informed approach into the everyday practices of their organization. The administrative staff, custodial staff and other people who are part of the organization’s day-to-day work are important participants, as are the organization’s executive leadership. Knowledge of trauma- informed approaches is relevant to all.

• Within a trauma-informed system there will be those who provide direct services to children and youth, and their families. These service providers will typically have a role that includes the provision of information, support for developing coping skills, sensitive monitoring of potential trauma-related behaviour, and referral to trauma- specific services if these are desired and required.

• Trauma-specific interventions are provided by mental health professionals, and are intended for those with a known trauma history.

12 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

FURTHER READING/LINKS

1. CONCEPT OF TRAUMA AND GUIDANCE FOR A TRAUMA- INFORMED APPROACH Introduces a concept of trauma and offers a framework for how an organization, system, service sector can become trauma-informed. Includes a definition of trauma (the three “E’s”), a definition of a trauma-informed approach (the four “R’s”), 6 key principles, and 10 implementation

domains. http://store.samhsa.gov/product/ SAMHSA-s-Concept-of-Trauma-and-Guidance-for- a-Trauma-Informed-Approach/SMA14-4884

3. TIP 57: TRAUMA-INFORMED CARE IN BEHAVIORAL HEALTH SERVICES Published by the US Substance Abuse Mental Health Services Administration. Assists behavioral health professionals in understanding the impact and consequences for those who experience trauma, treatment and support of patients, and

building a trauma-informed workforce. http://store. samhsa.gov/product/TIP-57-Trauma-Informed- Care-in-Behavioral-Health-Services/SMA14-4816

2. TRAUMA-INFORMED PRACTICE GUIDE This Guide was developed on behalf of the BC Provincial Mental Health and Substance Use Planning Council in consultation with researchers, practitioners and health system planners across B.C. The TIP Guide and Organizational Checklist support the translation of trauma-informed principles into practice. Included are concrete strategies to guide the professional work of practitioners assisting clients with mental health and substance

use concerns. http://bccewh.bc.ca/wp-content/ uploads/2012/05/2013_TIP-Guide.pdf

4. ADDRESSING THE HEALING OF ABORIGINAL ADULTS AND FAMILIES WITHIN A COMMUNITY- OWNED COLLEGE MODEL This report contributes to understanding of the impacts of historic trauma on learning and how incorporating culture in the learning environment through circle approaches and related strategies can foster respect, relationship building, trust and empowerment, all of which are connected

to trauma-informed practice. http://www. nccah-ccnsa.ca/Publications/Lists/Publications/ Attachments/143/2015_04_28_AguiarHalseth_ RPT_IntergenHealingEducation_EN_Web.pdf

13TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

3.3 Principles of Trauma- Informed Practice

Researchers and service providers have identified principles of trauma-informed practice. The following four principles have been distilled from the literature and practitioner input. The four principles provide a framework within which a trauma-informed approach may be incorporated:

1. TRAUMA AWARENESS: A trauma-informed approach begins with building awareness among staff and clients of the commonness of trauma experiences; how the impact of trauma can be central to development; the wide range of adaptations people make to cope and survive after trauma; and the relationship of trauma with a range of physical and mental health concerns. This knowledge is the foundation of an organizational culture of trauma-informed care [70] and one that supports worker wellness. Trauma- informed services involve service users, practitioners, managers, and all other personnel working in ways that demonstrate this awareness of the needs of people who have experienced trauma.

2. EMPHASIS ON SAFETY AND TRUSTWORTHINESS:

Physical, emotional, spiritual and cultural safety for clients is key to trauma-informed practice. Safety and trustworthiness are established through such practices as welcoming intake procedures; adapting the physical space to be warm, comfortable and inviting; providing clear information about programs and interventions; allowing the expression of feelings without fear of judgment; demonstrating predictable expectations; and creating crisis/safety plans [71]. The safety needs of practitioners are also considered within a trauma-informed service approach. Trauma-informed services demonstrate awareness of secondary traumatic stress and vicarious trauma. Key elements of trauma-informed services include staff education, coaching and supervision, and other policies and activities that support staff self-care.

3. OPPORTUNITY FOR CHOICE, COLLABORATION, AND CONNECTION:

Trauma-informed services create safe environments that foster a sense of efficacy for those receiving care. They work collaboratively with children, youth and families, with an emphasis on creating opportunities for choice and connection within the parameters of services provided. This experience of choice, collaboration, and connection involves embedding service user engagement in evaluating the services, and forming service-user advisory councils that inform practice on service design and service users’ needs, rights and grievances.

4. STRENGTHS BASED AND SKILL BUILDING:

Trauma-informed services, equipped with understanding of the effects of trauma and the skills that promote self-regulation and resiliency, assist children, youth and families in developing resiliency and coping skills. Practitioners and Elders emphasize teaching and modeling skills for recognizing triggers, calming, centering, and staying present. Mindfulness and other skills are not only seen as important for service users but also for service providers, so that emotional intelligence and social learning characterize work environments [72].

Those working within child and youth service areas (including school settings) can operationalize the principles of trauma-informed service by integrating practices such as observing for signs of trauma, screening for trauma (when within the scope of the service) , strengths-based assessment, and education about trauma.

The principles and practices are underpinned by provision of training and supervision, development of service partnerships, meaningful engagement of service users at every level of service access and delivery, as well as culturally competent and gender- informed practice.

Considering culture, gender, age and other influences on the experience of trauma is important when working with the principles of trauma- informed practice. The safety that is established through trauma-informed approaches creates a port

14 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

of entry for exploration of intersecting challenges that affect health, service access, preferences for care, as well as trauma.

The use of principles allows for each service area and each setting within MCFD, as well as those outside of MCFD, to tailor the implementation of trauma-informed approaches to their specific service. The collective process of implementation is in itself a trauma-informed practice, which develops awareness, builds trust, and communicates respect.

FURTHER READING/LINKS

Creating Trauma-Informed Child-Serving Systems, Service Systems Brief. 2007. The National Child Traumatic Stress Network http://www.nctsnet.org/resources/topics/creating- trauma-informed-systems [1]

The Ministry of Children and Family Development endorses Trauma-Informed Practice and provides or funds trauma-specific interventions. The “Trauma- informed Practice in Action” boxes throughout this document provide examples of trauma-informed practices that are already underway, including examples from MCFD and DAAs. In addition, MCFD Child and Youth Mental Health teams provide evidence-based trauma-specific interventions, such as Trauma-focussed Cognitive Behavioural Therapy ( TF-CBT )[73, 74] and MCFD funds almost 50 Sexual Abuse Intervention Programs throughout B.C., who provide trauma-specific services.

TRAUMA-INFORMED PRACTICE IN ACTION

Youth and families who are referred to The Maples Adolescent Treatment Centre have often experienced multiple traumas, the impacts of which have contributed to a variety of mental health diagnoses and behavioural challenges. By understanding the effects of attachment trauma in particular on a young person’s behaviour, caregivers are better equipped to respond in a way that balances the youth’s needs for connection and independence. To that end, youth are educated about their rights regarding services and are given choice in their care options. They, along with their families or caregivers and community supports, are invited to participate in services, including their multidisciplinary assessments and Care Plan meetings. Care Plan meetings have traditionally provided a thorough and inclusive understanding of the youth, family, and community systems from a variety of perspectives. A Collaborative Practice working group is currently piloting strategies to make Care Plan meetings more trauma-sensitive such as making them more inclusive, engaging, concise, and strength-focussed. Following the Care Plan meeting, each young person is assigned a Care Plan Consultant until they are 19 years old, to support the young person in giving a voice to the Care Plan document and provide ongoing consultation. This connection with a consultant empowers youth to collaborate with others on their own behalf and also leaves the door open for a return to Maples for respite if needed.

15TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

4. Implementing trauma- informed approaches

Trauma-informed practice means integrating an understanding of trauma into all levels of care, and supporting system engagement, workforce development, agency policy and interagency work. The diagram below illustrates these levels of service change. TIP implementation at each of these levels will be described in the following pages.

}...change should be made from both the top-down and bottom-up perspectives.~ – Conradi, L., et al., Promising practices

and strategies for using trauma-informed child welfare practice to improve foster care placement stability [78].

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A N D YO U T H

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16 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

4.1 TIP in Interactions with Children and Youth

W O R K W I T H C H I L D R E N

A N D YO U T H

" For traumatized children involved with the child welfare system, a consensus is mounting around several core areas of knowledge and practice change as reflecting trauma-informed practice:

1. An understanding about the impact of trauma on the development and behaviour of children and youth,

2. Knowledge about when and how to intervene directly in a trauma- and culturally-sensitive manner through strategic referrals,

3. Ensuring access to timely, quality, and effective trauma-focused intervention,

4. A case planning process that supports resilience in long term healing and recovery, and

5. Attention to self-care in response to working with traumatized children"

Fraser, et al. – Findings from the Massachusetts Child Trauma Project, page 235 [75]

The elements identified in the quote above are the core of trauma-informed practice with children and young people within the child welfare and other child- and youth-serving systems. Exposure to

trauma in childhood can affect a child’s development in multiple domains of functioning from acquiring language skills to displaying emotional problems, mood swings, impulsivity, emotional irritability, anger, aggression, anxiety, and depression. It is important that service providers apply a trauma- lens when trying to understand a child’s or youth’s behaviour. Children and youth with trauma histories may respond to triggers or overwhelming distress in ways that appear to be intentionally defiant or oppositional. However, their intention may simply be to resist overwhelming distress – sometimes in situations where they do not understand or cannot talk about what has happened to them or is happening for them [76]. Their behaviour may represent their best efforts to resist being overwhelmed. The challenge for child-serving agencies is to notice trauma reactions, to help the child or young person to self-regulate emotions and behaviors, to support relational capacity, and to make referrals where necessary for trauma-specific interventions tailored to their age, culture, and gender. Awareness of the physical, social, emotional, cultural and spiritual wounding experienced by some Aboriginal children and youth, as well as some immigrant and refugee children and youth, is critical in working with them, their families, and communities.

Trauma-informed practices are implemented in systems and settings regardless of disclosure of trauma. At the same time, a universally applied approach to screening for exposure to traumatic events and for endorsement of traumatic stress symptoms/adaptations/reactions is often cited as a key component of trauma-informed practice. The focus of such screening is to understand current effects of trauma on functioning (over describing the traumatic events), which plays an important role in determining whether treatment of any kind is needed. There are many ways to screen for trauma reactions – through self-report, caregiver tools, and caseworker awareness, discussion and integration tools [77].

17TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

As noted earlier, an understanding of trauma includes attention to other protective and risk factors, with particular attention to other adversity the child or youth may be experiencing. As the Adverse Childhood Experiences research – and other research on cumulative risk – makes clear, ‘multiples matter’, with there being a clear relationship between the number of adverse experiences and the negative effects on mental and physical health. Those facing more risks may need and benefit from additional supports and services that extend beyond the focus on their specific trauma history.

Trauma-informed approaches bring a focus to psychological as well as physical safety. A lack of psychological safety can impact interactions, including those with service providers, and can lead to a variety of maladaptive strategies for coping. The child or young person may continue to feel psychologically unsafe long after the physical threat has been removed and may be triggered by situations that seem unrelated. Parents may also feel psychologically unsafe due to their own possible histories of trauma, and/or the uncertainty surrounding their child’s well-being and custody.

Agencies working with mothers and children, who need support for mental health, substance use and a range of social, financial, housing, parenting and child development concerns, are emphasizing relationship-focused service delivery models for achieving trauma-informed goals. Given the impact of trauma on relational capacity, they have found that perceived support from service providers, and children’s and mothers’ ability to feel secure with others, is related to improved outcomes for mothers and children [78]. This focus on reparative and growth enhancing relationships that are “supportive, respectful, friendly, consistent, non- threatening, strengths-based, consistent with the child’s developmental abilities and individualized needs, and based on clear expectations and standards” [76, p. 39] – is a common thread in all descriptions of trauma-informed care with children and young people.

As such, trauma-informed practice is about relational change and support at all levels – the individual, the family, the worker, the agency, the community and the system. A recent study of outcomes for Hawaiian girls ages 11-18 achieved over two decades summarizes the multi-faceted, multilevel work involved in being trauma-informed as driven by principles of “community-based, individualized, culturally and linguistically competent, family driven, youth-guided, and evidence-based service”[79] in a way that emphasizes “trauma-informed and gender- responsive care”.

Trauma informed practice is a principle based approach that is situated in a responsive agency culture where workers are well trained and supported. Five ways in which trauma-informed principles can be seen in practice at the individual level with children and youth are included here, (and further examples and resources listed in Appendix 1):

1. Clear information and predictable expectations about support are provided.

2. Welcoming intake procedures are used, and they include a physically and emotionally safe environment.

3. Challenging behaviours are noticed and responded to, based on an understanding of trauma responses and an acceptance for a range of emotions.

4. A focus is placed on building relationships, acknowledging that because of trauma responses this can be difficult.

5. Skills for recognizing triggers, calming, centering and staying present are taught and modeled.

In each setting, these principles will play out differently, and will need to be tailored for diverse groups (by age, gender, culture). Examples of ways these principles have been adapted in various settings are described below.1

1 Please note that these examples are derived from practices outside of MCFD and should not be construed as MCFD sanctioned or approved practices. Rather they are to inspire thinking about how to apply the principles.

18 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

TRAUMA AWARENESS IN FOSTER CARE Raising trauma awareness among caregivers is an important step in helping children and adolescents who have experienced trauma. Caregivers who understand that trauma responses affect feelings and behaviors are more sensitive to potential trauma triggers for children in their care and are better able to respond to the underlying cause of “bad” behaviors in a helpful way. Within this kind of accepting environment children and youth can begin to understand their own feelings and reactions and to develop healthy coping skills and a sense of hope.[80] Agnosti (2013) describes how one foster care /caregiver training incorporated several strategies to keep trauma awareness at the forefront for caregivers. Trauma-informed education, training and skill-building strategies were incorporated into all foster parent trainings. Moreover, youth, parents, and foster parents were invited to new foster-parent trainings to discuss the trauma of foster placements and ways to minimize trauma and failed placements, which included building positive relationships with birth parents. Information about recognizing and responding to trauma across developmental stages was included in all foster parent newsletters and brochures, and an information card describing possible trauma indicators was developed for parents and caregivers [80].

CREATING SAFETY IN CHILD AND YOUTH MENTAL HEALTH SERVICES Trauma-informed care requires recognizing and tending to the interplay of the physical and interpersonal environment to promote feelings of safety. Within mental health residential care for children, trauma-informed approaches take into account the havoc trauma can have on development as evidenced by “flight, fight or freeze” reactions [81]. Bloom et al. describes ways of creating “sanctuary” for children and youth by focusing on relationship over social control [82]. Staff build emotional and interpersonal safety by explicitly and frequently explaining routines and expectations. Signage and pocket cards can provide reminders for both youth and staff [83]. Children’s “bad behavior” is viewed within the context of having unmet needs, and staff collaborate with children to anticipate and regulate their feelings and behaviors. These strategies reduce power and control struggles, which trigger trauma responses [84]. The American Association of Children’s Residential Centers make numerous suggestions for making the physical environment trauma-informed. For instance, maintaining inviting, comfortable and homelike surroundings contributes to a sense of belonging. “Comfort rooms” support self-soothing skills and promote self-regulation. Rethinking locks and barriers within the context of safety rather than control, and performing routine maintenance and immediately repairing damage may reduce triggers. Including residents and staff in regular walk-throughs with an eye toward reducing environmental stress and improving treatment interventions enhances feelings of safety through collaborative relationships [88].

19TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

TRAUMA-INFORMED PRACTICE IN ACTION

Complex Care and Intervention (CCI) is a trauma-specific model designed for children and youth (five to 15 years old) who have experienced significant trauma or maltreatment, and who exhibit substantial emotional, behavioural and interpersonal difficulties with extreme behaviour challenges and complex needs. It is a trauma- informed, developmentally sensitive, attachment-based service model which supports workers in moving from a caretaker to a collaborator role, and reduces the possibility of re-traumatization within services. The CCI Program includes Aboriginal cultural perspectives and provides suitable and culturally relevant tools for participants.

CCI Coaches come from across all ministry service streams and work with the child’s care team to create a child- specific intervention plan and support caregivers. Currently, CCI is piloted within 6 service delivery areas: South Island, Thompson Cariboo, Okanagan, Kootenays, North Central, and Fraser East. MCFD has initiated a process to expand the program to more communities across the province with preliminary evidence suggesting that there is a reduction in the need for children and youth to move into higher acuity levels of care, thereby reducing hardship for the client/family and costs for the system.

COLLABORATION AND CHOICE IN CHILD WELFARE SERVICES

Enhancing collaboration and choice in child welfare services can take many forms. For example, in Western Australia practitioners have developed specific child- protection assessment tools as a way to make the child-protection process trauma-informed. These tools provide choice and voice to children during the course of child protection cases; increase awareness and build collaboration between children, parents and workers; and explain to children the events that are happening to them and the concerns of others. Workers are trained to use the assessment tool and children are given the choice to participate using the tools and also the choice to share with their family or others connected with their case [85]. In Massachusetts, child welfare

workers use simple illustrations

to collaborate with children on

identifying and managing their

trauma triggers. The trigger-tool

pictures help to identify feelings,

and body reactions, and ways

to feel safe. Children can circle

pictures of situations that make

them feel scared, angry or sad –

being touched, someone yelling,

or hearing thunder for instance.

As well, pictures of activities, such

as having a special blanket, rocking,

or playing, identify activities

that help them to cope with

those feelings.

Building self-regulation skills

Much has been written about

the body/mind interconnection

of trauma and recovery and the

need to include somatic strategies

into self-regulation skills. [53, 86-

88]. In five residential treatment

centers in Canada, the U.S. and

Australia somatic strategies were

observed and documented [87]. All of the programs incorporated relaxation skills training, swimming and exercise, and dance, art, and music activities. Rhythmic and repetitive hands-on activities, like drumming, were noted to help children with feelings of hyperarousal. Most of the centres included activities with animals and nature, including gardening, and adventure-based activities like kayaking and ropes courses. Similar grounding strategies can be used outside of a therapeutic venue. For instance, playing “I Spy” or taking deep breaths together teaches grounding skills to children and youth. Making blankets and stuffed animals available, or having a sensory box filled with textured toys and objects can help children and youth learn to self-regulate in stressful situations [89].

Appendix 1 offers implementation ideas by service setting type.

20 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

BEST PRACTICES

• Maximize children’s and young people’s sense of safety; assist them in managing their emotions and in making meaning of their current coping strategies and trauma histories. Provide emotional safety for children/youth to talk about trauma and safety if they choose to.

• Include the perspectives of children and youth in defining what is triggering for them and what creates safety and learning. Involve them as appropriate in focus groups, roundtables and other methods for evaluating and improving services.

• Recognize how age and developmental trends impact the experience and effects of trauma for children and youth. Provide responses that are appropriate for their culture, age and cognitive, physical, and emotional developmental stages.

• Recognize how gender affects the types of trauma experienced and the expression of its effects, openness to discussing and truth-telling about trauma. Provide gender responsive options for support.

• Recognize how historical trauma affects Aboriginal children and youth, and involve Aboriginal youth, parents, aunts and uncles, Elders and communities in bringing holistic wellness and other culturally competent practices to trauma-informed approaches with Aboriginal children and youth.

• Continuously explain and clarify to children and youth the agency processes, next steps, and measures being taken to ensure their safety and wellness.

• Make the physical environment of service settings welcoming and safe. Signal through the physical environment and informational materials that talking about and getting support on trauma is welcome and available in the setting.

• Understand and map the supports and treatments available for children and youth experiencing trauma and build relationships with the provider agencies to facilitate appropriate and timely referrals.

• Use trauma-informed universal screening and other methods to understand the level of trauma a child/ youth is experiencing, as well as other adverse experiences in their lives. This can inform referrals for other supports and services, such as trauma- specific interventions or cultural connections. In child welfare, it can also inform appropriate placements and guard against multiple placements.

• Support and promote positive and stable relationships in children’s and young people’s lives.

FURTHER READING/LINKS

• A Focus on Relationships – The Mother Child Study: Evaluating Treatments for Substance-Using Women 2014, Mothercraft Press. http://www.mothercraft.ca/assets/ site/docs/resource-library/publications/ Mother-Child-Study_Report_2014.pdf

• Understanding Traumatic Stress in Children. 2006. The National Center on Family Homelessness. http://www.air.org/center/ homelessness-trauma-informed-care

• Tips for Talking With and Helping Children and Youth Cope After a Disaster or Traumatic Events: A guide for parents, caregivers and teachers https://store.samhsa.gov/shin/ content/KEN01-0093R/KEN01-0093R.pdf

• TIP Safety Tools: http://www.mass.gov/eohhs/ docs/dmh/rsri/safety-tool-for-kids-sample.pdf

• Making Sense of Sensory Behaviour: A Practical Approach at Home for Parents and Caregivers https://www.falkirk.gov. uk/services/social-care/disabilities/docs/ young-people/Making%20Sense%20of%20 Sensory%20Behaviour.pdf?v=201507131117

21TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

4.2 TIP in Interactions with Families

C O

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TION WITH FAM IL

IE S

Using a family-centred approach in child-serving

systems has been shown to produce better

outcomes for children, families, and the system itself

[90, 91]. For Aboriginal families, a family centred

approach is integrally linked to a child, youth,

community and culturally centred approach.

A family-centred approach is essential for

understanding the strengths and needs of families

and for effectively engaging family strengths that

support child recovery and resilience. B.C.’s Family

Mental Health and Substance Use Task Force (co-led

by the Ministry of Children and Family Development

and the Ministry of Health) has supported the

development of Families at the Centre: A Planning

Framework for Public Systems in BC (FATC), to assist

public system planners to move toward a family- centred approach in policy and practice, services and supports. FATC has been web-posted and disseminated across government, non-government organizations and Health Authorities in British Columbia.

A family approach to trauma-informed practice includes building awareness that, for families, as for individual children, “multiples matter”. That is, exposure to multiple adversities – including but not limited to trauma, can contribute to multiple and complex needs that have intergenerational impacts. Keeping this in mind when working with families can help inform a better understanding of family needs, and a more adequate response to those needs.

The potential for intergenerational impacts of trauma and other adversities can be reduced when a family focus, family engagement and specific supports and other family needs are provided. Family Group Conferencing, family support groups, and communication skills training for families are responses now in place in most child-serving systems – and more are needed. Family-focused processes that foster collaborative and inclusive decision making help shift power dynamics so that families co-create solutions that are relevant and actionable for them, rather than having solutions imposed upon them. For Aboriginal families and communities, these types of processes can tap into traditional wisdom, knowledge and healing practices that have historically been ignored or deliberately destroyed by colonization. Listening, assessing and finding

TRAUMA-INFORMED PRACTICE IN ACTION

MCFD’s Collaborative Practice Decision-Making (CPDM) is based on a trauma-informed framework. Family Group Conferences and Family Case Planning Conferences, which are components of the CPDM, bring individuals together who often have experienced multiple traumas and are engaged with the child welfare system as parents, caregivers, extended family or children. The conference is a place to explore parental and child strengths, which often include ways they have coped with trauma.

After the family’s strengths are explored, issues and goals where planning is needed are identified and discussed together by the family and the Ministry. At family group conferences, the family are supported to take the lead in developing their plan. As such the trauma-informed principles of awareness, collaboration and being strengths- based are critical to all family group conferencing and family case planning meetings.

22 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

solutions are key steps in the APPF Circle process.

The principles of trauma- informed practice as detailed below are particularly relevant to the engagement and support of families and caregivers, and underpin a family- centred response.

Awareness: Many trauma- informed initiatives ensure that parents, caregivers and foster parent associations are included in various levels of education and training – both with workers and separately - to support parents in using a trauma framework to better understand the stress reactions of children and learn more effective approaches to responsive care. Awareness also applies to parents and caregivers who have had traumatic experiences of their own, so that they may increase their ability to cope with adversity and their own reactions to trauma, and be better able to care for their children and develop and model positive coping strategies.

Safety and trustworthiness: Trauma-informed initiatives have documented the importance of giving repeated concrete clarifications to parents and caregivers about how children will be kept safe and repeated clarifications about the processes, supports and treatment that will be involved. Trustworthiness and safety also involve the avoidance of exposing the child and family to inaccurate or potentially re-traumatizing information [92].

Program model of the Trauma Adapted Family Connections program (Collins et al 2011)

PHASE 1 } Engagement } Assessment } Helping families meet their basic needs } Safety } Planning

PHASE 2 } Family psycho-education } Emotional regulation } Strengthening family relationships

PHASE 3 } Family shared meaning of trauma } Closure and endings

R E

F L

E C

T IO

N

T R

A N

S P

A R

E N

C Y

C O

L L

A B

O R

A T

IO N

Providing summaries, action points, and contact information using communication forms that meet the needs of the family ensures that misunderstandings are minimized.

Strengths and skills: Empowering caregivers by supporting and building their capacity to calm and reassure children is a key strategy in trauma-informed services. Families are offered opportunities for training on trauma effects and coping strategies, or offered evidence based resources and information on coping strategies, such as relaxation and physical exercise.

Choice, collaboration and connection: Trauma informed services provide an explanation of and involvement in family- youth collaborative meetings and other forms of engagement with families. They are aware of pacing, so that families can access services as they are ready, are able to participate fully in setting mutually agreed upon goals, and offered connection with other families

for mutual support. Offering contacts for skilled peer support such as The F.O.R.C.E. Society (see link below) and from cultural advisors can support all levels of this collaboration and connection.

An example of a family intervention that uses a trauma- informed approach is the Trauma Adapted Family Connections ( TA-FC). As can be seen from the diagram of this intervention (below), the intervention is phased: focusing on safety; teaching emotional regulation; and, helping families build new shared meaning. [90]

The well evidenced Strengthening Families program [93] focuses on a family’s strengths and protective factors through a partnership with the family and community programs to promote better outcomes. The Connect Parent Group© is an evidence-based program developed in B.C. that helps caregivers of children and teens use principles of attachment theory to strengthen parent- child relationships, understand

23TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

development, and respond effectively to difficult behaviour and challenging interactions [94]. A newly developed adaptation of Connect for foster parents deals expressly with the impact of trauma on a youth’s adjustment to being in care. Nurture the Mother-Nurture the Child is a trauma-informed, family-centred approach to supporting B.C. women with substance use issues who are pregnant and/or newly parenting that focuses on respect and dignity for these highly stigmatized women [95]. Safe Babies is a program for foster parents that supports their understanding of neurobiology when providing care to infants who been substance exposed [96]. All in all we are seeing more models that address parenting though trauma-informed, attachment- based and connection enhancing approaches. Some of these programs may also address related stressful conditions such as poverty, social marginalization, isolation, cultural disconnection and domestic violence.

In addition, groups such as The F.O.R.C.E. Society for Kids’ Mental Health provide peer support to families and caregivers seeking mental health related education, support and system navigation across B.C. Peer support for system navigation can play a significant role in reducing stress on parents and supporting access to trauma-informed and trauma- specific services.

BEST PRACTICES

• Understand that all children and families with histories of trauma have areas of strength and resilience, and support workers need to identify not only risk factors, but also foster and build protective factors for each child, youth and family.

• Provide training to families of all types (birth, adoptive, blended, foster, kinship, respite, families of choice etc.) on: bringing a trauma lens to understanding what factors may be affecting a child/youth’s behaviour, managing conflict and displaying empathy, and teaching coping and resilience strategies.

• Provide opportunities for families of all types who are parenting children and youth to enhance their own self-care and where relevant to access support/ treatment for their own experiences of trauma.

• Link to, refer to, and collaborate with multi- setting, multi-level, interagency supports and services that optimize child and family resilience.

• Involve brokers, liaisons and Elders to bridge trauma-informed and culture- and gender-informed approaches for children, youth and families, communities, and child and youth serving agencies.

FURTHER READING/LINKS

• Helping your child travel the “Road of Life” with resilience: http://www.reachinginreachingout. com/documents/Brochure-ResiliencyTips- newbornhearingscreening-FINALPDFDec31-14_001.pdf

• Understanding Child Traumatic Stress: A Guide for Parents: http://nctsn.org/sites/ default/files/assets/pdfs/ctte_parents.pdf

• Resources for Parents and Caregivers: http://www. nctsn.org/resources/audiences/parents-caregivers

• Foster Parent Support Services Society: http:// fpsss.com/wordpress/wp-content/uploads/2013/01/ Resources-on-Trauma-Informed-Care.pdf

• Adoption Let’s Learn Together: A guide for parents and teachers of adopted children in primary school in Northern Ireland: http://www. adoptionuk.org/sites/default/files/documents/ LetsLearnTogetherNIMarch2013.pdf

• Literature Review: A trauma-sensitive approach for children ages 0-8 years: http://www.whealth.com. au/documents/work/trauma/LiteratureReview.pdf

• Kelty Mental Health Resource Centre: www.keltymentalhealth.ca

• TCU Institute of Child Development: http://child.tcu.edu/

• Institute of Families for Child and Youth Mental Health: www.familysmart.ca

• School Health Centers: http://www.schoolhealthcenters. org/wp-content/uploads/2014/03/Trauma-Informed- Strategies-to-Deescalate-Classroom-Conflict.pdf

• Families at the Centre: Reducing the Impact of Mental Health and Substance Use Problems on Families: http://www2.gov.bc.ca/assets/gov/health/managing- your-health/mental-health-substance-use/child-teen- mental-health/families_at_the_centre_full_version.pdf

• F.O.R.C.E. Society for Kids Mental Health: www.forcesociety.com

24 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

4.3 TIP for Worker Wellness and Safety

W O

RK ER

W ELLN

ESS AND SAFET Y

" When working with children who have experienced maltreatment, parents who have acted in abusive or neglectful ways, and systems that do not always meet the needs of families, feelings of helplessness, anger, and fear are common. A trauma-informed system must acknowledge the impact of primary and secondary trauma on the workforce and develop organizational strategies to enhance resilience in the individual members of it."

– Chadwick Trauma-Informed Systems Project [97, p. 14]

Practitioners are affected by their work when they are providing support to people who have experienced severe trauma in their lives. Professionals in the workforce may be confronted with threats or violence in their daily work. They may also have histories of trauma themselves, and/ or be impacted by intergenerational trauma. Many workers experience secondary traumatic stress reactions, which can be both physical and emotional in nature, arising from their work with traumatized people. Secondary traumatic stress reactions are normal for professionals who work with families who have experienced trauma [98-100].

Awareness of secondary stress reactions and vicarious trauma, the range of their effects, and avenues for mitigating and addressing them are critical components of trauma-informed approaches. In a study with expert clinicians, researchers found

that practices such as developing mindful self- awareness, embracing complexity, having active optimism, and practicing holistic self-care were protective against secondary traumatization [101]. They also found that empathic engagement with traumatized clients appeared to be protective: that it is less about exposure to the stories of survivors than a lack of authentic connection that creates risk.

In a number of settings, support for collective analysis of critical incidents and general practitioner/ agency approaches as part of a larger workplace stress management plan has been noted to be important for reducing restraint and seclusion rates, which impact worker safety, but for overall worker support as well [102, 103]. Debriefing or problem solving meetings with peers, clients as well as supervisors have often been cited as helpful in considering current approaches to cases and incidents and what can be done differently going forth. Critical incident and other debriefings need to be conducted by appropriately trained individuals, need to be done routinely, and need to be free of stigma. Accessible and confidential on-the-job professional supports that provide staff opportunities to process their experiences and reactions individually or in groups are needed by some, beyond the more open debriefing approaches.

The BC Trauma-informed Practice Guide includes ideas for work at the personal level (self-awareness and self-reflection on the part of practitioners), the practice level (in our interactions with clients) and the organizational level. At the personal level it is essential that practitioners know themselves well and recognize what they bring to the interaction— their own story, diversity, culture, beliefs about recovery, triggers, and vulnerabilities. Practitioners are encouraged to pay attention to three key areas, known as the ABCs:

• Awareness of our needs, emotions, and limits

• Balance between our work, leisure time, and rest

• Connection to ourselves, to others, and to something greater (e.g., spirituality) [104]

25TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

Regular supervision and supportive consultation is important, as is peer support [105]. It is important that agencies understand the importance of consistently helping staff identify and manage the difficulties associated with their jobs. Many agency-level worker support strategies have been found useful, such as providing sufficient release time, having safe physical space for workers and making available supportive resources such as employee assistance counselling or support from a cultural advisor or Elder. Some agencies working with mothers and children have, as a staff group, learned resiliency enhancing approaches such as mindfulness practice [106]. This staff -level training in mindfulness has supported worker wellness as well as prepared practitioners to share such techniques with clients.

Other agency-wide interventions to support worker health and well-being, versus focusing only on self- care, have been piloted. One successful example is the Resilience Alliance Intervention involving staff at all levels of a child welfare organization (child protection specialists, supervisors, managers and deputy directors) in learning resilience skills, and safely discussing challenges and concerns with their peers while maintaining a focus on the team and on core concepts of optimism and collaboration [107]. Positive outcomes related to resilience, perceived co-worker and supervisor support, and decreased negative perceptions of themselves and their work were documented over multiple offerings of this intervention.

BEST PRACTICES

• Understand and recognize the risk of secondary traumatic stress for all staff members, and the agency as a whole.

• Provide training on secondary trauma and stress management for all staff, promote self- care and well-being through policies and communications and encourage ongoing discussion among staff and administration.

• Create and maintain a work environment that conveys respect and appreciation, that is safe and confidential, and that provides support for continuing education, supervision, collaboration, consultation, and planned mental health breaks.

• Support staff development, debriefing after critical incidents, individual/group supervision and related strategies that support worker health. Ideas for various combinations of strategies that workplaces have used to prevent and manage secondary trauma are linked to on the Child Welfare Information Gateway (see link below).

• Cultivate a workplace culture that normalizes (and does not stigmatize) getting help for mental health challenges and actively promotes awareness of the supports available to workers.

FURTHER READING/LINKS

• Saakvitne, K.W. and L. Pearlman, Transforming the pain: A workbook for vicarious traumatization. Traumatic Institute/Center for Adult and Adolescent Psychotherapy 1996, New York: Norton

• Van Dernoot Lipsky, L. Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others. 2009, San Francisco: Eberrett-Koehler

• Rothschild, B. and M. Rand, Help for the Helper: The Psychophysiology of Compassion Fatigue and Vicarious Trauma. 2006: Norton.

• Child Welfare Information Gateway, Secondary Trauma for Caseworkers: https://www.childwelfare.gov/topics/adoption/preplacement/caring-addressing/

• Mental Health Commission of Canada, Psychological Health and Safety: An Action Guide for Employers. 2012, MHCCC and the Centre for Applied Research in Mental Health & Addiction: Ottawa. ON.

26 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

4.4 TIP at the Agency and Interagency Level

T IP

A T

T

H E

AG E N

C Y A N D I N T E R AG E N

CY LE

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L

Trauma-informed practice is possible within organizations and systems that are themselves trauma-informed. Sandra Bloom and colleagues have documented how organizations are vulnerable to the impact of trauma and chronic stress, and how important it is for whole organizational cultures to shift towards democratic, non-violent (safe), emotionally intelligent ways of working in order for trauma-informed practice to thrive [72].

To reduce organizational stress, it is recommended that trauma-informed practice be integrated into the fabric of existing practice approaches to avoid the initiative fatigue that workers may begin to experience due to the frequency that organizations working with children and youth are asked to integrate new and promising initiatives into their daily practice [97, p. 15]. For example, many of the common initiatives associated with good child welfare practice such as family group decision making are consistent with a trauma-informed framework. Forums for discussion of trauma- informed practice can be helpful in identifying existing practices that could be considered to be trauma-informed, and in shifting, adapting and adopting practices that are consistent with the principles of trauma-informed approaches.

In the US, the Chadwick group identified that implementing trauma-informed practice at the organizational level in child welfare should include specific strategies for incorporating trauma into an agency’s: mission, vision, and core values; policy; practice principles; standards of professional practice; staff development and retention; evaluation of desired outcomes and the practice model’s impact on them; staff safety and well-being; supervisory practices; and casework practice [108, p. 50]. These strategies may also be relevant to settings other than child welfare such as health, mental health and school settings.

Checklists have been prepared to support such organizational level discussions and assessment toward becoming trauma-informed [109-112]. They contain service-user checklist versions, agency staff versions and integrated versions. The Trauma System Readiness Tool created for child welfare systems includes self-assessment of an agency’s:

• Training and education related to trauma;

• Screening and referral practices;

• Knowledge of trauma-specific treatment interventions;

• Awareness of and capacity to assess and address parent/caregiver trauma and its impact;

• Understanding of its role in mitigating the impact of trauma;

• Ability to create psychological safety for children and families, and promote positive and stable connections in the lives of children;

• Provision of education and support to caregivers, through co-learning educational opportunities; and

• Understanding of and efforts to reduce the impact of vicarious trauma on workers [112].

27TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

The physical environment of agencies (e.g. meeting spaces) can be an important part of creating safety, trustworthiness, and connection in agencies and meeting spaces. Creating a physical environment that is welcoming and safe does not necessarily require an expensive redesign [113]. Creating positive signage, paying attention to the inclusive nature of greeting children, youth and families, familiarizing them with the physical space, as well as providing “What to Expect” from services and supports can be helpful in creating a welcoming and safe space. Working with partners in Aboriginal communities is required for helping to determine culturally-safe ways of creating safe physical environments for Aboriginal people and is consistent with the Circle process outlined in the APPF.

Safe and trustworthy approaches to quality assurance processes, case review, debriefing of challenging incidents and supervision can be important mechanisms in achieving a trauma- informed workplace culture. Such mechanisms, coupled with practices for creating psychologically safe workplaces can reinforce a sense of collective learning, creativity and support as trauma-informed approaches are enacted in the workplace [114, 115]. Debriefing may also involve Elders or cultural advisors doing smudging or cleansing when there have been challenging incidents.

As mentioned, often local champions and teams lead these assessment processes that “tilt” practice toward being more responsive to youth and families who have experienced trauma. Work done at the local level to assess and determine the education, practice modifications and policy changes needed to bring a trauma lens to the work have included work in communities of practice, staff meetings and specialized forums.

BEST PRACTICES

• Conduct organizational level assessments that identify the range of practices and policies that might be initiated and/or enhanced to support trauma-informed practice. See Appendix 2 for examples of self- assessment questions.

• Facilitate culture change in the organization towards social learning and agency- wide emotional intelligence.

• Identify and map existing trauma- informed practices, which can be built upon and more broadly implemented.

• Incorporate trauma knowledge into all practice models.

• Integrate safe, respectful, learning-oriented, solution-focused approaches to case review, debriefing of incidents and supervision, paying close attention to language.

• Discuss how to address trauma experienced by different system stakeholders (children, parents, workers, Aboriginal communities) and how strategies for building resilience in all these groups can be linked in agency-wide approaches. Attention to the impact of intergenerational trauma is particularly important in such strategic planning for/with workers and communities.

• Share trauma-informed resources, and resources reflecting traditional Aboriginal healing practices, across systems.

• Integrate alternate forms of information sharing to support trust and ensure understanding between workers and families. For example, a written summary of what was discussed, action points, contact information, etc.

28 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

TRAUMA-INFORMED PRACTICE IN ACTION

The Vancouver Aboriginal Child and Family Services Society (VACFSS) embraces a trauma-informed approach to practice. Its work is grounded in an understanding that Aboriginal families have been, and continue to be, profoundly affected by the traumas of colonization, assimilation, residential schools, child welfare intervention, racism, violence and social inequality. VACFSS workers approach families with an acknowledgement of these intergenerational traumas, exploring with them “what has happened to you to get to where we are now?” The emphasis is on taking the time to listen to the family’s answers and to support them to define how they move forward in their healing. The agency is committed to the idea of “doing with” rather than “doing to” families, with widespread use of collaborative practices like circles and Family Group Decision-Making Conferences, and very few contested court cases. VACFSS’s holistic service delivery model encourages workers to attend to the physical, psychological, spiritual and cultural safety of families and to honor the traditions, wisdom and strengths inherent in Aboriginal peoples. Culture is seen as a primary pathway to healing. Elders offer their guidance to workers and families, and support the use of traditional practices like cultural teachings, ceremonies, prayers, brushings, smudging, sweats and circles. Families, caregivers, and social workers come together in regular cultural activity workshops and ceremonies. Families retain choice as to whether and how they participate. Trauma- informed practice at VACFSS includes acknowledging the perspectives of, and remaining in relationship with, all members of the child’s circle, while ensuring that central to the circle’s work are the needs of the child.

29TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

4.5 TIP at the Leadership Level – Relational System Change

T IP

A T

T H

E

PR OV

IN C IA

L AN D R E G I O NAL LEADERSH

IP LE

V E

L

" Creating trauma-informed child-serving systems requires increasing knowledge about trauma by integrating trauma focused information into systems; increasing skills for identifying and triaging traumatized children by providing resources and training to front-line staff and administrators in systems; and promoting strong collaborations between systems and disciplines".

– Creating Trauma-Informed Child-Serving Systems, The National Child Traumatic Stress Network

In contexts where trauma-informed practice has been applied in systems of care, leadership has been identified as foundational and integral to the outcomes achieved. In all cases, such leadership has been built upon recognized learning and leadership theories. The elements of leadership common to the implementation of Signs of Safety in child protection practice in Australia [116], the Children’s Aid Society Collaboration Agreements with the Violence Against Women Sector in Toronto [117], the statewide Massachusetts Child Trauma Project [75]; and the creation of trauma-informed child-serving systems by the National Child Traumatic Stress Network in the US [1] include:

VALUING COLLECTIVE LEARNING

• The learning processes in the implementation of trauma-informed practice in systems have involved all levels of management and leadership, together with practice leaders, workers, and youth and families.

• Learning has taken place not only through formal training, but also in cross-agency placements, in virtual communities, and via role modelling and supervision in enabling environments. For example in the implementation of Signs of Safety in Australia, practice leaders in each district lead e-learning, peer reflection and feedback initiatives; and deliberate, ongoing coaching and supervision (including coaching by credible peers) is made available. They have built upon a 70/20/10 learning model [118] where 70% of learning is acquired through work-based activities such as mentoring, debriefing and group reflection, 20% through networking and collaboration, and only 10% through formal learning strategies [116].

• Cultural safety is a cornerstone of trauma-informed practice; ongoing education in the history of Aboriginal peoples and Aboriginal worldviews is essential. Experiential learning through relationship-building only further strengthens cultural safety in Aboriginal communities. Working with Aboriginal partners in a culturally safe way, especially in the field of mental health, will support trauma-informed approaches to care and services.

• The leadership of system-wide implementation of trauma-informed practice has often broken ground in co-learning initiatives by promoting broad open stances of inquiry, critical thinking, appreciative inquiry, mentoring and use of learning collaboratives [75, 97].

30 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

ACTIVATING NATURAL CHAMPIONS

• Trauma-informed implementation strategies have recognized the need to actively support and motivate people to make shifts in practice. Change agents or champions who lead from practice locations support the learning of the people in the workforce, families, and other stakeholders at all stages of readiness for change. In the Massachusetts Child Trauma Project, the leadership teams are called TILTs (trauma-informed leadership teams) as they are charged with “tilting” practice towards change to be trauma-informed. In the evaluation of Maine’s trauma-informed system of care, they noted the importance of champions at the state leadership level, not only at the practice or agency level [119].

ORGANIZATIONAL CULTURE SHIFTS

• TIP implementation leaders have described the need to enable learning cultures at the system, agency and team levels. When a collective approach to learning and responsibility is established, accountability for decision making does not rest on the individual caseworker and there is less opportunity for reactive and crisis driven approaches. Collective approaches to learning need to engage cultural communities as partners in shifting the systems, so that culturally safe practices are used and fostered.

• There is recognition that, amid multiple internal and external pressures facing those working in child and youth care systems, that implementation of a trauma lens needs to be intentional, and all implementation strategies need to be linked to creating kind and hospitable organizational systems that foster both organizational and human capacity.

• Embracing the values and principles of the APPF in all work and interactions strengthens the implementation of trauma-informed practices. Using the APPF and TIP guide together will support a holistic and comprehensive approach to care in Aboriginal communities.

• Organizational shifts need to affect recruitment and hiring, so there is active recruitment of and outreach to prospective employees who are trauma-informed [3].

FOCUSING ON BUILDING PARTNERSHIPS, RELATIONAL SYSTEM CHANGE

• Good working relationships are central to the implementation of trauma-informed practice. The establishment of constructive working relationships with/between children, parents, families, cultural communities and practitioners, and between professionals in multiple agencies and systems have been the foundation. This is important as children who have experienced trauma and their families are often involved with multiple service systems including courts and the legal system, child welfare, schools, primary care, and mental health. Therefore, common language and frameworks need to be developed for documenting trauma history, exchanging information, coordinating assessments, and planning and delivering care collaboratively with families and communities [1]. Leadership is central to allocation of time and participation for such cross-system work. At the Toronto Children’s Aid Society, the leadership has endorsed joint training with professionals from other systems, collaboration through project-specific groups, regular joint meetings, staff cross-placement or participation (where staff, managers or student interns from one sector work or volunteer in the other sector’s agencies) [3, 117, 120].

• Practice relationships are a core foundation of the APPF and the formation of relationships with Aboriginal people will be better supported with a trauma-informed approach that recognizes the complex history between Canada and Aboriginal peoples. Understanding intergenerational impacts of the medical system on Aboriginal peoples and creating partnerships with Aboriginal peoples in the care of children and youth will support culturally safe service provision.

31TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

BEST PRACTICES

• Build a system-wide learning culture about trauma. Provide forums for training all staff, as well as providing co-learning opportunities with families, on types of trauma, common reactions to traumatic events, short- and long-term impact of trauma, and principles of trauma-informed practice.

• Identify leaders who can serve as TIP champions to promote change within their workplaces. Cultural advisors and Elders may also take such leadership roles.

• Link leaders in all six services areas, provincial programs, contracted agencies and Delegated Aboriginal Agencies (DAAs), in learning together and discussing and acting on trauma-informed approaches.

• Link leaders in child protection, mental health, education, youth justice, victim services, police, crown attorneys, community agencies, youth and family advocacy groups, Peer Support Agencies/Programs and other systems to collectively take a trauma-informed approach to their work with children, youth and families.

• Discuss with other systems the benefits of a trauma-informed approach and the importance of interagency collaboration when creating safe environments, learning about trauma and adapting practice and policy, and creating a trustworthy service net/network of support and treatment. This advocacy with leadership in other systems needs to include systems interacting with adults who are parents and/or caregivers, those working on cultural wellness interventions, gender-informed interventions, etc.

TRAUMA-INFORMED PRACTICE IN ACTION

MCFD’s Youth Custody Services has engaged in staff training in trauma-informed practice and have developed a trauma-informed working group. Ongoing professional development in self-regulation skills for both staff and youth is being implemented. Beyond staff training, specific program changes have been implemented. For example, one program revamped its “discipline” system from one that involved loss of privileges and levels and a lengthy process of regaining these privileges and levels, to provide a pro- active, strengths-based approach, based on individual needs. Staff noticed that youth felt more empowered and encouraged to try to meet their individual goals as a result.

32 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

• Maximize children’s and young people’s sense of safety, assist them in managing their emotions, and in making meaning of their current coping strategies and trauma histories.

• Include the perspectives of children and youth in defining what is triggering for them and what creates safety and learning.

• Continuously explain and clarify to children and youth the agency processes, next steps, and measures being taken to ensure their safety and wellness.

• Make the physical environment of service settings welcoming and safe. Signal through the physical environment and informational materials that talking about and getting support on trauma is welcome and available in the setting.

• Understand and map the supports and treatments available for children and youth experiencing trauma and build relationships with the provider agencies to facilitate appropriate and timely referrals.

• Use trauma-informed universal screening and other methods to understand the level of trauma and other adversities a child/ youth is experiencing in order to make appropriate placements and referrals and guard against multiple placements.

• Support and promote positive and stable relationships in children’s and young people’s lives.

• Recognize how gender affects the types of trauma experienced and the expression of its effects and openness to discussing trauma. Provide gender responsive options for support.

• Recognize how historical trauma affects Aboriginal children and youth, and involve Aboriginal youth, parents, family members, Elders and communities in bringing holistic wellness and other culturally competent practices to trauma-informed approaches with Aboriginal children and youth.

• Recognize how trauma may affect people who are resettling as immigrants, or as refugees fleeing war or other forms of violence. Trauma-informed approaches that do not force disclosure of trauma may be particularly relevant for those who wish to find stability in housing, work and social connection, over focussing on past harms.

• Recognize how age and developmental trends impact the experience and effects of trauma for children and youth. Provide responses that are appropriate for their age and cognitive, physical, and emotional developmental stage.

• Understand that all children and families with histories of trauma have areas of strength and resilience, and support workers need to identify not only risk factors, but also protective factors for each child and family.

• Provide training to families of all types (birth, foster, respite) on: bringing a trauma lens to understanding child behaviour, managing conflict and displaying empathy, and teaching coping and resilience strategies.

• Provide opportunities for families of all types who are parenting children and youth to enhance self-care and where relevant to access support/treatment for their own experiences of trauma.

• Link to, refer to and collaborate with multi-setting, multi-level interventions that optimize child and family resilience.

• Involve brokers, liaisons and Elders to bridge trauma-informed and culture- and gender- informed approaches for children and families, communities, and child serving agencies.

APPLYING GENDER, CULTURAL AND DEVELOPMENTAL LENSES

SUPPORTING CHILDREN AND YOUTH

INVOLVING FAMILIES AND PEERS

Overview of Guide

33TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

• Understand and recognize the risk of secondary traumatic stress for all staff members, and the agency as a whole.

• Provide training on secondary trauma and stress management for all staff, promote self-care and well-being through policies and communications and encourage ongoing discussion among staff and administration.

• Create and maintain a work environment that conveys respect and appreciation, that is safe and confidential, and that provides support for continuing education, supervision, collaboration, consultation, and planned mental health breaks.

• Support staff development, debriefing after critical incidents, individual/group supervision and related strategies that support worker health.

• Cultivate a workplace culture that normalizes (and does not stigmatize) getting help for mental health challenges and actively promotes awareness of the supports available to workers.

• Conduct organizational level assessments that identify the range of practices and policies that might be initiated and/ or enhanced to support trauma-informed practice.

• Facilitate culture change in the organization towards social learning and agency- wide emotional intelligence.

• Identify and map existing trauma-informed practices, which can be built upon and more widely used.

• Incorporate trauma knowledge into all practice models.

• Integrate safe, respectful, learning-oriented approaches to case review, debriefing of incidents and supervision.

• Discuss how to address trauma experienced by different system stakeholders (children, parents, workers) and how strategies for building resilience in all these groups can be linked in agency-wide approaches.

• Share trauma-informed resources including resources reflecting traditional Aboriginal healing practices across teams, agencies and systems.

• Integrate family-centred and trauma-sensitive forms of information sharing to support trust and ensure understanding between workers and families.

• Build a system-wide learning culture about trauma. Provide forums for training all staff on types of trauma, common reactions to traumatic events, short- and long-term impact of trauma, and principles of trauma-informed practice

• Identify leaders who can serve as trauma champions to promote change within their workplaces.

• Link leaders/champions in all six services areas, provincial programs, contracted agencies and Delegated Aboriginal Agencies in learning together and discussing and acting on trauma-informed approaches.

• Link leaders in child safety, mental health, education, youth justice, victim services, police, crown attorney’s and other systems to collectively take a trauma-informed approach to their work with children, youth and families.

• Discuss with other systems the benefits of a trauma- informed approach and the importance of interagency collaboration when creating safe environments, learning about trauma and adapting practice and policy, and creating a trustworthy service net/network of support and treatment.

WORKER WELLNESS AND SAFETY

AGENCY CULTURE AND POLICIES

ACTION BY LEADERSHIP

34 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

Guide Summary This Practice Guide offers recommendations for achieving multi-level implementation of trauma-informed approaches with the Ministry for Children and Family Development and other child, youth and family-serving agencies in B.C. This Guide recognizes that the key to trauma-informed approaches is leadership within child and youth serving systems of care, towards co-learning and collective work to integrate these practices. It underlines the critical importance of respect, involvement and wellness of workers and parents in trauma-informed approaches. It attends to how developmental, gender and cultural lenses need to be applied in the course of implementation of trauma-informed approaches. Overall it makes the case for how principles of trauma- informed practice- trauma awareness; safety and trustworthiness; choice, collaboration and connection; and strengths-based and skill building approaches- can be applied universally for the benefit of all.

35TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

References 1. National Child Traumatic Stress Network,

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37TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

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48. Bassuk, E., K. Konnath, and K. Volk, Understanding traumatic stress in children. 2006, The National Centre on Family Homelessness: Waltham, MA. p. 28.

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50. van Wesel, F., et al., I’ll be working my way back: A qualitative synthesis on the trauma experience of children. Psychological Trauma: Theory, Research, Practice, and Policy, 2012. 4(5): p. 516-526.

51. Overstreet, S. and T. Mathews, Challenges associated with exposure to chronic trauma: Using a public health framework to foster resilient outcomes among youth. Psychology in the Schools, 2011. 48(7): p. 738-754.

52. Perry, B.D., The neuroarcheology of childhood maltreatment: The neurodevelopmental costs of adverse childhood events, in The cost of maltreatment: Who pays? We all do, K. Franey, R. Geffner, and R. Falconer, Editors. 2001, Haworth Press: Binghamtom, NY. p. 15-37.

38 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

53. Perry, B.D. and M. Szalavitz, The boy who was raised as a dog; and other stories from a child psychiatrist’s notebook: What traumatized children can teach us about life, loss and healing. 2007, New York: Basic Books.

54. Mulvihill, D., The health impact of childhood trauma: an interdisciplinary review, 1997-2003. Issues in Comprehensive Pediatric Nursing, 2005. 28(2): p. 115-136.

55. Middlebrooks, J.S. and N.C. Audage, The Effects of Childhood Stress on Health Across the Lifespan. 2008, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control: Atlanta, GA.

56. Zero to Six Collaborative Group and NCTSN, Early Childhood Trauma. 2010, National Center for Child Traumatic Stress: Los Angeles, CA. p. 17.

57. Child Trauma Academy, Autism Spectrum Disorder & Trauma/Neglect: 101, in CTA Special Topics Series. 2009, Child Trauma Academy: Houston, TX. p. 4.

58. Bücker, J., et al., Cognitive impairment in school- aged children with early trauma. Comprehensive Psychiatry, 2012. 53(6): p. 758-764.

59. Association, D.-A.P., Diagnostic and statistical manual of mental disorders. Arlington: American Psychiatric Publishing, 2013.

60. Obadina, S., Understanding attachment in abuse and neglect: implications for child development. British Journal of School Nursing, 2013. 8(6): p. 290-295.

61. Lawson, D.M. and J. Quinn, Complex Trauma in Children and Adolescents: Evidence-Based Practice in Clinical Settings. Journal of Clinical Psychology, 2013. 69(5): p. 497-509.

62. Anda, R.F., et al., The enduring effects of abuse and related adverse experiences in childhood. European Archives of Psychiatry & Clinical Neuroscience, 2006. 256(3): p. 174-186.

63. Mabanglo, M.A.G., Trauma And The Effects Of Violence Exposure And Abuse On Children: A Review Of The Literature. Smith College Studies in Social Work, 2002. 72(2): p. 231-251.

64. Purvis, K.B., S.R. Parris, and D.R. Cross, Trust-based relational intervention®: principles and practices. Adoption factbook V, 2011: p. 497-503.

65. Quinn, A., Reflections on Intergenerational Trauma: Healing as a Critical Intervention. First Peoples Child & Family Review, 2007. 3(4): p. 72-82.

66. Leslie, M., ed. The Breaking the Cycle Compendium Volume 1: Roots of Relationship. 2011, Mothercraft Press.

67. Adolescent Trauma and Substance Abuse Committee, Understanding the links between adolescent trauma and substance abuse: A toolkit for providers. 2nd ed. 2008: The National Child Traumatic Stress Network.

68. NCTSN Core Curriculum on Childhood Trauma Task Force, The 12 core concepts: Concepts for understanding traumatic stress responses in children and families, in Core Curriculum on Childhood Trauma. 2012, UCLA-Duke University National Center for Child Traumatic Stress. : Los Angeles, CA, and Durham, NC.

69. Harris, M. and R.D. Fallot, Using Trauma Theory to Design Service Systems. 2001, San Francisco, CA: Jossey Bass.

70. Hopper, E.K., E.L. Bassuk, and J. Olivet, Shelter from the storm: Trauma-informed care in homelessness services settings. The Open Health Services and Policy Journal, 2010. 3: p. 80-100.

71. Fallot, R. and M. Harris, Creating Cultures of Trauma-Informed Care (CCTIC): A Self- Assessment and Planning Protocol. July 2009, Community Connections Washington, DC.

72. Bloom, S.L. and B. Farragher, Restoring Sanctuary: A new operating system for trauma-informed systems of care 2013, New York, NY: Oxford University Press

39TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

73. Mannarino, A. and J. Cohen. Clinician’s corner: Trauma-focused Cognitive Behavioral Therapy ( TF-CBT ) 2014 April 2016]; Available from: http://www.istss.org/education-research/traumatic- stresspoints/2014-october/clinician-s-corner- trauma-focused-cognitive-behavi.aspx.

74. Cohen, J.A., et al., Trauma-focused CBT for youth with complex trauma. Child Abuse & Neglect, 2012. 36(6): p. 528-541.

75. Fraser, J.G., et al., Implementation of a workforce initiative to build trauma-informed child welfare practice and services: Findings from the Massachusetts Child Trauma Project. Children and Youth Services Review, 2014. 44: p. 233-242.

76. Hodas, G.R., Responding To Childhood Trauma: The Promise And Practice Of Trauma Informed Care. 2006, Pennsylvania Office of Mental Health and Substance Abuse Services: Harrisburg, PA. p. 77.

77. Conradi, L., J. Wherry, and C. Kisiel, Linking Child Welfare and Mental Health Using Trauma- Informed Screening and Assessment Practices. Child Welfare, 2011. 90(6): p. 129-147.

78. Pepler, D., et al., A Focus on Relationships - The Mother Child Study: Evaluating Treatments for Substance-Using Women 2014, Mothercraft Press

79. Suarez, E., et al., Project Kealahou: Improving Hawai‘i’s System of Care for At-Risk Girls and Young Women through Gender Responsive,Trauma-Informed Care. HAWAI‘I JOURNAL OF MEDICINE & PUBLIC HEALTH, December 2014. 73(12).

80. Agosti, J., et al., Using Trauma-Informed Child Welfare Practice to Improve Placement Stability Breakthrough Series Collaborative: Promising Practices and Lessons Learned. 2013, National Child Traumatic Stress Network: Los Angeles, CA and Durham, NC.

81. Perry, B.D., Effects of traumatic events on children: An introduction. 2003, The Child Trauma Academy.

82. Bloom, S.L., The Sanctuary Model of organizational change for children’s residential treatment. Therapeutic Communities, 2005. 26(1): p. 61-78.

83. Ford, J. and M. Blaustein, Systemic Self- Regulation: A Framework for Trauma-Informed Services in Residential Juvenile Justice Programs. Journal of Family Violence, 2013. 28(7): p. 665-677.

84. American Association of Children’s Residential Centers, Redefining residential: Trauma-informed care in residential treatment 2010, Author: Milwaukee, WI. p. 5

85. Department of Child Protection, The Signs of Safety Child Protection Practice Framework. 2011, Government of Western Australia: East Perth, West Australia.

86. van der Kolk, B., The body keeps score: Brain, mind, and body in the healing of trauma. 2014, New York, NY: Penguin Books.

87. Taylor, M. Not in isolation: The importance of relationships and healing in childhood trauma. 2014.

88. St. Andrews, A., Trauma & resilience: An adolescent provider toolkit. 2013, Adolescent Health Working Group: San Francisco, CA.

89. Center for Improvement of Child and Family Services, Reducing the trauma of investigation, removal, and initial out-of-home placement in child abuse cases. 2009, Portland State University School of Social Work: Portland, OR.

90. Collins, K.S., et al., Trauma Adapted Family Connections: Reducing developmental and complex trauma symptomatology to prevent child abuse and neglect. Child Welfare, 2011. 90(6): p. 29-47.

91. Law, M., Rosenbaum, P., King, G., King, S., Burke- Gaffney, J., Moning-Szkut, T., Kertoy, M., Pollock, N., Viscardis, L., & Teplicky, R., How does family- centred service make a difference?, in Facts Concepts Strategy Sheets, C.C.f.C.D. Research, Editor. 2003, McMasters University: Hamilton, ON.

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92. Child Welfare Committee and National Child Traumatic Stress Network, Child Welfare Trauma Training Toolkit: Comprehensive Guide. 2008, National Center for Child Traumatic Stress: Los Angeles, CA. p. 44.

93. Kumpfer, K. and The Centre for Addiction and Mental Health, Strengthening Families for the Future. 2006, Centre for Addiction and Mental Health: Toronto, ON.

94. Maples Adolescent Treatment Centre, Connect Parent Group Brochure for Parents and Caregivers. Burnaby, B.C.

95. Vermont Oxford Network, “Nurture the Mother - Nurture the Child”: A Trauma-Informed, Family Centered Approach to Supporting Women with Substance Use Issues who are Pregnant and Newly Parenting - Video Companion and Facilitator’s Guide. January 2014.

96. Marcellus, L. and Foster Parent Support Services Society. Safe Babies Program. [cited 2015 April 27]; Available from: http://fpsss.com/ safe-babies-program/.

97. Chadwick Trauma-Informed Systems Project, Creating trauma-informed child welfare systems: A guide for administrators. 2013, Chadwick Center for Children and Families: San Diego, CA. p. 131.

98. Bride, B.E., J.L. Jones, and S.A. MacMaster, Correlates of secondary traumatic stress in child protective service workers. Journal of Evidence- Based Social Work, 2007. 4(3-4): p. 69-80.

99. Conrad, D. and Y. Kellar-Guenther, Compassion fatigue, burnout, and compassion satisfaction among Colorado child protection workers. Child Abuse & Neglect, 2006. 30(10): p. 1071-1080.

100. Jankoski, J.A., Is Vicarious Trauma the Culprit? A Study of Child Welfare Professionals. Child Welfare, 2010. 89(6): p. 105-120.

101. Harrison, R.L. and M.J. Westwood, Preventing vicarious traumatization of mental health therapists: Identifying protective practices. Psychotherapy: Theory, Research, Practice, Training, 2009. 46(2): p. 203-219.

102. Azeem, M.W., et al., Effectiveness of six core strategies based on trauma informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital. Journal of Child & Adolescent Psychiatric Nursing, 2011. 24(1): p. 11-15.

103. Regel, S., Post-trauma support in the workplace: The current status and practice of critical incident stress management (CISM) and psychological debriefing (PD) within organizations in the UK. Occupational Medicine, 2007. 57(6): p. 411-416.

104. Richardson, J.I., Guidebook on Vicarious Trauma: Recommended solutions for anti- violence workers. 2001, London, ON: Family Violence Prevention Unit, Health Canada.

105. Child Welfare Collaborative Group, National Child Traumatic Stress Network, and The California Social Work Education Center, Child Welfare Trauma Training Toolkit: Trainer’s Guide. 2008, National Center for Child Traumatic Stress: Los Angeles, CA. p. 114.

106. Jean Tweed Centre, Trauma Matters: Guidelines for Trauma-Informed Services in Women’s Substance Use Services March 2013, Jean Tweed Centre: Toronto, ON.

107. ACS-NYU Children’s Trauma Institute, Addressing Secondary Traumatic Stress Among Child Welfare Staff ND, NYU: New York, NY. p. 5.

108. Hendricks, A., Applying a trauma lens to child welfare practice, in Creating trauma- informed child welfare systems: A guide for administrators. 2013, Chadwick Center for Children and Families: San Diego, CA. p. 49-53.

41TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

109. Poole, N., et al., Trauma Informed Practice Guide May 2013, British Columbia Centre of Excellence for Women’s Health and Ministry of Health, Government of British Columbia: Victoria, B.C.

110. Fallot, R. and M. Harris Creating cultures of trauma-informed care (CCTIC): A self- assessment and planning protocol. 2009. 2.2, 1-18.

111. Guarino, K., et al., Trauma-Informed Organizational Toolkit for homeless services. 2009, Center for Mental Health Services, SAMHSA, and he Daniels Fund, NCTSN and WK Kellog Foundation http://66.104.246.25/ucla/ Trauma_Informed_Organizational_Toolkit.pdf: Rockville, MD.

112. Chadwick Trauma-Informed Systems Project, Trauma System Readiness Tool. 2013, Chadwick Center for Children and Families: San Diego, CA. p. 16.

113. Prescott, L., et al. 10 Tips for Recovery- Oriented, Trauma-Informed Agencies. Available from: http://www.homelesshub.ca/ library/10-Tips-for-Recovery-Oriented-Trauma-

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114. Canadian Centre for Occupational Health and Safety. Guarding Minds @ Work. April 27, 2015]; Available from: http://www. guardingmindsatwork.ca/info/safety_what.

115. HR Proactive Inc. Psychologically Safe Workplace. April 27, 2015]; Available from: http://www.psychologicallysafeworkplace.ca/ index.html.

116. Salveron, M., et al., ‘Changing the way we do child protection’: The implementation of Signs of Safety® within the Western Australia Department for Child Protection and Family Support. Children and Youth Services Review, 2015. 48(0): p. 126-139.

117. Goodman, D., Summary Report of the 2010/11 an the 2011/12 Annual Reports from the CAS/ VAW Collaboration Agreement Committees. n.d., Children’s Aid Society, Toronto.

118. Jennings, C., C. Tucker, and H. Rutherford, 70:20:10 Framework explained: Creating high performance cultures. 2013: 70:20:10 Forum Pty Limited.

119. Horby Zeller Associates, THRIVE Maine’s Trauma-Informed System of Care, Final Evalution Report. Maine Department of Health and Human Services: Portland, ME.

120. Goodman, D., et al., Children Affected by Substance Abuse (CASA) Phase 2 (2011): Impact of CASA-2 Training & Consultations on Toronto Child Welfare Workers’ Knowledge, Skills & Confidence in Serving Families with Substance Misuse. March 2012, Children’s Aid Society Toronto, Jean Tweed Centre & Child Welfare Institute: Toronto. p. 23.

42 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

Appendix 1: Practical TIP Strategies for working with children, youth and families In essence, trauma-informed practice is about applying principles: awareness, safety, trustworthiness, choice, collaboration, being strengths-based and skills-building.

In each setting, these principles will play out differently, and will need to be tailored for diverse groups (by age, gender, culture).

In general, being trauma-informed means:

• providing clear information and predictable expectations about support provided

• offering welcoming intake procedures

• seeing and responding to challenging behaviours through a trauma lens; tolerating a range of emotions

• recognizing when someone is triggered (or experiencing the effects of trauma) and providing support

• focusing on relational growth, acknowledging that because of trauma responses this can be difficult

• adapting the physical space, so as to not re-traumatize

• fostering the development of resiliency and coping skills

• teaching and modeling skills for recognizing triggers, calming, centering and staying present

• creating safety plans

• recognizing the role of substance use as a coping mechanism, not only as an illness or problem independent of trauma, helping service users to understand these connections, and be less reliant on substance use as a mechanism to cope, and less self-critical for using substances as a coping mechanism

• providing choices as to preferences for support

• working collaboratively, providing services users with opportunities to rebuild control

• helping service users identify their strengths

• having skills, knowledge, and values that are trauma-informed, as workers

• providing opportunity for workers to debrief challenging incidents and decisions

• supporting an organizational culture of ‘emotional intelligence’ and ‘social learning’

43TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

Descriptions of key general strategies in online resources:

TITLE STRATEGY LINK

A Long Journey Home: A guide for generating trauma-informed services for mothers and children experiencing homelessness[1]

Detailed guide that includes practical checklists, assessments and charts for all social service providers, for example: • The conflicting definition of safety: service

users vs. service providers, pg. 14 • Strengths-based, person-first language, pgs.

17-18 • Building authentic relationships, pg. 27 • Common triggers and responses for women

with trauma histories, preventative measures, and grounding techniques, pgs. 30-33

http://homelesshub.ca/sites/ default/files/ALongJourneyHome. pdf

BC Trauma-Informed Practice Guide[2]

Developed for workers in mental health and substance use, this guide includes a number of generalizable strategies: • Appendix 3 – skills and strategies for talking

with and engaging clients, pgs. 58-65 • Appendix 6a: Quick Ways to Ground (self-

care), pgs. 81-82

http://bccewh.bc.ca/wp-content/ uploads/2012/05/ 2013_TIP- Guide.pdf

Trauma-informed: The Trauma Toolkit, Klinic Community Health Centre, Manitoba[3]

• Trauma and the experiences of immigrant families, pgs. 39-42

• Impact of residential school experiences, pgs. 46-47

• First Nations concepts on healing and resilience, pgs. 53-57

http://trauma-informed.ca/ wp-content/uploads/2013/10/ Trauma-informed_Toolkit.pdf

Trauma Matters: Guidelines for Trauma-Informed Practices in Women’s Substance Use Services[4]

This manual offers practical strategies and resources for mothers/families experiencing trauma, sexual abuse and substance use that are generalizable to other settings and populations: Appendix A: Guidelines for trauma-informed care with specific examples: • Acknowledgement Practices, pg. 141 • Safety Practices, pgs. 142-143 • Trustworthiness Practices, pgs. 143-144 • Choice & Collaboration Practices, pgs. 144-145 • Relational & Collaborative Approaches,

pg. 145 • Strength-based Modalities, pgs. 145-146 • Supporting Staff, pgs. 146-148

http://jeantweed.com/wp- content/themes/JTC/pdfs/ Trauma%20Matters%20 online%20version%20August% 202013.pdf

44 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

TITLE STRATEGY LINK

Trauma Matters: Guidelines for Trauma-Informed Practices in Women’s Substance Use Services[4]

• Building Clinical Infrastructure, pg. 148 • Policies & Procedures, pgs. 149-151 • T-I Practices with Staff, pgs. 151-153 • Developing Linkages with Allied Services,

pg. 153 • Appendix C: models for working with

women who are using substances and have experienced trauma, sexual abuse, pg. 160-163

http://jeantweed.com/wp- content/themes/JTC/pdfs/ Trauma%20Matters%20 online%20version%20August%20 2013.pdf

Trauma and Resilience: An Adolescent Provider Toolkit[5]

Trauma-informed strategies for working with adolescents – easy to use graphic format • Building blocks for healthy development,

pg. 27 • Restorative practices for trauma-informed

care, pg. 46 • Trauma-informed Consequences in practice,

pgs. 47-49

https://rodriguezgsarah.files. wordpress.com/2013/05/ traumaresbooklet-web.pdf

Trauma-Informed Child Welfare Practice Toolkit, Chadwick Trauma-Informed Systems Project[6]

Toolkit is free to download with registration and includes the following components: 1. Creating Trauma-Informed Child Welfare

Systems: A Guide for Administrators, 2nd Ed.[7] 2. Desk Guide on Trauma-Informed Mental

Health for Child Welfare[8] 3. Desk Guide for Trauma-Informed

Child Welfare for Child Mental Health Practitioners[9]

4. Guidelines for Applying a Trauma Lens to a Child Welfare Practice Model[10]

5. Trauma Systems Readiness Tool – a community assessment tool for individuals in the child welfare system[11]

http://www.chadwickcenter.org/ ctisp/images/TICWPracticeToolkit. pdf

Aboriginal Peoples and Historic Trauma: the process of intergenerational transmission

• Provides an overview of the existing knowledge of trauma, how it is defined, and how it must be conceptualized within the context of Aboriginal people.

• Describes the characteristics and patterns of behaviour that are typical in Aboriginal families living with intergenerational trauma.

• Examines the psychological, physiological and social processes by which trauma can be transmitted

• Highlights the interconnectedness of these • processes in transmitting trauma through

the generations and calls for holistic healing strategies that are implemented not only within the health domain but in other domains as well.

http://www.nccah-ccnsa.ca/ Publications/Lists/Publications/ Attachments/142/2015_04_28_ AguiarHalseth_RPT_ IntergenTraumaHistory_EN_Web. pdf

45TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

The following tables offer links illustrating where trauma-informed practices have been applied when working with different populations.

SERVICES FOR YOUNG CHILDREN AND FAMILIES WITH YOUNG CHILDREN

TITLE STRATEGY LINK

Breaking the Cycle – The Roots of Relationship[13]

Detailed information about Breaking the Cycle’s trauma-informed programs for parenting and pregnant women who use substances. • Issues that affect mothers’ substance use and

ability to keep children safe, pgs. 30-33, and, Effects on children, pgs. 34-36;

• Integrated maternal-child perspective on FASD, pgs. 41-43, and, Mothers affected by FASD, pgs. 44-46

• 10 basic principles of Motivational Interviewing, pg. 68-70

• 5 basic strategies for using Motivational Interviewing, pg. 70-71

http://www.mothercraft.ca/ assets/site/docs/resource-library/ publications/BTC_Compendium_ Rev.Ed_Jul.2011.pdf

Early Childhood Trauma, Zero to Six Collaborative Group, NCTSN[14]

• “Identifying and Providing Services for Young Children who have been Exposed to Trauma: For Professionals”, pg. 8-11

http://www.nctsnet.org/sites/ default/files/assets/pdfs/ nctsn_earlychildhoodtrauma_08- 2010final.pdf

Literature review: A trauma- sensitive approach for children aged 0-8 years[15]

• Chart on neurodevelopment, p. 10 • Continuum of responses to threat, p. 12 • Behavioural problems of children with

trauma, pp. 17-18 • Strategies for relationship-based practices,

pp. 22-23

http://www.whealth.com.au/ documents/work/trauma/ LiteratureReview.pdf

46 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

SERVICES FOR CHILDREN AND YOUTH WITH SPECIAL NEEDS (CYSN)

TITLE STRATEGY LINK

“Facts on Traumatic Stress and Children with Developmental Disabilities”, National Child Traumatic Stress Network[16]

• Information of prevalence of trauma in children with developmental disabilities and what may influence incidence of trauma, pg. 2-7

• Suggestions for modifying evaluations or therapy to meet needs, pg. 7

• “Special Diagnostic Considerations with Clients Who Have Developmental Disabilities” provides practical information regarding communication, cognition, and social skills that may help anyone who is working with children who have developmental disabilities, pg. 8

• “Suggestions for Therapy” offers ways for communicating with children with developmental disabilities that are useful for everyone, pg. 9

http://www.nctsn.org/ sites/default/files/assets/ pdfs/traumatic_stress_ developmental_disabilities_final. pdf

“Addressing the Trauma Treatment Needs of Children Who Are Deaf or Hard of Hearing and the Hearing Children of Deaf Parents”, National Child Traumatic Stress Network[17]

Primer for understanding abuse and trauma within the experience of deafness in the lives of children and families, pg. 31-38 Practical guidance for understanding behaviors and attitudes of and towards deaf persons within a trauma-informed framework include: 1. Figure 1: “Three Cultural Norms within Deaf

Identities”, pg. 11

2. Table One: “Influence on Severity of Hearing Loss on Communicative Functioning”, pg. 15

3. “Communicating with Your Deaf or Hard of Hearing Client”, pg. 39

4. “Appendix A: Helpful Websites”, pg. 53-54 5. “Appendix B: Cultural versus Pathological

Views of Deafness”, pg. 55

http://www.nctsn.org/sites/ default/files/assets/pdfs/Trauma_ Deaf_Hard-of-Hearing_Children_ rev_final_10-10-06.pdf

“Making Sense of Sensory Behaviour: A practical approach at home for parents and carers”[18]

• Understanding sensory reactions in children (over- and under sensitivity), pp. 3-4

• Calming strategies, pp. 6, 11, 13 • Alerting strategies, p. 7 • Sensory strategies for personal care, pp. 8-10

http://www.falkirk.gov.uk/ services/social-care/disabilities/ docs/young-people/Making%20 Sense%20of%20Sensory%20 Behaviour.pdf?v=201507131117

Creating Trauma-informed Child Welfare Systems: A Guide for Administrators[7]

• The Role of Developmental Delays, pg. 23 http://www.chadwickcenter.org/ CTISP/images/CTISPTICWAdmin Guide2ndEd2013.pdf

47TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

TITLE STRATEGY LINK

“Let’s Learn Together: A guide for parents and teachers of adopted children in primary schools in Northern Ireland”[19]

Background on development, trauma, and behaviour including skills and strategies for parenting and teaching. • Using “social stories” for difficult situations,

p. 39 • Special education and learning difficulties,

pp. 40-42 • Developing Individual Education Plans,

pp. 42-44

http://www.adoptionuk.org/ sites/default/files/documents/ LetsLearnTogetherNIMarch2013. pdf 

SERVICES FOR CHILDREN AND YOUTH WITH MENTAL HEALTH CHALLENGES

TITLE STRATEGY LINK

“Innovations in Implementation of Trauma-Informed Care Practices in Youth Residential Treatment: A Curriculum for Organizational Change”[20]

A curriculum of implementing out-of-home placement mental health treatment programs: 1. Organizational factors across 6 domains that

create success in implementing trauma- informed care, pgs. 6-9 of linked PDF

2. Table 1: Organizational self-assessment, pg.13-14 of linked PDF

http://jpo.wrlc.org/bitstream/ handle/11204/769/4422. pdf?sequence=1

“Redefining Residential: Trauma- Informed Care in Residential Treatment”[21]

Steps to creating trauma-informed treatment facility: 1. Universal precaution and key setting

characteristics, pg. 2 2. Leadership - 8 steps to build TI organization,

pg. 2-3 3. Environment - Physical & Interpersonal, pg. 3 4. Programming, pg. 3-4 5. Child/Youth – individual response plans,

pgs. 4-5

http://www.aacrc-dc.org/sites/ default/files/paper_8_trauma- informed.pdf

“Empirically Supported Treatments and Promising Practices”, National Child Traumatic Stress Network[22]

• Individual fact sheets on empirically supported trauma services and interventions, including the target population, and cultural information

http://www.nctsn.org/resources/ topics/treatments-that-work/ promising-practices

“Healing the Hurt: Trauma- informed Approaches to the Health of Boys and Young Men of Color”[23]

• Foster care/Child Welfare, pgs. 50-55 • The Sanctuary Model, pgs. 62-68

http://www.issuelab.org/ resource/healing_the_hurt_ trauma_informed_approaches_ to_the_health_of_boys_and_ young_men_of_color

“Not in Isolation: The Importance of Relationships and Healing in Childhood Trauma”[24]

• Examples of items for a sensory box as a grounding strategy, pg. 25

http://aic.gov.au/media_library/ conferences/2015-accan/ accan_2015_presentations/ wednesday_1_april/Michelle_ Taylor_Not_in_Isolation.pdf

48 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

SERVICES RELATED TO CHILD SAFETY, FAMILY SUPPORT AND CHILDREN IN CARE

TITLE STRATEGY LINK

Trauma Informed Care- Connecticut Department of Children and Families

• 17 Guiding Principles for trauma-informed care, pg. 12-13

• 10 Strategies for working with families and children experiencing trauma, pg. 13-16

• 5 Essential Elements of Practice with specific and detailed examples of best practices for each element and questions for workers to ask families, children and themselves pg. 16-23

http://www.ct.gov/dcf/cwp/view. asp?a=4368&Q=514042

Rise, an online magazine with downloadable issues[27]

• Provides perspectives of parents with experience in the child welfare system; insight for both workers and families and may assist understanding and collaboration. Some notable issues include: “The Impact of Trauma on Parenting” “I made a Mistake”, not “I am a Mistake” “Generations in Foster Care” “Facing Race in Child Welfare” “Relationships with Foster Parents”

www.risemagazine.org

Using Trauma-Informed Child Welfare Practice to Improve Placement Stability – Breakthrough Series Collaborative: Promising Practices and Lessons Learned [28]

• Raising awareness of parents & caregivers, pgs. 7 & 29

• Conducting inclusive team meetings, pgs. 14 & 43

http://www.nctsn.org/sites/ default/files/assets/pdfs/using_ ticw_bsc_final.pdf

“Reducing the trauma of investigation, removal and out- of-home placements”[29]

• Trauma-informed Practice Strategies for Caseworkers, pgs. 16-19

• Trauma-informed Practice Strategies for Foster Parents, pgs. 20-21

http://ocfs.ny.gov/main/cfsr/ Reducing%20the%20trauma%20 of%20investigation%20 removal%20%20initial%20 out-of-home%20plcaement%20 in%20child%20abuse%20cases. pdf

The Other Side of the Door: A Practical Guide for child welfare workers working with First Nations, Inuit and Metis Peoples. 2nd edition

http://cwrp.ca/publications/2966

49TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

ADOPTION-RELATED SERVICES

TITLE STRATEGY LINK

Using Trauma-Informed Child Welfare Practice to Improve Placement Stability – Breakthrough Series Collaborative: Promising Practices and Lessons Learned[28]

• Raising Awareness of Parents and Caregivers, pg. 29

• Facilitating connection between birth and foster parents, pg. 13 & 41

http://www.nctsn.org/sites/ default/files/assets/pdfs/using_ ticw_bsc_final.pdf

Guidelines for Applying a Trauma Lens to a Child Welfare Practice Model, Chadwick Trauma-Informed Systems Project[10]

• Adoption & Guardianship, pg. 72-74 • Post-permanency Supports, pgs. 75-76

http://muskie.usm.maine.edu/ helpkids/PMNetworkDocs/ Trauma-Informed%20PM%20 2013%20CTISP.pdf

“Parenting after trauma: Understanding your child’s needs – A guide for foster and adoptive parents”, American Academy of Pediatrics and Dave Thomas Foundation for Adoption[30]

• 3-page handout with tips and strategies for parents whose children have experienced trauma

https://www.healthychildren. org/English/family-life/family- dynamics/adoption-and-foster- care/Pages/Parenting-Foster- Adoptive-Children-After-Trauma. aspx

“Let’s Learn Together: A guide for parents and teachers of adopted children in primary schools in Northern Ireland”[19]

• Background on “what makes adoption different” addressing development, trauma, and behaviour including skills and strategies for parenting and teaching.

• Development and Trauma, pg. 4-9 • Helping children develop executive

functioning skills, p. 11 • Ways to reduce stress, p. 18 • Learning to wait, p. 23 • Three things to prevent meltdowns, p. 27 • Using “social stories” for difficult situations,

p. 39

http://www.adoptionuk.org/ sites/default/files/documents/ LetsLearnTogetherNIMarch2013.pdf

SERVICES FOR YOUTH INVOLVED WITH THE CRIMINAL JUSTICE SYSTEM

TITLE STRATEGY LINK

“Sanctuary and Supports for Girls in Crisis”, a Girls Matter Webinar

• Creating trauma-informed, gender-responsive services.

• Webinar with Stephanie Covington, Jeannette Pai-Esponosa, and Kimberly Sokoloff Selvaggi. Continuing Education credits and downloadable slides

http://www.samhsa.gov/women- children-families/trainings/ sanctuary-supports

Healing the Hurt: Trauma- informed Approaches to the Health of Boys and Young Men of Color[23]

• Cycle of violence, pg. 26 • Juvenile justice/Re-entry/Prison, pg. 55-61

http://www.issuelab.org/ resource/healing_the_hurt_ trauma_informed_approaches_ to_the_health_of_boys_and_ young_men_of_color

50 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

TITLE STRATEGY LINK

“Systemic Self-Regulation: A Framework for Trauma- Informed Services in Residential Juvenile Justice Programs”[31]

• 5 field-tested models are recommended from study showing value of implementing trauma-informed self-regulation-based services in juvenile justice residential facilities, pg. 9-10

http://www.traumacenter. org/products/pdf_files/ Trauma%20Services%20in%20 Residential%20Juvenile%20 Justice%20Settings_Ford_ Blaustein.pdf

LEADERSHIP

TITLE STRATEGY LINK

“Making Strengths-Based Practice Work in Child Protection: Frontline Perspectives” by Carolyn Oliver[32]

• A dissertation and study on strengths- based solution-focused approaches in child protection and the challenges workers face in providing them, including specifics on the Signs of Safety model.

• Gives 12 key management strategies to support workers in providing strengths-based approaches, Page 297.

• Lists recommendations for MCFD based on 224 worker surveys and 24 worker interviews within MCFD, Pages 310-313

https://open.library.ubc.ca/ cIRcle/collections/ubctheses/24/ items/1.0165904

Using Trauma-Informed Child Welfare Practice to Improve Placement Stability – Breakthrough Series Collaborative: Promising Practices and Lessons Learned[28]

• Providing Coaching & Support, pgs. 6 & 27 • Providing Training to Child Welfare Partners,

pg. 49 • Using Trauma-informed Forms and Language

with Partners, pg. 51

http://www.nctsn.org/sites/ default/files/assets/pdfs/using_ ticw_bsc_final.pdf

Creating Trauma-informed Child Welfare Systems: A Guide for Administrators[7]

• Recommendations from the Field, pg. 15 http://www.chadwickcenter.org/ CTISP/images/ CTISPTICWAdminGuide 2ndEd2013.pdf

“Implementation of a workforce initiative to build trauma- informed child welfare practice and services: Findings from the Massachusetts Child Trauma Project”[33]

• Describes methods of successful implementation in child welfare and mental health services.

• Child Welfare, pg. 3 of PDF 1. Determine elements of trauma-informed

practice 2. Training & Curricula 3. Trauma-Informed Leadership Teams –

“TILTs”—charged with “tilting” practice • Mental Health, pg. 4 of PDF

1. Adopt 3 evidence-based treatments (EBTs) 2. Screening for individual needs and

best EBT 3. Disseminate EBTs through learning

community model 4. Readiness, implementation, and evaluation

http://www.traumacenter.org/ products/pdf_files/Trauma- informed_child_welfare_MA_ G0001.pdf

51TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

WORKER WELLNESS

TITLE STRATEGY LINK

“The Cost of Caring: Secondary Stress and the Cost of Working with High-Risk Children and Families”, Bruce D. Perry, MD[34]

• Case examples of common situations for workers pgs. 3-8

• Secondary trauma and who is at risk, pgs. 10-12

• Individual indicators of distress, pg. 14 • Care strategies, pgs. 15-16

https://childtrauma.org/wp- content/uploads/2014/01/ Cost_of_Caring_Secondary_ Traumatic_Stress_Perry_s.pdf

“Secondary Trauma and the Child Welfare Workforce”, in CW360: A Comprehensive Look at a Prevalent Child Welfare Issue”[35]

• An issue devoted to secondary trauma with many articles of interest. Of note is an Agency Discussion guide on page 38

http://www.nctsn.org/sites/ default/files/assets/pdfs/ CW360_2012.pdf

“Secondary Traumatic Stress: A Fact Sheet for Child Serving Professionals”, NCTSN[36]

• A partial list of signs and symptoms of secondary trauma, pg 2

• Sorting out related conditions, pg. 2 • Strategies for Prevention and Intervention,

page 4 • Resources, including self-assessment tools,

pg. 4-5

http://www.nctsn.org/sites/ default/files/assets/pdfs/ secondary_traumatic_tress.pdf

Psychological Health & Safety: An Action Guide for Employers, Mental Health Commission of Canada and Centre for Applied Research in Mental Health and Addiction[37]

• The P6 Framework – a improvement process for making a healthy workplace, pg. 4

• Self-care tools, pg. 27 • Integrating Mental Health Care into

the Workplace, pg. 48

http://www. mentalhealthcommission.ca/ sites/default/files/Workforce_ Employers_Guide_ENG_1.pdf

SCHOOLS

TITLE STRATEGY LINK

Child Trauma Toolkit for Educators[38]

• Observational cues that trauma may be present: Preschool pg. 8, Elementary pg. 10, Middle School pg. 12, High School pg. 14

• A Guide for Parents, pgs. 18-19

http://rems.ed.gov/docs/nctsn_ childtraumatoolkitforeducators.pdf

Reducing the trauma of investigation, removal and out- of-home placements[29]

• Trauma-informed Practice Strategies for Educators, pg. 28

http://ocfs.ny.gov/main/cfsr/ Reducing%20the%20trauma%20 of%20investigation%20 removal%20%20initial%20out- of-home%20plcaement%20in%20 child%20abuse%20cases.pdf

“Using Trauma-Informed Practices to De-escalate Classroom Conflict”[39]

• Preventative and de-escalation strategies, pg. 23-24

http://www.schoolhealthcenters. org/wp-content/uploads/2014/03/ Trauma-Informed-Strategies-to- Deescalate-Classroom-Conflict.pdf

52 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

TITLE STRATEGY LINK

Helping Traumatized Children Learn, Massachusetts Advocates for Children[40]

• Specifics on the impact of trauma on: • Academic performance, pgs. 22-32 • Classroom behavior, pgs. 34-38

http://traumasensitiveschools. org/tlpi-publications/download- a-free-copy-of-helping- traumatized-children-learn/

“Moving from Evidence to Actions: Schools”, the Safe Start Center Series on Children Exposed to Violence[41]

• Responding to children’s disclosure, pg. 5 http://www.behavioralinstitute. org/uploads/Schools_safe_ start_center_IssueBrief3_ OJJDP_1-2010.pdf

“Calmer Classrooms: A guide to working with traumatised children”[42]

• Relationship-based strategies for the classroom, pp. 17-28

http://ccyp.vic.gov.au/ childsafetycommissioner/ downloads/calmer_classrooms.pdf

1. Prescott, L., et al., A Long Journey Home: A Guide for Creating Trauma-Informed Services for Mothers and Children Experiencing Homelessness. 2008, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, the Daniels Fund, National Child Traumatic Stress Network, W.K. Kellogg Foundation: Rockville, MD.

2. British Columbia Centre of Excellence for Women’s Health, Trauma-Informed Practice Guide. 2013.

3. Centre, K.C.H., Trauma-informed: The Trauma Toolkit, 2nd Edition. 2013.

4. Jean Tweed Centre, Trauma matters: Guidelines for trauma-informed practices in women’s substance use services. 2013: Toronto, ON.

5. St. Andrews, A., Trauma & resilience: An adolescent provider toolkit. 2013, Adolescent Health Working Group: San Francisco, CA.

6. Project, C.T.I.S., Trauma-informed Child Welfare Practice Toolkit. 2013: San Diego, CA.

7. Chadwick Trauma-Informed Systems Project, Creating trauma-informed child welfare systems: A guide for administrators. 2013, Chadwick Center for Children and Families: San Diego, CA. p. 131.

8. Chadwick Trauma-Informed Systems Project, Desk Guide on Trauma-informed Mental Health for Child Welfare. 2013, Chadwick Center for Children and Families: San Diego, CA. p. 17.

9. Chadwick Trauma-Informed Systems Project, Desk Guidle on Trauma-informed Child Welfare for Child Mental Health Practitioners. 2013, Chadwick Center for Children and Families: San Diego, CA. p. 22.

10. Chadwick Trauma-Informed Systems Project, Guidelines for Applying a Trauma Lens to a Child Welfare Practice Model. 2013, Chadwick Center for Children and Families: San Diego, CA. p. 97.

11. Chadwick Trauma-Informed Systems Project, Trauma System Readiness Tool. 2013, Chadwick Center for Children and Families: San Diego, CA. p. 16.

12. Marcellus, L. Nurture the Mother — Nuture the Child. in Annual Meeting & Quality Congress: Convening the Worldwide Community of Practice. 2013. Chicago, IL: Vermont Oxford Network.

13. Leslie, M., ed. The Breaking the Cycle Compendium Volume 1: Roots of Relationship. 2011, Mothercraft Press.

14. Zero to Six Collaborative Group and NCTSN, Early Childhood Trauma. 2010, National Center for Child Traumatic Stress: Los Angeles, CA. p. 17.

15. Dwyer, J., et al., Literature review: A trauma-sensitive approach for children aged 0-8 years. 2012, Women’s Health Goulburn North East: Wangaratta, AU.

16. Charlton, M., Kliethermes, M., Tallant, B., Taverne, A., Tishelman, A., Facts on traumatic stress and children with developmental disabilities. 2004, National Child Traumatic Stress Network.

17. Durity, R., et al., Addressing the Trauma Treatment Needs of Children Who Are Deaf or Hard of Hearing and the Hearing Children of Deaf Parents. 2006, National Child Traumatic Stress Network Los Angeles, CA. p. 70.

53TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

18. Children with Disabilities Team, Making sense of sensory behaviour: A practical approach at home for parents and carers. Falkirk Council Social Work Services: Falkirk, UK.

19. Lavery, S., Let’s learn together: A guide for parents and teachers of adopted children in primary school in Northern Ireland. 2013: Adoption UK, Health and Social Care.

20. Hummer, V.L., et al., Innovations in implementation of trauma-informed care practices in youth residential treatment: a curriculum for organizational change. Child Welfare, 2010. 89(2): p. 79-95.

21. American Association of Children’s Residential Centers, Redefining residential: Trauma-informed care in residential treatment 2010, Author: Milwaukee, WI. p. 5

22. National Child Traumatic Stress Network. Empirically Supported Treatments and Promising Practices. [cited 2015; Available from: http://www.nctsn.org/resources/ topics/treatments-that-work/promising-practices.

23. Rich, J.A., et al., Healing the Hurt: Trauma-Informed Approaches to the Health of Boys and Young Men of Color. 2009, The Center for Nonviolence and Social Justice: Drexel University. p. 86.

24. Taylor, M. Not in isolation: The importance of relationships and healing in childhood trauma. 2014.

25. Hopper, D., Relaxation skills 4 kids: An educational resource for parents, teachers, & professionals. 2010, Life Skills 4 Kids: Australia.

26. Connecticut Department of Children and Families, Trauma-Informed Care Practice Guide. 2012, Connecticut Department of Children and Families: Hartford, CT. p. 24.

27. Rise: Stories by and for parents affected by the child welfare system. May 25, 2015]; Available from: www. risemagazine.org.

28. Agosti, J., et al., Using Trauma-Informed Child Welfare Practice to Improve Placement Stability Breakthrough Series Collaborative: Promising Practices and Lessons Learned. 2013, National Child Traumatic Stress Network: Los Angeles, CA and Durham, NC.

29. Center for Improvement of Child and Family Services, Reducing the trauma of investigation, removal, and initial out-of-home placement in child abuse cases. 2009, Portland State University School of Social Work: Portland, OR.

30. American Academy of Pediatrics and Dave Thomas Foundation for Adoption, Parenting After Trauma: Understanding Your Child’s Needs. 2013, American Academy of Pediatrics: Washington, DC. p. 4 pages

31. Ford, J. and M. Blaustein, Systemic Self-Regulation: A Framework for Trauma-Informed Services in Residential Juvenile Justice Programs. Journal of Family Violence, 2013. 28(7): p. 665-677.

32. Oliver, C., Managing strength-based practice work in child protection: Frontline perspectives, in Social Work. 2014, University of British Columbia: Vancouver, BC. p. 341.

33. Fraser, J.G., et al., Implementation of a workforce initiative to build trauma-informed child welfare practice and services: Findings from the Massachusetts Child Trauma Project. Children and Youth Services Review, 2014. 44: p. 233-242.

34. Perry, B.D., The cost of caring: Secondary traumatic stress and the impact of working with high-risk children and their families. 2014, The ChildTrauma Academy: Houston, TX.

35. Center for Advanced Studies in Child Welfare, ed. Secondary Trauma and the Child Welfare Workforce. CW360: A Comprehensive Look at a Prevelant Child Welfare Issue, ed. School of Social Work. 2012, University of Minnesota.

36. NCTSN, Secondary Traumatic Stress: A Fact Sheet for Child-Serving Professionals ND, National Child Traumatic Stress Network: Los Angeles, CA.

37. Gilbert, M. and D. Bilsker, Psychological Health and Safety: An Action Guide for Employers. 2012, Mental Health Commission of Canada and the Centre for Applied Research in Mental Health and Addiction.

38. NCTSN Schools Committee, Child Trauma Toolkit for Educators. 2008, National Child Traumatic Stress Network: Los Angeles, CA. p. 21.

39. Rader, J., Using Trauma Informed Strategies to De- Escalate Classroom Conflict in James Morehouse Project. El Cerrito High School: El Cerrito, CA.

40. Massachusetts Advocates for Children, Helping Traumatized Children Learn. 2005: Boston, MA.

41. Escudero, P., et al., Moving From Evidence to Action: Schools, in The Safe Start Center Series on Children Exposed to Violence. 2010, Safe Start Centre: North Bethesda, MD. p. 12.

42. Downey, L., Calmer classrooms: A guide to working with traumatised children. 2007, Melbourne, Victoria, Australia: Child Safety Commissioner.

54 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

Appendix 2: Trauma-Informed Practice Principles Trauma-informed practice means integrating an understanding of past and current experiences of violence and trauma into all aspects of service delivery. The goal of trauma-informed systems is to avoid re-traumatizing individuals and support safety, choice, and control in order to promote healing.

Trauma Awareness Trauma awareness is the foundation for trauma informed practice. Being ‘trauma aware’ means that individuals understand the high prevalence of trauma in society, the wide range of responses, effects and adaptations that people make to cope with trauma, and how this may influence service delivery (e.g., difficulty building relationships, missing appointments).

Safety and Trustworthiness Physical, emotional, spiritual, and cultural safety are important to trauma-informed practice. Safety is a necessary first step for building strong and trustworthy relationships and service engagement and healing. Developing safety within trauma- informed services requires an awareness of secondary traumatic stress, vicarious trauma, and self-care for all staff in an organization.

Choice, Collaboration and Connection Trauma-informed services encourage opportunities for working collaboratively with children, youth and families. They emphasize creating opportunities for choice and connection within the parameters of services provided. This experience of choice, collaboration, and connection often involves inviting involvement in evaluating the services, and forming service user advisory councils that provide advice on service design as well as service users’ rights and grievances.

Strengths Based and Skill Building Promoting resiliency and coping skills can help individuals manage triggers related to past experiences of trauma and support healing and self-advocacy. A strengths-based approach to service delivery recognizes the abilities and resilience of trauma survivors, fosters empowerment, and supports an organizational culture of ‘emotional learning’ and ‘social learning.’

55TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

Appendix 2: Trauma-Informed Practice Principles Early Years Services

GETTING STARTED: TRAUMA-INFORMED PRINCIPLES ‘IN ACTION’

The goal of trauma-informed systems is to avoid re-traumatizing individuals and support safety, choice, and control in order to promote healing. The following discussion questions are intended for small groups to consider and reflect on their work and to ask “What are we doing well? What else can we be doing?”

Trauma Awareness Do all staff in your program or organization have a basic understanding of the causes of trauma and possible effects?

What kind of information about trauma is available to the families you work with?

Are there staff or programs within your service area that may be able to provide trauma-specific services if a child, parent or caregiver asks for additional support with healing from trauma?

Are there community Elders/traditional knowledge keepers that can speak to resilience and healing in Aboriginal communities?

Safety and Trustworthiness What is the first point of contact with your program for the families you work with, e.g., phone message, outreach worker, receptionist? What strategies for creating a welcoming and safe environment already exist?

Take a walk through the waiting areas, the reception area, group spaces, and interview rooms at your organization. Do they increase feelings of safety for both service users and staff?

What steps have been taken that reflect a holistic and engaged process to support cultural safety?

Choice, Collaboration and Connection When working with families, do you encourage open communication? Provide choices in care and support whenever possible?

How are mistakes or uncertainties handled in your program or organization? Are they viewed as opportunities for learning?

How do you support inclusion and family, children, and community voice?

What are some of your strengths in working with people, e.g., friendly, creative, and how do you use them to build relationships with others?

Strengths Based and Skill Building To what extent are you aware of and using ‘person- first’ language, e.g., “children with special needs”?

How is education and support related to vicarious or secondary trauma provided within your organization?

How do children and families in your organization influence program delivery? Are there opportunities for peer support, participation in program planning, participatory evaluation methods?

56 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

Appendix 2: Trauma-Informed Practice Principles Services For Children and Youth with Special Needs

GETTING STARTED: TRAUMA-INFORMED PRINCIPLES ‘IN ACTION’

The goal of trauma-informed systems is to avoid re-traumatizing individuals and support safety, choice, and control in order to promote healing. The following discussion questions are intended for small groups to consider and reflect on their work and to ask “What are we doing well? What else can we be doing?”

Trauma Awareness Do all staff in your program or organization have a basic understanding of the causes of trauma and possible effects?

Are direct service staff able to provide information to caregivers about behavioral effects of trauma for children with different special needs?

How does the Aboriginal family and community define a child with special needs? What are the beliefs and values about disability/ability?

Safety and Trustworthiness What is the first point of contact with your program for the families you work with, e.g., phone message, outreach worker, receptionist? What strategies for creating a welcoming and safe environment already exist?

Take a walk through the waiting areas, the reception area, group spaces, and interview rooms at your organization. Do they increase feelings of safety for both service users and staff?

What steps have been taken that reflect a holistic and engaged process to support cultural safety?

Choice, Collaboration and Connection When working with families, do you encourage open communication? Provide choices in care and support whenever possible?

When engaging with children with special needs, do you consider strategies for minimizing anxiety and building relationships (e.g., slowing down speech, using visuals, and presenting one idea at a time)?

While participating in your program, what opportunities are there for families to provide feedback?

Strengths Based and Skill Building To what extent are you aware of and using ‘person- first’ language, e.g., “children with special needs”?

How is education and support related to vicarious or secondary trauma provided within your organization?

Are there opportunities within your particular program to teach coping and self-regulation skills specific to children with special needs (e.g., focus on increasing self-soothing rather than enhancing insight)?

57TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

Appendix 2: Trauma-Informed Practice Principles Child and Youth Mental Health Services

GETTING STARTED: TRAUMA-INFORMED PRINCIPLES ‘IN ACTION’

The goal of trauma-informed systems is to avoid re-traumatizing individuals and support safety, choice, and control in order to promote healing. The following discussion questions are intended for small groups to consider and reflect on their work and to ask “What are we doing well? What else can we be doing?”

Trauma Awareness Do all staff in your program or organization have a basic understanding of the causes of trauma and possible effects?

Do staff in specific program areas understand how trauma may intersect and affect diagnosis, symptomatology and recovery from other mental health issues?

Are there staff or programs within your service area that may be able to provide trauma- specific services (e.g., EMDR) if a child, parent or caregiver asks for additional support with healing from trauma?

Safety and Trustworthiness What is the first point of contact with your program for the families you work with, e.g., phone message, outreach worker, receptionist? What strategies for creating a welcoming and safe environment already exist?

Take a walk through the waiting areas, the reception area, group spaces, and interview rooms at your organization. Do they increase feelings of safety for both service users and staff?

What steps have been taken that reflect a holistic and engaged process to support cultural safety?

Choice, Collaboration and Connection When working with families, do you encourage open communication? Provide choices in care and support whenever possible?

While participating in your program, what opportunities are there for families to provide feedback, ask questions, or express their concerns? How is this feedback responded to and by whom?

What opportunities are there in your organization for staff to provide feedback, ask questions or express their concerns?

Strengths Based and Skill Building To what extent are you aware of and using ‘person- first’ language, e.g., “children with special needs”?

How is education and support related to vicarious or secondary trauma provided within your organization?

Can your program shift away from an emphasis on client deficits to one on strengths? Do you ask about people’s interests, goals, coping skills, community connections, survival strategies, spirituality, etc?

58 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

Appendix 2: Trauma-Informed Practice Principles Child Safety, Family Support and Children in Care Services

GETTING STARTED: TRAUMA-INFORMED PRINCIPLES ‘IN ACTION’

The goal of trauma-informed systems is to avoid re-traumatizing individuals and support safety, choice, and control in order to promote healing. The following discussion questions are intended for small groups to consider and reflect on their work and to ask “What are we doing well? What else can we be doing?”

Trauma Awareness Do all staff in your program or organization have a basic understanding of the causes of trauma and possible effects?

Are you able to recognize the effects of intergenerational and childhood trauma in the families you work with?

What kind of information about trauma is available to the families you work with? Is it accessible, up- to-date, and tailored to the population you work with (e.g., age, language, culture)? Can you offer self-help resources for supporting healing from trauma?

Safety and Trustworthines What triggers might there be for your clients while interacting with your service? How do the effects of trauma influence their ability to engage with your service (e.g., attend appointments, ask questions, respond appropriately to decisions)?

Physical, cultural, and emotional safety for both service users and staff should be considered together. For example, what are your program’s policies about lights and locks? What might be comfortable and safe for one person might feel restrictive or triggering for another.

Choice, Collaboration and Connection How do you promote partnerships in decision making? What does reciprocity mean in terms of sharing the collective responsibility?

When working with families, do you allow them the freedom to express their feelings without judging or censoring? Can there be flexibility in the structure of meetings and appointments – available times, length, or style?

How are mistakes or uncertainties handled in your program or organization? Are they viewed as opportunities for learning?

Strengths Based and Skill Building Are there opportunities to help children, youth, and caregivers develop coping skills? Are you comfortable creating safety plans where there might be concerns about grief and suicide risk?

Are you able to provide information to caregivers about how separation, anxiety and fear, and adversity affect child behavior? Can you provide caregivers with suggestions for promoting self- regulation and coping with difficult circumstances? How can you support their self-care as well as your own?

59TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

Appendix 2: Trauma-Informed Practice Principles Adoption Services

GETTING STARTED: TRAUMA-INFORMED PRINCIPLES ‘IN ACTION’

The goal of trauma-informed systems is to avoid re-traumatizing individuals and support safety, choice, and control in order to promote healing. The following discussion questions are intended for small groups to consider and reflect on their work and to ask “What are we doing well? What else can we be doing?”

Trauma Awareness Do all staff in your program or organization have a basic understanding of the causes of trauma and possible effects?

What kind of information about trauma is available to the families you work with? Is it accessible, up-to-date, and tailored to the population you work with (e.g., age, language, culture)?

Are there opportunities within your particular service area to share information about trauma related to adoption? Strategies for fostering attachment?

Safety and Trustworthiness What is the first point of contact with your program for the families you work with, e.g., phone message, outreach worker, receptionist? What strategies for creating a welcoming and safe environment already exist?

Take a walk through the waiting areas, the reception area, group spaces, and interview rooms at your organization. Do they increase feelings of safety for both service users and staff?

Choice, Collaboration and Connection What are you already doing to encourage collaboration with families, with other programs and organizations, and with other systems of care? What else could you be doing?

While participating in your program, what opportunities are there for families to provide feedback, ask questions, or express their concerns?

How are mistakes or uncertainties handled in your program or organization? Are they viewed as opportunities for learning?

Strengths Based and Skill Building To what extent are you aware of and using ‘person- first’ language, e.g., “children with special needs”, “youth with substance use problems”, “fathers who have trauma histories”, etc? Are there ways to role model this type of language for others?

Do you ask about people’s interests, goals, coping skills, community connections, survival strategies, spirituality, etc.?

60 TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

Appendix 2: Trauma-Informed Practice Principles Youth Justice Services

GETTING STARTED: TRAUMA-INFORMED PRINCIPLES ‘IN ACTION’

The goal of trauma-informed systems is to avoid re-traumatizing individuals and support safety, choice, and control in order to promote healing. The following discussion questions are intended for small groups to consider and reflect on their work and to ask “What are we doing well? What else can we be doing?”

Trauma Awareness Do all staff in your program or organization have a basic understanding of the causes of trauma and possible effects? What topics or issues would you benefit from learning more about?

Are there staff or programs within your service area that may be able to provide trauma-specific services if a child, parent or caregiver asks for additional support with healing from trauma? What is the referral process like for these services, is there is waitlist, who is eligible?

Safety and Trustworthiness Physical, cultural, and emotional safety for both service users and staff should be considered together. For example, what are your program’s policies about lights and locks? What might be comfortable and safe for one person might feel restrictive or triggering for another - what can you do to find a balance?

Review rules, expectations, and consequences. Are they clearly displayed, stated, predictable and consistent?

Is there a plan for reducing and handling critical incidents? Is there routine debriefing?

Choice, Collaboration and Connection While participating in your program, what opportunities are there for youth to provide feedback, ask questions, or express their concerns?

What opportunities are there in your organization for staff to provide feedback?

When working with youth, do you encourage open communication; allow them the freedom to express their feelings without judging or censoring; provide choices in care and support whenever possible?

Strengths Based and Skill Building Can your program shift away from an emphasis on client deficits to one on strengths? E.g., Do you ask about people’s interests, goals, coping skills, survival strategies, spirituality, etc.?

How is education and support related to vicarious or secondary trauma provided within your organization?

Are there opportunities within your program delivery to focus on skill-building, e.g., self- regulation, awareness of triggers, coping skills?

61TRAUMA-INFORMED PRACTICE GUIDE FOR WORKING WITH CHILDREN, YOUTH AND FAMILIES

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