Juvenile Justice TF-CBT Learning Collaborative. Two Year Report (FY15-FY16)

Transcription

1 e Juvenile Justice TF-CBT Learning Collaborative Two Year Report (FY15-FY16) Mayte Restrepo, MA, MPH, Program Coordinator Heather Sapere, MA, Data Analyst Jason Lang, Ph.D., Director of Dissemination and Implementation Child Health and Development Institute of Connecticut With the contribution of The Consultation Center at Yale April 2017

2 2 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT Table of Contents Summary 3 Learning Collaborative Background. 6 Pre/Post Training Survey Outcomes... 9 Child Trauma Screen Implementation (CTS) Results. 12 Staff Perceptions about CTS Implementation. 17 Justice-Involved Youth in TF-CBT Services 18 Outcomes for Justice-Involved Youth in TF-CBT Services 21 Success, Limitations, and Recommendations 26 Appendixes

3 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 3 Summary CHDI in partnership with CSSD and a group of child trauma and juvenile justice experts conducted two cohorts of 10 months each of a Learning Collaborative in Juvenile Justice and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) from FY15 to FY16. The Learning Collaborative, pioneered by the National Child Traumatic Stress Network (NCTSN), is based upon the Breakthrough Series Collaborative model developed by the Institute for Healthcare Improvement. It focuses on a quality improvement methodology that promotes system-wide transformation and rapid adoption of evidence-based practices. TF-CBT is an evidence-based treatment that can mitigate the emotional and behavioral consequences of trauma exposure. The mission of this Collaborative was to support juvenile justice-involved youth to recover from exposure to trauma through improved identification, access to evidence-based treatment, and improved collaboration between juvenile justice and mental health providers. Nine juvenile court districts were involved in the Collaborative. In each court district teams formed with Juvenile Probation Officers (JPOs), staff from the Child Youth Family Support Center (CYFSC), and administrative and clinical staff from a TF-CBT agency. A total of 46 JPOs, 20 CYFSC staff, and 43 provider agency staff participated in this Collaborative. The present report is divided into four main sections. The first one is dedicated to the findings that The Consultation Center at Yale obtained from pre and post training surveys to assess the impact of the Collaborative in trauma-informed knowledge, agency practices and personal practice. Trauma-informed knowledge and practices increased significantly for both juvenile justice staff and TF-CBT providers in each cohort of the Learning Collaborative. The second section of the report presents an analysis of the data collected from more than 1600 justice-involved youth screened for trauma by JPOs and CYFSC staff using the Child Trauma Screen (CTS). This analysis offers demographic information about the youth who were Data show that 77% of the justice-involved youth screened reported being exposed to potentially traumatic events, while 48% of the youth reported experiencing two or more types of trauma. Females were exposed to potentially traumatic events at significantly higher rates than males (80% vs. 74%); in particular, females experienced higher exposure to sexual abuse than males (18% vs. 3%). 34% of the youth screened reported high levels of traumatic stress reactions Females reported high traumatic stress reactions at greater rates than males (47% vs. 24%) No significant differences in trauma exposure or trauma reactions were found by race and ethnicity. 26% of all youth screened were referred to trauma services, while 31% were referred to other mental health services. 104 youth were referred to TF-CBT services (13%)

4 4 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT screened, as well as the prevalence and magnitude of trauma exposure by racial/ethnicity and gender. The third section of the report looks at the TF-CBT treatment outcomes for justice-involved youth. From September 2014 through June 2016, 135 youth received TF-CBT services. These youth were primarily female (53%) of White and Hispanic origin (36% each), and between 16 and 18 years old (65%). Data show that Justice-involved youth in TF-CBT treatment experienced 8.4 potentially traumatic events on average at baseline. No differences were found in trauma exposure between youth from different racial/ethnic and gender backgrounds. 67% of these youth met likely PTSD criteria and 48% met criteria for likely depression. Females reported higher PTSD and depression symptoms than males. No differences were found in PTSD and depression symptoms at baseline in terms of race/ethnicity. Follow up assessments showed 42% overall reduction in PTSD symptoms, while 69% of the youth who had a PTSD diagnosis before treatment no longer met this criteria at follow up. Follow up assessments showed a 38% overall reduction in depression symptoms, while 58% of the youth who were diagnosed with depression before the treatment did not meet this criteria at follow up. 28% of justice-involved youth successfully completed TF-CBT treatment. Lastly, we conclude this report by describing the limitations and successes of this Learning Collaborative and present some recommendations for CSSD and TF-CBT providers. Some of the main achievements include: Implementation of the Child Trauma Screen in Juvenile Probation and the CYFSCs in all the court districts in the state Follow up of justice-involved youth in TF-CBT treatment. Significant change in trauma-informed knowledge and practice on the part of Juvenile Probation Officers, staff from the CYFSCs, and behavioral health providers. Significant improvements in collaboration between justice staff and behavioral health providers participating in the Collaboratives In terms of limitations, we observed that Advances in trauma-informed practice were not uniform for all the participants in the Learning Collaborative 4

5 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 5 Some behavioral health agencies experienced internal barriers to make changes to their provision of services and specifically with outreach to youth and their families in their role as outpatient providers and given the funding limitations of outpatient clinical services The number of justice-involved youth referred to trauma services and specifically to TF- CBT was modest. TF-CBT is not currently available or funded for in-home service, limiting outreach for difficult to engage families Engagement of justice-involved youth in outpatient TF-CBT was challenging for some providers Recommendations 1. Continue supporting trauma-informed efforts including trauma screening to identify the trauma exposure and needs of justice-involved youth 2. Continue to support access to trauma-focused behavioral health services for justiceinvolved youth (e.g. TF-CBT, TARGET, and/or others). Initial results from youth receiving TF-CBT indicate significant clinical improvements and high rates of remission of likely PTSD diagnosis among youth receiving treatment 3. Examine the impact of trauma screening and trauma-focused services on recidivism to better understand how to address trauma among justice-involved youth while maintaining an emphasis on reducing recidivism 4. Encourage JPOs and CYFSCs to continue their partnership with TF-CBT providers and to focus on strategies for working together to successfully engage youth in services through collaborative efforts 5. Consider investing in preventative approaches to delinquency and involvement with the judicial system for at-risk children/youth who have minimal or no involvement with the judicial system, but are at high risk for such involvement, including those who have high rates of trauma exposure

6 6 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT Learning Collaborative Background The Connecticut Department of Children and Families (DCF) has funded the TF-CBT Coordinating Goals of the JJ TF-CBT Learning Collaborative Center at the Child Health and Development Institute (CHDI) to support improved access to evidence-based trauma focused treatment for youth in Connecticut since In 2014, the Court Support Services Division (CSSD) partnered with 1 Increase understanding of how trauma impacts the behavior and decision making of youth involved with the juvenile justice system. DCF and CHDI, together with other experts in trauma and juvenile justice, to fund a two-year Improve the identification of youth 2 initiative to improve access to trauma-focused involved in the juvenile justice services for youth in the juvenile justice system. system that are suffering from trauma exposure and traumatic Using the Breakthrough Series Collaborative stress. structure and the Model for Improvement framework developed by the Institute for Healthcare Improvement and adapted by the NCTSN to disseminate evidence-based practices for children 3 Improve access to evidence based trauma focused treatment delivered with fidelity. exposed to trauma, TF-CBT was disseminated and implemented through a Learning Collaborative process that combined in-person trainings with continuous clinical consultation by TF-CBT experts and technical assistance by CHDI during the course of 10 months for each cohort. Teams formed by juvenile probation officers, staff from the Child Youth and Family Support Centers, behavioral health clinicians, and family partners were created in each of the court districts involved. Table 1 shows the number of participants in each court district. Each Collaborative year consisted of five days of in-person training (learning sessions), consultation calls between TF-CBT experts and clinicians, and technical assistance for the implementation of TF-CBT with justice-involved youth. CHDI also held site visits with the teams and conference calls with the faculty to coordinate learning sessions training content and provide closer support to the teams. Through this Collaborative, Juvenile justice staff were trained to administer the 10-item Child Trauma Screen (Lang & Connell, 2017) and mental health providers were trained to provide TF- CBT to youth involved in the justice system. TF-CBT is a component based treatment model that incorporates a baseline trauma assessment in addition to psychoeducation, relaxation techniques, affect expression and cognitive coping skills, trauma narration, in-vivo mastery of 6

7 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 7 trauma reminders, conjoint youth-caregiver sessions, and enhancing safety elements. Representatives from the two systems strengthen their partnerships by establishing common goals, strategies, and outcomes to assure that justice-involved youth engaged in trauma treatment. During the two learning collaboratives, 46 probation officers, 20 CYFSC staff, and 43 clinical provider staff from 8 agencies were trained. Table 1 shows additional detail about the staff trained and agencies/court districts represented. Year Court District JPOs CYFSC BH Agency Cohort I Cohort II New Britain New Haven Rockville Torrington Waterbury Willimantic Bridgeport Hartford Middletown Total 1 JPO Supervisor 4 JPOs 1 Clinical Coordinator 2 JPO Supervisors 2 JPOs 2 Clinical Coordinator 1 JPO Supervisor 3 JPOs 1 Clinical Coordinator 1 JPO Supervisor 2JPOs 1 Clinical Coordinator 2 JPO Supervisors 2 JPOs 1 Clinical Coordinator 1 JPO Supervisor 3 JPOs 1 Clinical Coordinator 1 JPO Supervisor 4 JPOs 1 JPO Supervisor 4 JPOs 2 JPO Supervisor 4 JPOs 12 JPOS Sup 28 JPOs 6 Clinical Coordinators 1 Program Director 1 Clinical Coordinator 1 Program Director 3 Clinical Coordinators 1 Clinical Coordinator 1 Clinical Coordinator 1 Program Director 1 Clinical Coordinator 1 Clinical Coordinator 1 Clinical Coordinator 1 Program Director 1 Clinical Coordinator 1 Program Director 1 Clinical Coordinator 1 Program Director 2 Clinical Coordinators Wheeler Clinic 1 Senior Leader 1 Coordinator/Sup 3 Clinicians Yale Child Study Center 1 Senior Leader 1 Coordinator/Sup 4 Clinicians CHR 1 Senior Leader 1 Coordinator 2 Clinicians CJR 1 Senior Leader 5 Clinicians CJR 2 Clinicians CHR 1 Senior Leader 1 Supervisor 2 Clinicians Child Family Guidance 1 Coordinator/Sup 3 Clinicians Wheeler Clinic 1 Senior Leader 1 Coordinator/Sup 2 Clinicians 1 Program Director Community Health Center 1 Senior Leader 1 Coordinator/Sup 4 Clinicians 9 Program Directors 11 Clinical Coordinators 7 Senior Leaders 9 Coordinators 27 Clinicians 46 Probation Staff 20 CYFSC Staff 43 TF-CBT Staff

8 8 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT Table 1. JJ TF-CBT Learning Collaborative Teams. Participants from both systems shared information about the services provided by each while attempting to increase understanding of each other s context, procedures, and language. This process was informed by the report and analysis of data related to the collaboration process and the identification-referral-treatment of youth who have experienced trauma events. 8

9 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 9 Learning Collaborative Outcomes 1. Trauma-Informed Expertise of Juvenile Justice Staff and Behavioral Health Clinicians Goal: Increase understanding of how trauma impacts the behavior and decision making of youth involved with the juvenile justice system. CHDI subcontracted with The Consultation Center at Yale to evaluate the impact of the Learning Collaborative by measuring participants reports about their knowledge of youth trauma, the trauma-informed policy of their agency, and the agency and personal trauma-informed practice before and at the end of each Collaborative year. Staff outcomes for cohort one have been presented previously. Here we present staff-level outcomes for cohort two participants including 17 juvenile justice staff and 12 behavioral health clinicians. Repeated Measures General Linear Modeling (GLM) was implemented to determine if there were significant changes over time by role for (1) Trauma Training and Education, and the Trauma Informed System of Care Instrument (TISCI) scales, (2) Agency Policy, (3) Agency Practice, and (4) Individual Practice. Pre/Post Training Survey Outcomes a. Trauma Training and Education measures the degree of trauma-focused training and education staff believed they received, including how trauma affects: the brain and body, developmental differences in children, attachment, internal and externalizing symptoms, cultural differences, and psychological safety. As presented in Figure 1.1 and 1.2, rates of exposure to trauma-related training and educational content increased significantly from pre-test to post-test for both JJ Court & CYFSC staff and BH provider participants. 1 At post-test both JJ Court & CYFSC staff and BH providers from both cohorts indicated their level of training and education to be higher than 4 demonstrating, on average, they felt they had quite a bit of trauma-focused training and education once the learning collaborative sessions were completed. 1 Cohort 1: (F= 6.37, p=.015); Cohort 2: (F= 20.71, p<.001)

10 10 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT Cohort 1. Trauma Knowledge: Training and Education Cohort 2. Trauma Knowledge: Training and Education Mean Score JJ Court & CYFSC staff BH Providers Mean Score JJ Court & CYFSC staff BH Providers 1 Pretest Posttest 1 Pretest Posttest Figure 1.1 Changes in Trauma Knowledge for Cohort 1 LC Figure 1.2 Changes in Trauma Knowledge for Cohort 2 LC Participants Participants Rating Scale: 1=None, 2=A Little, 3=Some, 4=Quite a Bit, 5=Extensive. b. Trauma Policy and Practice was measured using the Trauma Informed System of Care Instrument (TISCI). The TISCI is comprised of 18 items and has three subscales where staff rate their perceptions of Agency Policy, Agency Practice and Personal Practice in relation to trauma. Each of the three subscales is rated on a 5-point scale from 1-5. Subscale scores are determined by weighting each item within the subscale and computing in a way that presents each subscale as a percentage for interpretation. Agency Policy assesses whether the organization has policies, practices, or structures that support trauma-informed service delivery for children and families. Evaluation results indicate statistically significant improvements over time for both JJ Court & CYFSC staff and BH provider participants regarding the Agency Policy domain for both Learning Collaborative cohorts 2 (see Appendixes section for graphic representation). Agency Practice assesses whether the organization has adopted specific treatment methods or has resources available to support trauma-informed service care. Evaluation results demonstrated statistically significant improvements over time for both JJ Court & CYFSC staff and BH provider participants from both Learning Collaborative cohorts regarding the Agency Practice domain 3 (see Figures 1.3 and 1.4). A trend level effect was found for role where BH provider staff from both cohorts rated their agency practices more favorably with respect to trauma-informed care prior to beginning LC activities. 4 Additionally, findings from Cohort 2 2 Cohort 1: F= 16.04, p<.001; Cohort 2: F= 6.65, p= Cohort 1: F= 3.65, p<.065; Cohort 2: F= 15.24, p= Cohort 1: F=11.95, p=.002; Cohort 2: F= 3.75, p=

11 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 11 revealed that although JJ Court & CYFSC staff and BH staff saw an improvement over time, JJ Court & CYFSC staff showed a larger increase than BH staff. 5 Percentage Cohort 1: Change in Agency Practice JJ Court & CYFSC staff BH Providers Percentage Cohort 2: Change in Agency PracKce JJ Court & CYFSC staff BH Providers 0 Pretest Posttest 0 Pretest Pos3est Figure 1.3 Changes in Agency Practice for LC Cohort 1 Cohort 2 Participants Figure 1.4 Changes in Agency Practice for LC Participants Personal Practice assesses personal knowledge and practices related to addressing trauma for children on their caseload. Figures 1.5 and 1.6 present statistically significant improvement over time for both JJ Court & CYFSC staff and BH provider participants from both Learning Collaborative cohorts on their own personal practice. 6 Cohort 1: Changes in Individual Practice (TISCI) Cohort 2: Change in Individual Practice (TISCI) Percentage JJ Court & CYFSC staff BH Providers Percentage JJ Court & CYFSC staff BH Providers 0 Pretest Posttest 0 Pretest Posttest Figure 1.5. Changes in Individual Practice for LC Cohort 1 Figure 1.6. Changes in Individual Practice for LC Cohort 2 Participants Participants 5 F=5.04, p= Cohort 1: F= 25.26, p<.001; Cohort 2: F= 11.31, p=.003

12 12 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 2. Child Trauma Screen (CTS) Implementation Results GOAL: Improve the identification of youth involved in the juvenile justice system that are suffering from trauma exposure and traumatic stress The CTS was implemented in juvenile probation and the CYFSCs. The CTS screens for four types of trauma exposure: witnessing physical violence, experiencing physical violence, experiencing sexual abuse, and other types. It also assesses six empirically derived PTSD symptoms to determine level of distress related to trauma exposure. CSSD began implementing trauma screening of youth in the judicial system in The six CYFSCs involved in the Learning Collaborative that year screened youth with the CTS. During the second year of this initiative, the CYFSCs and Juvenile Courts in the Bridgeport, Hartford and Middletown court districts used the CTS to identify trauma needs of justice-involved youth and to refer to TF-CBT services. By May 2016, all Juvenile Probation Officers and CYFSCs started screening for trauma using the CTS; CHDI assisted CSSD with development of a protocol for trauma screening, including a train-the-trainer for judicial clinical staff to train others. Following administration of the CTS to youth, CYFSC staff and JPOs indicated what referrals were made for youth who were screened. The CTS measures, including referral information, were collected, analyzed, and reported by CHDI. Analysis of the data collected from the CTS administered between September 2014 and June 2016 shows: o 1627 youth involved in the juvenile justice system were screened for trauma o The majority of youth were screened by the CYFSC Clinical Coordinators (1450, 89%) o 58% of the youth screened were males o The majority of the youth screened (48%) were between 16 and 18 years old o White and Hispanic youth represent more than 70% of the youth screened for trauma (36% each). Figure 2.1 shows the percentage of youth screened for trauma by race/ethnicity and sex 12

13 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 13 Percentage of Youth Screened for Trauma by Race/Ethnicity & Sex (n=1463) 20% 21% 16% 13% 12% 15% Males Females 1.5% 1.50% White Black Hispanic Other Figure 2.1. Percentage of Justice-Involved Youth Screened for Trauma by Race/Ethnicity and Sex. Trauma Prevalence Seventy-seven percent of youth screened positive for trauma exposure, with 74% of males and 80% of females reporting that they experienced at least one potentially traumatic event. Overall, youth reported an average of 1.5 of the 4 traumatic events on the CTS, while 48% of the youth reported experiencing two or more types of trauma. Figure 2.2 shows the percentage of trauma exposure by race/ethnicity and sex. Differences in trauma exposure by race/ethnicity and sex were analyzed using a 2 (sex) by 4 (race) ANOVA. Results indicate that the differences between males and females for trauma exposure are statistically 7 significant, in which females report higher rates of trauma exposure than males. 8 No significant difference was found in terms of race/ethnicity in the rates of trauma exposure. The interaction effect between race and sex was also not significant. 7 F=4.76, p<.05 8 Females: (M = 1.6, SD = 1.2); Males:(M = 1.4, SD = 1.1).

14 14 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT Percentage of Justice-Involved Youth Experiencing Trauma by Race/Ethinicity and Sex (n=1463) 82% 79% 75% 75% 76% 76% 73% 86% Males Females White Black Hispanic Other Figure 2.2 Percentage of Justice-Involved Youth Experiencing Trauma by Race/Ethnicity and Sex Rates of trauma exposure to the four types of trauma on the CTS are shown in Table 2.1. More than half of the youth screened witnessed physical violence while a third had experienced it directly. Furthermore, nearly 1 in 10 youth experienced sexual abuse. A chi-square test was conducted to determine if there was an association between sex and race/ethnicity and the experience of each trauma type. Results show a significant association between sex and sexual abuse, 9 with females reporting higher rates of sexual abuse than males (18% vs 3%). Additionally, females report higher rates of other traumas than males. 10 There was no significant association between sex and witnessing violence or sex and experiencing violence. There was no significant association for any type of trauma and race/ethnicity. Witnessed Violence Experienced Violence Experience Sexual Abuse Experience Other Trauma White Males 55% 30% 3% 50% White Females 56% 32% 18% 60% Black Males 58% 34% 8% 50% Black Females Hispanic Males Hispanic Females 51% 28% 5% 44% 60% 33% 4% 46% 57% 41% 18% 61% 9 x 2 (1, n = 1591) = 106.6, p <.000, phi = x 2 (1, n = 1591) = 106.6, p <.000, phi =

15 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 15 Table 2.1 Percentages of Justice-Involved Youth Experiencing CTS Trauma Types Trauma Reactions The CTS includes six PTSD symptom items. A score of 6 or higher out of a maximum of 18 indicates a high likelihood of PTSD diagnosis and suggests the need for a more comprehensive trauma assessment or clinical services. o 34% of the youth screened scored 6 or higher (n=550) o 47% of females screened scored 6+ and 24% of males scored 6+ The percentages of youth scoring 6 or higher on the CTS by sex and race/ethnicity are shown in Figure 2.3. Differences in PTSD symptom scores by race and sex were analyzed 11 for those who scored six or higher. Results show that PTSD symptom scores did not vary by race/ethnicity, and that females had higher PTSD symptom scores than males. 12 The interaction effect between race and sex was also not significant. Justice-Involved Youth Needing Trauma Assessment by Race/ Ethnicity and Sex (N=1627) 47% 51% 23% 22% 24% 30% Males Females White African-American Hispanic Figure 2.3 Percentages of Justice-Involved Youth In Need of a Trauma-Assessment, as indicated by a score of 6+ on the CTS 11 Using a two-way between-groups ANOVA 12 There was a statistically significant main effect for sex, F (1, 474) = 15.4, p <.000, partial eta squared =.011, with females (M = 9.8, SD = 3.01) reporting significantly higher trauma reactions than males (M = 8.6, SD = 2.42).

16 16 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT Service Referral (n=1432) Referral information is based upon reports of CYFSC staff and JPOs who administered the CTS to youth and then indicated referral information on the CTS form. There was some variation in whether and how referral information was coded by staff, thus service referral information accuracy may vary (e.g. if a referral was made following submission of the CTS to CHDI, this would not be captured in the data). o 26% of all youth screened were referred to trauma services (n=375), of which 52% were males and 46% females. Race/Ethnicity & Sex Trauma Services Other MH Services All Youth 26% 31% 43% White Males 21% 28% 51% White Females 26% 38% 35% African American Males 32% 30% 38% African American Females 23% 32% 45% Hispanic Males 24% 30% 46% Hispanic Females 28% 35% 37% Table 2.2 Percentages of Justice-Involved Youth Referred to Mental Health Services No Referral o o o o o o o 13% of the youth screened were referred to TF-CBT services 16% of females and 10% of males screened were referred to TF-CBT. Hispanics overall tended to be referred to TF-CBT at relatively higher rates (29%) than any other group. White females and Hispanic females were referred to TF-CBT in higher proportions than any other group (16% each) Of the youth who scored 6 or higher, 14% were referred to TF-CBT, 21% to TARGET at the CYFSC, and 37% to other mental health services. These differences in race/ethnicity and sex in the rates of referrals to services do not account for the trauma exposure and symptom severity differences by race/ethnicity and sex. Although 41% of females reported symptoms indicating the need for a more comprehensive trauma assessment, only 26% of females were referred. In comparison, while 25% of males reported symptom levels that would indicate the need for a trauma assessment, 26% of males were referred. Although females scored much higher on trauma reactions than males on the CTS, the referral rate to trauma services was the same for both females and males (26%). Staff Perceptions about the CTS 16

17 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 17 Staff were asked to complete a series of questions about the feasibility and utility of the CTS following the first five times each staff person administered the CTS to youth. A total of 770 staff surveys were collected, and are summarized below. Staff responses indicate: o The CTS was helpful at identifying trauma experiences and trauma symptoms in more than 40% of the youth who were screened. o The CTS was useful at identifying the family s needs with 53% of youth screened. o The majority of juvenile justice staff considered the CTS very easy or easy to use. o Figure 2.4 shows staff reactions for the youth and caregiver screens. Staff Reactions N=770 Youth Caregiver 86% 80% 69% 70% 91% 91% 44% 43% 42% 42% 54% 53% Help Identify New Trauma Hx Help Identify New Trauma Symptoms Help Understand Needs Client Felt Comfortable Time was worth Very Easy and Easy to Administer Figure 2.4 Staff Feedback on CTS Helpfulness

18 18 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 3. TF-CBT Services to Justice-Involved Youth GOAL: Improve access to evidence based trauma focused treatment delivered with fidelity Children Served There were a total of 135 juvenile justice involved youth who received TF-CBT between September 2014 and June By the end of June 2016, there were 36 youth still receiving TF-CBT (27%) and 99 youth who had ended treatment (73%). See appendixes for a breakdown of children served and number of active cases by court district (Figure 3.1). Of the 135 children who received TF-CBT, 53% were female, 46% were male, and 1% was intersex. The majority of children identified as being either White or Hispanic (36% each). In addition, 8% were between the ages of 8-12, 27% were between the ages of 13-15, and 65% were between the ages of Figure 3.1 shows the breakdown of children receiving TF-CBT by race/sex. Percentage of Youth Served by Race/Sex N=135 25% 21% 20% 18% 17% 16% 15% 10% 10% 10% 6% 5% 2% 0% White Black Hispanic Other Males Females Figure 3.1. Percentage of Youth Served by Race/Sex 18

19 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 19 Baseline Trauma Exposure Types and frequency of exposure to potentially traumatic events are measured with the Trauma History Screen (THS) administered by the TF-CBT clinician. The THS is a more comprehensive assessment of trauma exposure, and includes 20 different types of potentially traumatic or stressful life events, and one open-ended question. Justice-involved youth reported an average of 8.4 traumatic events. The four most common traumatic events youth experienced are shown in Table 3.1. Type of Trauma Male Females Being separated from loved one 64% 70% Seeing someone use drugs 71% 68% Witnessing fighting 74% 84% Knowing someone who died 85% 87% Table 3.1 Main Types of Trauma Experienced By Youth Served Differences in baseline trauma exposure by race and sex were analyzed using a two-way between-groups ANOVA. Results show that there are no differences in trauma exposure by race/ethnicity or sex. 13 When asked on the THS what trauma bothers them the most, the top three potentially traumatic events that bothered youth the most were: Trauma Bothers the Most - Males Trauma Bothers the Most Females Knowing someone who died (26%) Being forced to see or do something sexual (27%) Being separated from a loved one (23%) Knowing someone who died (21%) Being physically hurt (9%) Being separated from a loved one (9%) Table 3.2. Main Types of Trauma Bothering Youth Served 13 The main effects for race, F (3, 126) = 1.19, p =.31, and sex, F (1, 126) =.01, p =.92, were not significant. The interaction effect between race and sex was also not significant, F (3, 126) =.92, p =.43.

20 20 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT Baseline PTSD and Depression Symptoms Baseline PTSD and depression symptoms were assessed through the use of the Child PTSD Symptom Scale (CPSS) and the Short Mood and Feelings Questionnaire (SMFQ). Justiceinvolved youth scored an average of 20.7 on the CPSS (N=129), while 67% of youth had a score of 16 or higher, indicating a likely diagnosis of PTSD. In terms of depression symptoms, justiceinvolved youth scored a 9.1 on average (N=128), while 48% of youth scored an 8 or higher, indicating depression symptoms. Figure 3.2 shows the breakdown of CPSS scores by sex and race. A two-way between groups ANOVA examining differences in PTSD symptoms at baseline by race and sex showed that females reported higher PTSD symptoms than males 14 and that there were no differences by race/ethnicity. 15 There was also no significant interaction between race and sex on baseline PTSD symptoms. 16 Similarly, females report higher depression symptoms at baseline than males. 17 No differences were found in depression symptoms at baseline between White, Black and Hispanic youth. 18 There was no significant interaction between race and sex on baseline depression symptoms. 19 Figure 3.3 shows the breakdown of SMFQ scores by sex and race. 14 There was a significant main effect for sex, F (1, 120) = 8.9, p =.003, partial eta squared =.07, such that females (M = 23.1, SD = 10.8) reported higher PTSD symptoms than males (M = 17.8, SD = 10.4). 15 F (3, 120) = 2.3, p = F (3, 120) = 1.19, p = There was a significant main effect for sex, F (1, 119) = 19.0, p =.000, partial eta squared =.138, such that females (M = 11.2, SD = 6.6) reported higher depression symptoms than males (M = 6.6, SD = 5.2). 18 White youth (M = 6.8, SD = 4.7); Black youth (M = 9.7, SD = 6.7) and Hispanic youth (M = 9.8, SD = 6.6) 19 F (3, 119) = 2.3, p =

21 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 21 Average Child CPSS Baseline Scores By Sex and Race White Black Hispanic Other N=48 N=26 N=43 N=11 Males Females 16+ Clinical Cutoff Figure 3.2. Average Child CPSS Baseline Scores by Sex and Race Average Child SMFQ Baseline Scores By Sex and Race White Black Hispanic Other N=48 N=25 N=25 N=11 Males Females 8+ Clinical Cutoff Figure 3.3. Average Child SMFQ Baseline Scores by Sex and Race Outcomes for Justice-Involved Youth in TF-CBT Services PTSD Symptoms Pre and Post Treatment To measure results from TF-CBT, CPSS scores from before and after treatment were analyzed for 54 youth who had both a baseline and at least one follow-up assessment. There was a

22 22 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT statistically significant decrease in CPSS scores from first assessment to follow-up assessment, 20 which was a 42% overall reduction in PTSD symptoms. Of the 36 youth who scored a 16 or higher on the CPSS at baseline, indicating a likely diagnosis of PTSD, 69% no longer met this criteria at follow-up assessment, suggesting a strong likelihood of remission of PTSD diagnosis following treatment. A reliable change analysis 21 indicated that 39% of youth showed reliable improvement, 18% showed partial improvement, and 43% showed no improvement from first assessment to followup assessment. Statistical analysis 22 showed no significant differences between White, Black and Hispanic youth on reliable change. 23 Other statistical tests conducted showed no significant differences in PTSD scores pre and post treatment between White, Black and Hispanic youth. 24 Figure 3.4 shows the mean CPSS scores at baseline and follow-up by sex group. Significant differences were found between females and males, such that females had significantly higher PTSD scores pre and post treatment than males, however both males and females showed similar improvements in symptoms from pre to post treatment First assessment (M = 19.9, SD = 10.9) compared to follow-up assessment (M = 11.5, SD = 9.9), t (52) = 5.78, p < Reliable change is measured by first calculating the difference between pre and post assessment scores to determine a change score. The change score is then compared to a Reliable Change Index (RCI) value; the change from pre to post assessment is considered reliable and not due to chance if it exceeds the RCI value. Reliable improvement is measured by a decrease of 11 or more points on the CPSS and a decrease of 7 or more points on the SMFQ from first assessment to follow-up assessment. 22 A one-way between-groups ANOVA 23 F (3, 49) = 2.52, p = A mixed between-within subjects ANOVA 25 Females (M = 22.9, SD = 10.3; M = 14, SD = 10.1) compared to males (M = 16.1, SD = 10.7; M = 8.3, SD = 8.7). 22

23 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT Average Pre/Post CPSS Scores by Sex Male Female Baseline Follow-Up Figure 3.4. Average Child CPSS Scores Pre and Post Treatment by Sex Depression Symptoms Pre and Post Treatment To measure results from TF-CBT, we looked at SMFQ scores before and after treatment for 54 youth who had both a baseline and a follow-up assessment. Analysis 26 showed that there was a statistically significant decrease in depression scores from first assessment to follow-up assessment, which was a 38% overall reduction in depression symptoms. Of the 26 youth who scored an 8 or higher on the SMFQ at baseline, indicating depressive symptoms, 58% no longer met this criteria at follow-up assessment. A reliable change analysis 27 indicated that 26% of youth showed reliable improvement, 16% showed partial improvement, and 58% showed no improvement from first assessment to followup assessment. There were no differences between White, Black and Hispanic youth in depression symptoms as baseline Paired-samples t-test. 27 Reliable change is measured by first calculating the difference between pre and post assessment scores to determine a change score. The change score is then compared to a Reliable Change Index (RCI) value; the change from pre to post assessment is considered reliable and not due to chance if it exceeds the RCI value. Reliable improvement is measured by a decrease of 11 or more points on the CPSS and a decrease of 7 or more points on the SMFQ from first assessment to follow-up assessment. 28 Results from a one-way between-groups ANOVA showed no statistically significant differences between race/ethnic groups, F (3, 50) = 1.78, p =.16

24 24 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT Other statistical tests conducted showed no significant differences in depression scores pre and post treatment between White, Black and Hispanic youth. 29 Figure 3.5 shows the mean SMFQ scores at baseline and follow-up by sex. Significant differences were found between females and males, such that females had significantly higher depression scores pre and post treatment than males. 30 Average Pre/Post SMFQ Scores by Sex Male Female Baseline Follow-Up Figure 3.5. Average Child SMFQ Scores Pre and Post Treatment by Sex Length of Stay and Discharge Status TF-CBT Sessions and Length of Stay (Closed Cases) The average length of stay for children who received TF-CBT was 4.9 months. Youth attended an average of 13 TF-CBT sessions. The number of sessions ranged from 1 to % of youth had 4 or more sessions. While the developers of the TF-CBT model suggest most youth can complete TF-CBT in 12 to 24 sessions, and the Connecticut average is between 17 and 22 sessions, 30% of juvenile justice involved youth had less than 4 sessions, indicating likely dropout from treatment. Figure 13 shows the breakdown of the percentage of youth by number of sessions for closed cases. Data also showed that on average, Other males stayed in TF-CBT treatment the longest (about 8 months). 29 A mixed between-within subjects ANOVA 30 Females (M = 10.2, SD = 6.3; M = 6.4, SD = 5.9) compared to males (M = 5.3, SD = 4.8; M = 3.3, SD = 3.5). 24

25 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 25 Statistical analysis showed no significant differences in terms of race/ethnicity or sex in the length of stay. 31 Figure 3.6 shows the average number of months youth stayed in TF-CBT by race and sex. Average Number of Months in TF-CBT Treatment by Race/Sex Months in TF-CBT Treatment White Black Hispanic Other N=35 N=21 N=36 N=6 Male Female Figure 3.6. Average Number of Months in TF-CBT Treatment by Race/Sex Discharge Status Of the 99 closed TF-CBT cases during the period: Discharge Reasons for JJ Youth in TF-CBT n=99 4% Completed Tx 28% successfully completed TF-CBT treatment. 10% 28% Referred to Other Services The remainder of the children ended TF-CBT for different reasons, such as the family moving out of the area or 31% 27% Family Moved/ Discontinued Only Trauma Assessment discontinuing treatment (29%), the child being referred for other services Other (27%), or other reasons. Figure Discharge Reasons for JJ Youth in TF-CBT There were no differences by race or sex in rates of treatment completion A two-way between groups ANOVA showed the main effects for race, F (3, 90) = 2.12, p =.10, and for sex, F (1, 90) =.42, p =.52, were not significant. The interaction effect between race and sex was also not significant, F (3, 90) =.33, p =.80.

26 26 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 4. Successes, Limitations and Recommendations There were several successes in the two years of the JJ TF-CBT Learning Collaborative but there were also barriers for achieving the proposed goals. One accomplishment we want to highlight is the establishment of a uniformed procedure for identifying trauma history and trauma reactions in youth who are in juvenile probation and youth referred to the CYFSC in all the court districts in the state. CSSD and CHDI worked together in the development of protocol for the administration of the Child Trauma Screen (CTS). JPOs and CYFSC staff involved in the Collaborative were trained in the administration of the CTS, and Court Clinical Coordinators were trained to train remaining staff. As a result, more than 1600 justice-involved youth were screened for trauma needs between September 2014 and June CHDI also generated a system for the collection and analysis of the CTS administered by juvenile justice staff. We have built capacity to provide reliable data on the main types of trauma events and the number of trauma types experienced by justice-involved youth, as well as their trauma symptom level. CHDI has also implemented a system for the collection and analysis of TF-CBT outcomes. Clinicians who participated in this Learning Collaborative used the EBP-Tracker system to enter individual case data for youth in TF-CBT services that was later analyzed to present reports on treatment outcomes. By the end of June 2016, there were 135 youth involved in the justice system that had been participating in TF-CBT. Although this number is lower than the proposal goal of 200 youth in two years, we are seeing that those youth who stay in services for at least three months improve in terms of PTSD symptoms. Sixty-nine percent of youth who met criteria for PTSD at the beginning of treatment, no longer did at their last assessment. One more achievement of the Learning Collaborative is related to participants change in trauma-informed knowledge and practice. Data from the pre and post training survey demonstrate juvenile probation officers, CYFSC staff, and TF-CBT providers that participated in the Learning Collaborative showed significant increases in their trauma-informed knowledge and improvements in their trauma-informed practices. Similar results were found in both cohorts. Results from the focus groups conducted at the end of the first year show that participants found improved collaboration between juvenile justice staff and mental health providers as a result of 32 The results of the chi-square test indicated no significant association between race and treatment completion, x 2 (3, n = 98) = 1.1, p =.77, phi =.107. There was also no significant association between sex and treatment completion, x 2 (1, n = 98) = 1.7, p =.19, phi =

27 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 27 the Collaborative. Participants reported better communication, more knowledge about each other s systems, and more relationship building, which all have a positive impact in the referral process. Limitations Although overall Collaborative participants experienced an increase in the level of collaboration between the systems, some agencies and their local judicial staff struggled to do so. A common challenge was related to the limitations of outpatient providers to do outreach and in-home service/home visits that may be beneficial to some of the more difficult to engage justiceinvolved youth. Another limitation was the number of youth being referred to trauma-focused servies. By the end of June 2016, only 126 youth in the justice system had received TF-CBT services. Considering that more than 1600 youth were screened and 67% were determined to have significant levels of PTSD symptoms to warrant further clinical assessment or treatment, we find it important to continue examining the reasons why more youth are not being referred for traumafocused services (or being connected with services if they are referred). One potential explanation relates to the lack of in-home trauma treatments. Currently, reimbursable trauma treatments are only available at out patient behavioral health agencies. At the same time, there are in-home treatments available to justice-involved youth that have been proved to reduce recidivism such as Multi-Systemic Therapy (MST) and Intensive In-Home Child and Adolescent Psychiatric Services (IICAPS), even though they do not focus on youth trauma. Further exploration of the role of multiple services and what is most effective for complex youth who may have trauma and other mental health needs is recommended. Engagement of justice-involved youth in TF-CBT services was a challenge that the behavioral health providers often experienced. Clinicians link the lack of engagement in treatment to not only concrete barriers such as transportation and time, but also barriers due to past experiences with the system, stigma, and lack of family support. In addition, clinicians point out that a great proportion of the youth referred to TF-CBT are youth who have experienced a multitude of problems, in addition to the mental health reason for referral. This fact makes it much more challenging to provide effective trauma treatment, especially when there is not support for case management with current reimbursement systems. Recommendations for CSSD

28 28 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 1. Continue supporting trauma-informed efforts including trauma screening to identify the trauma exposure and needs of justice-involved youth 2. Continue to support access to trauma-focused behavioral health services for justiceinvolved youth (e.g. TF-CBT, TARGET, and/or others). Initial results from youth receiving TF-CBT indicate significant clinical improvements and high rates of remission of likely PTSD diagnosis among youth receiving treatment. 3. Encourage JPOs and CYFSC staff to refer youth to TF-CBT or other trauma-focused services when indicated 4. Explore opportunities for better integration or coordination of trauma-focused treatments with more intensive in-home services, including evaluation of what works best for whom through integrated data analysis and evaluation across systems and programs 5. Provide opportunities for clinical providers of trauma-focused services to work closely with judicial staff around the needs of justice-involved youth and to understand the judicial system; opportunities for cross-training and cross-system case discussion are recommended to support ongoing collaboration that was often developed in the Collaboratives 6. Examine the impact of trauma screening and trauma-focused services on recidivism to better understand how to address trauma among justice-involved youth while maintaining an emphasis on reducing recidivism. For example, a better understanding of the interaction between trauma, mental health services, delinquent behaviors, and recidivism and how to determine which interventions will be most effective for whom, could inform guidelines about service recommendations. 7. Encourage JPOs and CYFSCs to continue their partnership with TF-CBT providers and to focus on strategies for working together to successfully engage youth in services. 8. Consider investing in preventative approaches to delinquency and involvement with the judicial system for at-risk children/youth who have minimal or no involvement with the judicial system, but are at high risk for such involvement, including those who have high rates of trauma exposure. 28

29 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT Appendixes Staff Outcomes Cohort 1: Change in Agency Policy Percentage JJ Court & CYFSC staff BH Providers 0 Pretest Posttest Figure 5.1. Changes in Agency Policy for LC Cohort 1 Participants Cohort 2: Change in Agency Policy Percentage JJ Court & CYFSC staff BH Providers 0 Pretest Posttest Figure 5.2. Changes in Agency Policy for LC Cohort 2 Participants

30 30 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT Child Trauma Screen (CTS) Implementation Results Justice-Involved Youth Screened for Trauma N=1627 Juv. Probation CYFSC Figure 5.3. Total Number of Justice-Involved Youth Screened for Trauma by Court District Trauma Exposure Among Justice-Involved Youth (N=1627) 26% 18% 4% 23% 29% No trauma 1 Trauma Type 2 Trauma Types 3 Trauma Types 4 Trauma Types Figure 5.4. Magnitude of Trauma Exposure Among Justice-Involved Youth 30

31 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 31 Type of Trauma Exposure Among Justice-Involved Youth (n=1619) 60% 40% 20% 57% 33% 9% 53% 0% Witness Physical Violence Experience Physical Violence Experience Sexual Abuse Other Figure 5.5. Type of Trauma Exposure Among Justice-Involved Youth Percentage of Justice-Involved Youth Experiencing Other Types of Trauma (n=660) 54.5% 12.4% 10.6% 2.0% 20.0% Figure 5.6. Percentage of Justice-Involved Youth Experiencing Other Types of Trauma

32 32 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT Percentage of Trauma Types Experienced by Males (n=944) Percentage of Trauma Types Experienced by Females (n=683) 17% 1% 25% No trauma 1 Trauma Type 19% 8% 20% No Trauma 1 Trauma Type 26% 31% 2 Trauma Types 3 Trauma Types 4 Trauma Types 25% 28% 2 Trauma Types 3 Trauma Types 4 Trauma Types Figure 5.7. Trauma Types Experienced By Males by Females Figure 5.8. Trauma Types Experienced Referrals to TF-CBT Services by Race/Ethnicity and Sex (n=104) 20% 15% 10% 5% 7% 16% 10% 5% 13% 16% Males Females 0% White African American Hispanic Figure 5.9. Percentage of Youth Referred to TF-CBT By Race/Ethnicity and Sex 32

33 JJ TF-CBT LEARNING COLLABORATIVE TWO YEAR REPORT 33 TF-CBT Services to Justice-Involved Youth Total Number of Closed and Active Cases by Court District Sept 2014-June Active Cases as of June 30 Closed Cases as of June 30 Figure 5.10 Total Number of Children Served and Number of Active Cases by Court District