the time has come: integrating trauma‐informed prevention...

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UCLA Semel Institute for Neuroscience and Human Behavior

The Time Has Come: Integrating Trauma‐informed Prevention within

Systems of CarePatricia Lester, MD

Nathanson Family Professor of PsychiatryDirector, Division of Population Behavioral Health



UCLA

Division of Population Behavioral Health

Pritzker Center for Strengthening

Children and Families

Nathanson Family Resilience Center

UCLA TIES for Families

Child Anxiety, Resilience, Education & Support

Semel Institute for Neuroscience and Human

Behavior

Luskin School of Public Affairs

David Geffen School of Medicine

Graduate School of Education and Information Studies

Leadership & Policy

Professional DevelopmentEducation & Training

InnovativeTechnology

TranslationalResearch

Division of Population Behavioral Health

Population Behavioral Health & Wellness

Family Development Program

Prevention within Systems: A Population Behavioral Health Approach to Well Being

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RECREATION CHILD WELFARE

HEALTH CARE

MENTAL HEALTH

EDUCATION

COMMUNITY

SPIRITUALITY

FAMILY

INDIVIDUAL

Ecological Framework for Prevention:Engaging with System of Support


HEALTH CARE

MENTAL HEALTH

EDUCATION

COMMUNITY

SPIRITUALITY

FAMILY

INDIVIDUAL

Prevention Across a Continuum of Care: Opportunities to Support & Optimize Life Trajectories

Adapted from National Academy of Sciences, 2016

• Billions of dollars and decades of research have been invested in the development of practices, programs, guidelines, and interventions to affect individual‐level health‐related behavior and outcomes

• Benefits of preventive interventions to support positive developmental and well‐being outcomes in children and families has a strong research base, the translation of this evidence into practice has lagged far behind.

• Dissemination of existing EBP is low across most community and clinical settings, with research identifying a range of barriers to successful implementation.

(IOM 2009, Glasgow & Chambers, 2012; Kazdin & Blase, 2011; Rotheram‐Borus et al, 2012).

Translation Gap from Research to Practice: Preventive Intervention

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Common Elements Framework

Prevention researchers have increasingly proposed a paradigm shift is needed in how we apply, expand, and diffuse the evidence based of interventions.

“Common elements framework” is used to identify, coordinate and monitor the delivery of components from established EBP

• Focuses on professional training and development, • Supports a flexible approach to evidence informed delivery across

different settings and populations• Encourages tailoring informed by empirical evidence about

treatment efficacy and effectiveness, AND local evidence through the delivery process

(Chorpita & Daleiden, 2009; Becker et a, 2013, Mohr et al 2016)

Learning Community System: Using the “Adaptome” Model

Adaptome, a proposed set of approaches, processes, and infrastructure needed to advance the science of intervention adaptation and implementation

• Service Setting• Target Audience• Core Components• Mode of Delivery• Cultural Relevance

Chambers and Norton / Am J Prev Med 2016

PREVENTION PRACTICE LEARNING COMMUNITY

ADAPTOME DATA PLATFORM

INTERVENTION a

AdaptationCore

Components

INTERVENTION b

AdaptationCore

Components

INTERVENTION d

AdaptationCore

Components

INTERVENTION c

AdaptationCore

Components

Adaptome Data Commons

• Taxonomy of Adaptations• Core Components• Outcomes Data Capture• Contextual Factors• Analytic Strategies

Knowledge Development

• Science of Adaptation• Science of Implementation• Intervention Development• Designing for Evolution

EVIDENCE

INFLUENCE

ImprovedPractice

Delivery System

Chambers and Norton / Am J Prev Med 2016;51(4S2):S124–S131

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Trauma‐informed Service SystemsAdapted from National Child Traumatic Stress Network

• Recognize and respond to the impact of traumatic stress on those who have contact with the system

• Infuse and sustain trauma awareness, knowledge, and skills into organizational cultures, practices, and policies:

• Routinely screen for trauma exposure and related symptoms.

• Use evidence‐based, culturally responsive assessment and treatment for traumatic stress and associated mental health symptoms.

• Make resources available to clients and providers on trauma exposure, its impact, and treatment.

• Engage in efforts to strengthen resilience and protective processes

• Address parent and caregiver trauma and its impact on the family system.

• Emphasize continuity of care and collaboration across systems.

• Maintain an environment of care for staff that addresses secondary traumatic stress, and that increases staff wellness.

• Address the intersections of trauma with culture, history, race, gender, location, and language, acknowledge the compounding impact of structural inequity, and are responsive to the unique needs of diverse communities.

https://www.nctsn.org/resources/what‐trauma‐informed‐child‐and‐family‐service‐system

Informed by Resilience Processes to Elevate Life Course Trajectories

A shift from deficit to adaptive strength

Social Justice

Focus on the wins

Honoring and building

connections and belonging

Not just stabilizing or catching up

….flourishing

Applying the Adaptome Framework:Trauma‐ & Resilience‐Informed Approach to Prevention

Education Health Care Community Military Families

• Service Setting• Audience• Core Components

• Cultural Relevance• Mode of Delivery• Workforce Well‐being

Requires• Mapping & Monitoring Infrastructure for CQI• Learning System: Training & Technical Support

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HEALTH CARE

MENTAL HEALTH

EDUCATION

COMMUNITY

SPIRITUALITY

FAMILY

INDIVIDUAL

Ecological Framework for Prevention:Engaging with System of Support


HEALTH CARE

MENTAL HEALTH

EDUCATION SPIRITUALITY

FAMILY

COMMUNITY

INDIVIDUAL

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FOCUS is a trauma‐informed resilience‐building intervention adapted from this team’s evidence based preventive interventions for families facing adversity. It has been tailored for military families through a community participatory process.

FOCUS is delivered as a continuum of prevention services within military communities, including group, individual, family models, and through virtual and mobile platforms

FOCUS provides core resilience education and skills to help families, parents, youth, and couples:

• Understand the impact of transitions and challenges on families, including those facing physical or behavioral health injuries

• Identify, manage, and discuss emotions

• Develop problem‐solving and goal‐setting skills to enhance self‐efficacy

• Communicate effectively about the impact of transitions, deployments, trauma, and loss

• Strengthen couple/family relationships and functioning

• Enhance parenting and co‐parenting skills

FOCUS Resilience Model: Public Health Approach to Supporting Military Families in Transition

Implementation Science:

Public Health Prevention

Translating Research to Practice

Family Based Prevention

Science

Family Resilience Framework

Traumatic Stress and Developmental Systems

Research

FOCUS ResilienceEnhancing Intervention

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• Changes in social support and resources

• Community level stress

• Changes in family roles and routines

• Impact on children, parenting, and co‐parenting

• Concerns about safety and danger

• Anxiety and depression

• Geographic mobility

• Financial concerns

• Possible parental mental health problems, physical injury, or loss: caregiving burden for spouse

Audience: Starting with Military/Veteran Family Experiences, Voice & Research

• Well‐being of children and their families are inextricably linked

• Family members can play a significant role in enhancing or impeding the recovery of youth affected by trauma or adversity

• Families prefer family approaches over individual approaches for mental health care

• Cultural relevance of family readiness

MacDermid, Lester et al, 2013

Cultural Relevance of Family‐Centered Prevention for Military Families

• Family real time check‐up• Customizes services to family needs

• Family level education• PTSD, TBI, Injury education• Child Stress Reactions• Developmental guidance

• Individual and Family CBT Skill Building • Emotional Regulation, Communication, Goal Setting,

Problem Solving, Managing Trauma, Loss & Stress Reminders

• Family narrative timeline• Link skills to family (and child) experience• Develop shared family meaning• Bridge estrangements• Co‐parenting

FOCUS Core Elements(Lester et al, 2011; 2016; Saltzman, et al, 2011; Beardslee et al 2013)

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• Custom care delivery system for providers

• Assessment and clinical decision making tool from iPad

• Real‐time data analytics ensure programs are working

Embedded Screening Drives Personalized Delivery, Risk Screening & Stepped Care, & Continuous Quality Improvement

70%Program Completion

Mobile Platforms

Group‐level Briefings

Psychoeducation Workshops

Trauma‐informed Consultation

Skill‐building Groups

FOCUS Family Resilience Training

Mode of Delivery: FOCUS Core Elements as a Prevention Suite of ServicesLester et al, 2016; Beardslee et al 2011

FOCUS Impact on Family Psychological Health

• Children reported increased use of positive coping strategies in dealing with stressful events, including significant increases in problem solving (p = .0001) and emotional regulation on KidCope (p = .005).

• Children ages 6‐18 reported decreased anxiety symptom on MASC (p<0.01)

• Parents reported reductions in child conduct problems (p<.0001), Reductions in emotional symptoms (p=.001), such as anxiety and depressive symptoms, and improvements in child prosocial behaviors on SDQ (p=.01).

• Parents reported decreased levels of their own PTSD (PCL), depression (p<.01) and anxiety symptoms (BSI) (p=.002).

• Family functioning improved (problem solving, communication, roles, affective responsiveness, behavior control) on FAD (p < .0001).

Lester, Saltzman et al., “Evaluation of a Family Centered Prevention Intervention for Military Children and Families Facing Wartime Deployments.” Am J of Public Health, 2012.

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Families with Children: Child Adjustment over Time3,810 children ages 3‐18; 54% were boys

–1,426 (40.8%) Service Members and 2,073 (59.2%) Civilian Parents

Journal of the American Academy of Child & Adolescent Psychiatry 2016 55, 14‐24DOI: (10.1016/j.jaac.2015.10.009)

Parent Anxiety and Depression SymptomsOver Time

Couples Psychological Health (OSD)

Both service members and civilian spouse/partners showed statistically significant reductions in the prevalence of at‐risk levels of anxiety and depressive symptoms from Intake to Post Intervention.

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2019 FOCUS Site LocationsArizona

Marine Corps Air Station Yuma

California

Marine Corps Air Ground Combat Center

Twentynine Palms

Marine Corps Base Camp Pendleton

Naval Base Ventura County

Naval Base San Diego

Marine Corps Recruit Depot, San Diego

Naval Base Coronado

Marine Corps Logistics Base Barstow

Marine Corps Air Station Miramar

Florida

MacDill Air Force Base

Hawaii

Joint Base Pearl Harbor‐Hickam

Marine Corps Base Hawaii

Mississippi

Keesler Air Force Base

Naval Construction Battalion Center Gulfport

Stennis Space Center

New Mexico

Cannon Air Force Base

North Carolina

Marine Corps Base Camp Lejeune

Marine Corps Air Station Cherry Point

Marine Corps Air Station New River

South Carolina

Marine Corps Air Station Beaufort / Parris Island

Marine Corps Recruit Training Depot

Virginia

Marine Corps Base Quantico

Naval Station Norfolk

Joint Expeditionary Base Little Creek and Fort Story

Washington

Joint Base Lewis‐McChord

Naval Air Station Whidbey Island

Japan

Kadena Air Base

Marine Corps Base Okinawa

U.S. Army Garrison Torii Station

Marine Corps Air Station Iwakuni

• VTC Virtual Home visiting FOCUS early childhood‐ 6 session parenting coaching and dyadic model

• NICHD RO1 Randomized trial for Military Connected Families with young children – Virtual Home Visiting

(Mogil et al, 2014)

In Home Tele‐Behavioral Health Reaching Families Where They Live

FOCUS Early Childhood Tele‐HealthPreliminary Outcomes from a Randomized Trial

• Population Recruited: 199 children ages 3‐6194 mothers and 155 fathers

Primary caregivers in the FOCUS‐EC intervention reported relative to those in the control condition:

• Significantly greater improvements in self‐reported parent‐child relationships at 3, 6 and 12 months

• Significantly greater reductions in total parenting stress at 12 months

• Reductions in Parent PTSD symptoms from baseline to 6 months

• Mother‐child dyads in the intervention group were observed to have significantly greater improvements in parenting and parent‐child interactions among participants in the FOCUS‐EC intervention group relative to the control group.

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• Personalized delivery of high quality care management, scale and reach of care.

• Family‐centered care and prevention beyond traditional clinical settings.

• Research challenges in context of rapid innovations.

Leveraging Mobile Technology for Behavioral Health Continuum of Care

Setting and Audience: UCLA/VA Veteran Family Wellness Center

• Translating family and relationship‐centered care to the VA system

• Utilizing a wellness approach to engage Veterans and families

• Continuum of in person and tele‐wellness services and connection

• Academic‐VA‐Community Partnerships

Family Centered Resilience & Prevention

Screening Relationship Enhancement

CaregiversCouplesChildrenFamily

Health & WellnessMindfulness

YogaMeditation

Arts Programs

In‐Home Virtual

ResourcesCommunity Resources

UCLA/VAVeteran Family Wellness Center

Life‐SkillsParenting ClassesSchool Readiness

RecreationSports Programs to support

family and community connections

Family Peer Navigation

Community & VA Care

mHealth & WellnessMobile Apps

Web‐based Platforms

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HEALTH CARE

MENTAL HEALTH

EDUCATION

COMMUNITY

SPIRITUALITY

FAMILY

INDIVIDUAL

Ecological Framework for Prevention:Engaging with School Mental Health to Children & Families


HEALTH CARE

MENTAL HEALTH

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SPIRITUALITY

FAMILY

INDIVIDUALEDUCATION

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Research on Setting & Population: Traumatic experiences take a measurable toll on academic achievement

Decreased IQ and reading

ability

More suspensions, expulsions

Lower GPA Decreased high‐school graduation

rates

More days absent from

school

SOURCES (left to right): Delany‐Black et al., 2003; LAUSD survey, 2006; Hurt et al., 2001; Hurt et al., 2001; Grogger, 1997.

618,970 Students

80% Living in poverty

94 Languages spoken

157,619 English language learners

7,000+ Students in foster care18,000 Students homeless

Adaptation for Los Angeles Unified School District

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Universal screen of risk and protective

factors

Universal prevention curriculum

Targeted mental health screening

Tier 2 and Tier 3

evidence‐based

intervention

Resilience Check‐In FOCUS Resilience Curriculum

Wellness Check‐Up

Groups (CBITS)

A Population Health Approach Developed in Partnership with LAUSD

Trauma‐ & Resilience‐Informed School Community

School

Classroom

Family

Student

• Professional Development for teachers/staff (trauma & self‐care)

• FOCUS Resilience Curriculum, a skill‐building classroom curriculum

• FOCUS on Parenting groups

• Cognitive Behavioral Intervention for Trauma in Schools (CBITS)

• Individual counseling

• Data collection & management tool replaced paper screening

• School Mental Health Staff records interviews, assessments, and scores electronically

• Link to academic data and reporting

Interpretation, scoring, and management done in Real time‐managed by school team

Tracking student wellness across the District

Continuous Quality Improvement Requires Data Monitoring Infrastructure

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Brief universal survey of risk and resilience factors that assesses:

• Social skills

• Empathy

• Problem‐solving

• Self‐efficacy & Self‐awareness

• School safety

• Traumatic stress risk

• Help‐seeking behaviors

• School support

Resilience Check‐In

48% of Students were Found to be at Moderate/High Risk for PTSD (n=9196)

High risk for PTSD significantly associated with low GPAHigh Risk for PTSD significantly associated with low attendance

Adapting Core Components with LAUSD Partners: FOCUS Resilience Curriculum(Ijadi‐Maghsoodi et al, 2016)

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HEALTH CARE

MENTAL HEALTH

EDUCATION

COMMUNITY

SPIRITUALITY

FAMILY

INDIVIDUAL

Ecological Framework for Prevention:Engaging with Health Systems


MENTAL HEALTH

EDUCATION

COMMUNITY

SPIRITUALITY

FAMILY

INDIVIDUAL

HEALTH CARE

Trauma‐Informed Health Systems: Integrating WorkforceWell‐Being within Training & Practice

Addressing secondary trauma

Enhancing Wellness & Resilience

Attention to MoralDistress/Injury

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Mental Health Treatment

2 ‐ Resilience Training

3 ‐ Trained Peer Support

General Wellness Initiatives

1 ‐ Wellness App Connectd – A Self Care ToolA

mount of effort targeting

individuals at risk

General Education & Outreach:Preventative before an event

Evidence‐based Skilled Peer Support:Preventative

Professional Mental Health Services: Interventional after symptoms

Evidence‐based Education & Self Help:Preventative & Interventional

UCLA Professional Resilience Package

Brenda Bursch, PhD

Workforce Well‐Being: Trauma‐Informed Prevention Across the Health System

Self Assessment Anonymous screens for

anxiety, depression, trauma, burnout, alcohol use, and health behaviors

Track scores over time

Evidence‐based Education and Tools

Local Resources

“Connectd” –Adapted as UCLA Professional Wellness App

Scalable evidence‐based resilience skills training to mitigate against exposure to high stress and trauma: Reflective Narrative Timeline Emotion Regulation Communication with Angry Individuals Effective Boundary Management Depression, Anxiety, Trauma, Personal

Toolbox

Adapted from FOCUS program, found to be effective with military personnel and their families.

Addresses stigma with use of actual events.

Selective Prevention UCLA Resilience Training

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HEALTH CARE

MENTAL HEALTH

EDUCATION

COMMUNITY

SPIRITUALITY

FAMILY

INDIVIDUAL

Ecological Framework for Prevention:Training Center of Excellence with Los Angeles County


HEALTH CARE

EDUCATION

COMMUNITY

SPIRITUALITY

FAMILY

INDIVIDUAL

MENTAL HEALTH

Creating Learning Communities

Practice‐Based Adaptation &

Cultural Customization

Consultation & Coaching

Partnership & Collaboration

Continuous Quality Monitoring

Interactive Online Learning Platforms

Prevention Training Center of Excellence

DHS

DPH

School Districts

Libraries

Parks and Recreation

DCFS

Juvenile Justice

DPSS

Child Care Providers

DMH

Resource Centers

Early Education Centers

Prevention Training Center

Of Excellence

Trauma/Resilience Informed Care

Training

Core Principles of Trauma /Resilience‐Informed Care• Safety• Trust and transparency• Peer support• Collaboration and

mutuality• Voice, choice, and self

agency• Culturally, historically,

sexual identity, gender‐identity appropriate

• Dissemination of best practices

• Understanding the many systems that impact individuals & families

• Intra‐agency referrals

Creating a “Learning” Community System

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• Adapting EBI Core Components

• Community Partnered Participatory Processes

• Continuous Data Monitoring: Leverage Cloud Computing Technology and Real Time Screening

• A “Learning” Training Institute/On Line Hub: to support and sustain community practice

• Flexible Platforms: Utilization of Suite of Services along Public Health Continuum‐ Multiple Delivery Platforms

• Workforce Well‐being: Integrating professional development and management tools that address secondary stress & burnout.

• Engagement Strategies: Materials Development, Partnered Marketing, Community Training; Mobile Tools, Continuous feedback through implementation monitoring/partnered practicesHealthcare Professional Wellness

Program

School‐Based Resilience Curriculum

FOCUS for Military Families

Lessons Learned from Integrating Prevention into Systems of Care

Patricia Lester, MD

[email protected]://dpbh.ucla.edu

Foundational & Outcome Research for FOCUS ProgramLester P, Peterson K, Reeves J, et al. The long war and parental combat deployment: Effects on military children and at‐home spouses. Journal of the American Academy of Child and Adolescent Psychiatry. 2010;49(4): 310‐320.

Mogil C, Paley B, Doud B, …. Lester P. Families OverComing Under Stress (FOCUS) for early childhood: Building resilience for young children in high stress families. Journal of Zero to Three. 2010;31(1):10‐16.

Lester P, Mogil C, Saltzman W, et al. FOCUS (Families OverComing Under Stress): Implementing family‐centered prevention for military families facing wartime deployments and combat operational stress. Military Medicine. 2011; 176(1):19‐25.

Beardslee W, Lester P, Klosinski L, Saltzman W, Woodward K, Nash W, Mogil C, Koffman R, & Leskin G. Family‐centered preventive intervention for military families: Implications for implementation science. Prev Sci. 2011 Dec;12(4):339‐48.

Lester P, & Bursch B. The long war comes home: Mitigating risk and promoting resilience in military children and families. Psychiatric Times. 2011; 28(7).

Saltzman WR, Lester P, Beardslee WR, Layne C M, Nash WP. Mechanisms of risk and resilience in military families: Theoretical and empirical basis of a family‐focused resilience enhancement program. Clin Child Fam Psychol Rev. 2011 Sep; 14(3):213‐30.

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Foundational & Outcome Research for FOCUS ProgramLester P, Saltzman W, Woodward K, et al. Evaluation of a family‐centered prevention intervention for military children and families facing wartime deployments. Am J Public Health. 2012 Mar;102 Suppl 1:S48‐54. Epub 2011 Nov 28.

Lester P. War and military children and families: Translating prevention science into practice. J Am AcadChild Adolesc Psychiatry. 2012; 51(1):3‐5.

Green S, Nurius PS, Lester P. Spouse Psychological Well‐Being: A Keystone to Military Family Health. Journal of Human Behavior in the Social Environment. 2013; 23, (6): 753‐768.

MacDermid SW, Lester P, Marini C, Cozza S, Sornborger J, Strouse T, Beardslee W. Approaching Family‐Focused Systems of Care for Military and Veteran Families. Military Behavioral Health. 2013; 1, 1‐10.

Lester P, Stein J A, Saltzman W, Woodward K, MacDermid SW et al. Psychological health of military children: Longitudinal evaluation of a family‐centered prevention program to enhance family resilience. Military Medicine. 2013; 178 (8), 838‐845.

Foundational & Outcome Research for FOCUS ProgramLester P, Paley B, & Saltzman W. Military Service, War, and Families: Considerations for Child Development, Prevention and Intervention, and Public Health Policy. Clinical child and family psychology review.2013; 16(3), 229‐232.

Saltzman WR, Pynoos RS, Lester P, Layne CM, & Beardslee WR. Enhancing family resilience through family narrative co‐construction. Clinical Child and Family Psychology Review.2013; 16, (3), 294‐310.

Paley B, Lester P, & Mogil C. Family Systems and Ecological Perspectives on the Impact of Deployment on Military Families. Clinical Child and Family Psychology Review. 2013; 16 (3), 245‐265.

Lester P, Flake E. How Wartime Military Service Affects Children and Families. The Future of Children: Military Children and Families. 2013; 23(2), 121‐142.

Beardslee WR, Klosinski LE, Saltzman W, Mogil C, Pangelinan S, McKnight CP, & Lester P. Dissemination of Family‐Centered Prevention for Military and Veteran Families: Adaptations and Adoption within Community and Military Systems of Care. Clinical Child and Family Psychology Review. 2013;16 (4), 394‐409.

Garcia E, De Pedro K, Astor RA, Lester P, & Benbenishty R. FOCUS School‐Based Skill‐Building Groups: Training and Implementation. Journal of Social Work Education.2015: 51:sup1, S102‐S116.

Foundational & Outcome Research for FOCUS ProgramMogil C, Hajal N, Garcia E, Kiff C, Paley B, Milburn N, & Lester P. FOCUS for Early Childhood: A virtual home visiting program for military families with young children. Journal of Contemporary Family Therapy. 2015; 37(3), 199‐208.

Flittner O’Grady AE, MacDermid Wadsworth S, Willerton E, Cardin JF, Topp D, Mustillo S, & Lester P. (2015). Help seeking by parents in military families on behalf of their young children. Psychological services, 2015;12(3), 231.

Wadsworth SM, Cardin JF, Christ S, Willerton E, O'Grady AF, Topp D, ... & Mustillo S. Accumulation of Risk and Promotive Factors among Young Children in US Military Families. American journal of community psychology, 2016; 57(1‐2), 190‐202.

Lester P, Liang LJ, Milburn N, Mogil C, Woodward K, Nash W, ... & Beardslee W. Evaluation of a family‐centered preventive intervention for military families: Parent and child longitudinal outcomes. Journal of the American Academy of Child & Adolescent Psychiatry, 2016; 55(1), 14‐24.

Saltzman WR, Lester P, Milburn N, Woodward K, & Stein J. Pathways of Risk and Resilience: Impact of a Family Resilience Program on Active‐Duty Military Parents. Family Process. 2016; Dec 1;55(4):633‐46.

the time has come: integrating trauma‐informed prevention...

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