trauma-informed systems of care for youth and their families. fit best within the context of juvenile justice diversion.

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This publication was produced by the National Center for Mental Health and Juvenile Justice at Policy Research Associates, Inc., and the Technical Assistance Collaborative, Inc., as a part of the 2014-15 Policy Academy-Action Network Initiative. This effort was sponsored by the John D. and Catherine T. MacArthur Foundation and the Substance Abuse and Mental Health Services Administration. Strengthening Our Future: Key Elements to Developing a Trauma- Informed Juvenile Justice Diversion Program for Youth with Behavioral Health Conditions

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ACKNOWLEDGEMENTSProject StaffOlivia Allen Project Assistant | National Center for Mental Health and Juvenile JusticeJoseph CocozzaDirector | National Center for Mental Health and Juvenile JusticeAaron HillProject Assistant | National Center for Mental Health and Juvenile JusticeKarli KeatorDivision Director | National Center for Mental Health and Juvenile JusticeJohn MorrisIndependent Consultant | Technical Assistance Collaborative, Inc. Travis Parker Senior Project Associate | National Center for Mental Health and Juvenile JusticeProject ConsultantsChristopher BransonAssistant Professor of Child and Adolescent Psychiatry | New York University School of Medicine Keith CruiseAssociate Professor and Associate Chair for Undergraduate Studies at Rose Hill | Fordham UniversityJulian FordProfessor, Department of Psychiatry | University of Connecticut HealthFred MeserveyIndependent Consultant | National Center for Mental Health and Juvenile Justice, Policy Research Associates SAMHSA RepresentativesRebecca FlatowLead Public Health Analyst | Substance Abuse and Mental Health Services Administration Larke Huang and Mental Health Services Administration State Delegation ContributorsSirrilla Blackmon, Deputy Director | FSSA Division of Mental Health and Addiction, Indiana; Bettina Borders, First Justice | Lindsay Chretien, Parent Coordinator |Massachusetts; Ursula Davis, System of Care Director | Georgia Division of Family and Children™s Services; Edward Dolan, Commissioner | Massachusetts Probation Service; Christine Doyle, | Georgia Department of Juvenile Justice; Terrence Flynn , Regional Director for the Southern Region | Massachusetts Department of Children and Families; Adolphus Graves, | Fulton County Juvenile Court, Georgia; Craig Hargrow, Director of the Juvenile Justice Division | Tennessee Commission on Children and Youth; Lisa Mantz, Associate Judge | Newton County Juvenile Court, Georgia; Debra Pinals, Assistant Commissioner of Forensic Services | Massachusetts Department of Mental Health; Kevin Riley, Assistant Deputy Chief | Marion Superior Court Juvenile Probation, Indiana; Joshua Sprunger, | NAMI Indiana; Susan Steckel, | Tennessee Department of Mental Health and Substance Abuse Services; Altha Stewart, | Just Care Family Network, Tennessee; Keri Virgo , Project Director | Jenny Young , Juvenile Justice Advocate | Marion Superior Court Juvenile Probation, Tennessee ©2016

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CONTENTSIntroduction ..1An Integrated Policy AcademyŒAction Network Initiative ..1Background ..3Issue and Scope . 3Reducing Disparities .. 4Psychological Trauma and Its Effects .5Understanding Post-traumatic Stress 5Key Links Between Exposure to Traumatic Events and Trauma-related Disorders 5Avoid Exacerbating Trauma-related disorders 8SAMHSA™s Concept of Trauma and Guidance for a Trauma-Informed Approach .9Outcomes 12Systems 12Youth/Family/Community 13Implementation Domains ..14Leadership .. 15Identify Champion(s) 15Cross-System NetworkingŠLinking Leaders 16Policy and Procedures 18Policy 18M.O.U.s 19Legislation 20Environment .. 22Physical 22Communication 22Safety 23Engagement and Involvement 24Youth Voice 24Family and Non-Traditional 25Community 27Cross Sector Collaboration . 29Information/Data Sharing 29Intervention Continuum . 32Prevention 33Screening 34Assessment 35Treatment 36

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Continuing Supports 37Funding Strategies 39Workforce Development . 40Increasing Staff Understanding of Child Trauma 40Skills for Working with Trauma Survivors 42Preventing Vicarious Trauma 45Self-Care 46Organization Steps 47Building and Supporting Staff Resilience 47Quality Assurance and Evaluation ..51Progress Monitoring 51Fidelity 51Outcomes 51References .54

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1INTRODUCTIONThe majority of youth in contact with the juvenile justice system in this country have a diagnosable behavioral health condition (Shufelt & Cocozza, 2006; Teplin et al., 2013; Wasserman, McReynolds, Schwalbe, Keating, & Jones, 2010). In addition, approximately 60 percent of youth in contact with the juvenile justice system and diagnosed with a mental illness or substance use disorder have both (Shufelt & Cocozza, 2006; Wasserman, McReynolds, Schwalbe, Keating, & Jones, 2010). Many youth end up in the juvenile justice system, not because of the seriousness of their crime but because appropriate community-based treatments and services to have not been recognized, or the relevant service systems are not coordinating effectively. Given the complexity of their needs and the documented inadequacies of their care within the juvenile justice system, there is a growing sentiment that, whenever safe and feasible, youth with behavioral health conditions should be diverted as early as possible to effective community-based treatments and services (Skowyra & Cocozza, 2006). To effectively identify and respond to youth with behavioral health conditions in contact with the juvenile justice system, states must adopt a specialized approach that integrates a wide array of service agencies and court processes, coordinates mental health and substance use services and supports, emphasizes early intervention, and uses evidence-based programs and practices to treat the complex needs of these youth.For many youth, this means employing a trauma-informed approach to care. According to a recent national survey on children™s exposure to violence, approximately two out of every three children will be exposed to violence, crime, or abuse in their homes, schools, and communities (Finkelhor, Turner, Ormrod, Hamby, & Kracke, 2009). These already to violence among children in juvenile justice settings where more than 75 percent of youth have experienced traumatic victimization (Abram et al, 2004; Ford, Chapman, Connor, & Cruise, 2012). These high rates of trauma have far-reaching and severe consequences. Children exposed to violence settings and to engage in delinquent behaviors that may lead to contact with the juvenile and criminal justice systems (Felitti et al., 1998; Ford, Chapman, Connor, & Cruise, 2012). An Integrated Policy AcademyŒAction Network InitiativeThis initiative, coordinated by the National Center for Mental Health and Juvenile Justice (NCMHJJ) and the Technical Assistance Collaborative (TAC), was jointly funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the John D. and Catherine T. MacArthur JUVENILE JUSTICEmental disorder substance use disordertraumatic-event exposure20%8%25%70%46.2%90%GENERAL POPULATIONPrevalence of Mental and Substance Use Disorders and Traumatic-event exposure among Youth in the Juvenile Justice System

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3to enhance public safety. This report provides strategies for embedding trauma-informed approaches into diversion policies and practices.Issue and ScopeThe juvenile justice system and its component parts are faced with seemingly dichotomous and sometimes competing goals: (1) ensuring public safety from adolescents who have committed delinquent acts, and (2) promoting the rehabilitation, positive development, and well-being of those same adolescents so that they can become productive adult citizens. On the one hand, this requires careful and appropriate supervision that is commensurate with offense severity and with the ongoing risk the young people who have committed delinquent acts pose to their communities and to themselves. On the other hand, effective rehabilitation requires a behavioral care environment that responds to those factors that contribute to such offenses. These factors may include physical illnesses and disabilities, family relational problems, dangerous community environments, and mental and substance use disorders. In addition, a growing body of research is now documenting the prevalence of trauma-related disorders among adolescents presenting to juvenile justice systems and how traumatic experiences can compound and worsen mental and substance use disorders. The resulting behavioral manifestations of traumatic stress are frequently daunting and oppositional, exhibiting with behaviors that appear intractable.More than two-thirds of children will experience one or more traumatic events by the time they reach age 16 (Copeland, Keeler, Angold, & Costello, 2007). Intentional traumatic- event exposures include sexual and physical abuse, rape, exposure to domestic violence, victimization by bullying and violence in schools and community settings, and being a witness to violent crimes and death. Exposures also include unintentional or circumstantial traumas such as the sudden death of a parent or family member, an automobile or other serious accident, life threatening illnesses or injuries, or a separation from a parent caused by family breakup or imprisonment. Many persons who experience a traumatic event will manifest acute reactions to the trauma BACKGROUNDEmbedding change into systems of care requires an environment that is open to new strategies for ensuring public safety and enriching youth potential through effective rehabilitation and the enhancement of overall system accountability. The juvenile justice system has evolved into a system that is ready to adopt a trauma-informed system of care (see The Fourth Wave: Juvenile Justice Reforms for the Twenty-First Century ).of incarceration placed on their budgets and how these burgeoning costs compromised their ability to meet other brain development revealed that adolescents are different from adults. Full maturation is not reached until well into one™s 20s. As a consequence, adolescents are less culpable for delinquent acts than adults, and juvenile justice systems have moved away from the fiadult time for adult crimefl model to one that treats the offender as an individual and creates an effective balance among the goals of rehabilitation, personal accountability, and the assurance of public safety. Given this context, now is an opportune time to consider applying the emerging science surrounding trauma to the juvenile justice system. Youth involved in the juvenile justice system are disproportionally exposed to traumatic events compared to the general adolescent population. Among youth in the juvenile justice system, prior traumatic-event exposure is associated with higher rates of mental and substance use disorders, academic problems, suicide attempts, and premature death. Trauma experts have argued that trauma survivors frequently cope with traumatic stress in ways that increase their risk of arrest (DeHart & Moran, 2015; Ford, Chapman, Mack, & Pearson, 2006; Kerig, Becker, & Egan, 2010). Most relevant to justice system professionals, traumatic-event exposure is linked to harsher legal outcomes for adolescents (Baglivio et al., Baskin & Sommers, 2013; Cauffman, Monahan, & Thomas, 2015; Chauhan, Reppucci, & Turkheimer, 2009; Levenson & Socia, 2015; Li, Chu, Goh, Ng, & Zeng, 2015).In some jurisdictions, trauma-informed approaches are already being employed to improve youth outcomes and

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4and yet will heal and recover without lasting negative life impairments. Other people may develop long-term disorders because fitraumatic experiences complicate a child™s or an adult™s capacity to make sense of their lives and to create meaningful relationships in their families and communitiesfl (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014, p. 5).Several studies have found that youth entering the justice system have disproportionately high ratesŠbetween 50 and 75 percentŠof diagnosable mental disorders (Cocozza, Trupin & Teodosio, 2003; Teplin et al., 2013). The traumatic experiences of these youth frequently contribute to the development of behavioral health conditions or exacerbate and intensify the symptoms of these disorders. Post-Traumatic Stress Disorder (PTSD) occurs considerably more often among youth in juvenile justice settings than among youth in the general population (Cruise & Ford, 2011). Approximately 90 percent of youth in juvenile detention facilities report a history of exposure to at least one potentially traumatic event (Ford, Grasso, Hawke, & Chapman, 2012; Teplin et al., 2013). The majority of youth presenting at probation intake will suffer from a mental or substance use disorder, and the vast majority will have experienced at least one traumatic event. In many cases, these traumatic events will interact with mental and substance use disorders to intensify behavioral reactions. Experts advise that trauma-informed care environments more effectively respond to trauma-related disorders and lead to more effective treatments for related mental and substance use disorders. By more effectively others in the justice system can expect youth to experience increased levels of success with diversion services and more fully comply with dispositional requirements. Better life outcomes should also be realized.Reducing DisparitiesWhile trauma can affect anyone, certain groups appear to be at higher risk. For youth, many of the higher risk groups are the same as those at higher risk for contact with the juvenile justice system. Understanding traumatic stress in the context of this related elevated risk will lead to more effective care and better outcomes, including increased community

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5safety, reduced recidivism, more effective rehabilitation, and increased productivity as adults. Among other populations, certain ethno-racial groups (e.g., African-American, Latino- Americans, and Native Americans), LGBTQ (Lesbian, Gay, Bisexual, Transgendered, and Questioning) youth, and youth living in poverty are all at higher risk of contact with the juvenile justice system and exposure to trauma. Taking into account the ethno-cultural, lifestyle, and life circumstances of such groups is important to guiding effective diversion efforts. Psychological Trauma and Its EffectsUnderstanding Post-traumatic StressSimply put, trauma refers to an external event that is extremely stressful for an individual. For some, potentially traumatizing events may lead to temporary acute reactions with no resultant longer-term disorders. Trauma-related disorders arise due to an individual™s internalization processes (i.e., how he or she interprets the potentially traumatic event) intertwined with brain chemistry and brain development factors. For example, some abused children experience long-term life impairments. Other children may lose trust in adults, resulting in attachment disorders and leading to depression, withdrawal, or actively resistant and oppositional behavior. It appears that trauma-related disorders arise from a combination of one™s biological and psychological makeup, family and peer relationships, other environmental factors, and exposure to traumatic events. Preexisting factors make some more vulnerable to processing potentially traumatic events in a negative way. These factors can include mental and substance use disorders and experience with prior traumatic events (Cruise & Ford, 2011). PTSD is the most commonly known and studied psychological disorder associated with exposure to traumatic events; however, there is emerging research to indicate that prolonged exposure to traumatic events and exposure to several different types of events can lead to a phenomenon known as complex trauma. Complex trauma reactions lead to severe disruptions in a young person™s psychosocial development that affect his or her ability to self-regulate stressful situations and to form essential attachment bonds with family members and other adults (Ford et al., 2012). This can lead to severe depression, somatic complaints, and problems with anger, aggression, and other outwardly inappropriate behaviors.In summary, traumatic stress resulting from an external event or events that are internalized may lead to wide-ranging behavioral manifestations. For adolescents, these behavioral manifestations can include anger, aggression, alterations in developmental maturation, suicide risk, substance use problems, moodiness, and withdrawal.Key Links between Exposure to Traumatic Events and Trauma-related DisordersSeveral factors can affect the intensity, duration, and overall severity of an adolescent’s reactions to trauma. Four are Preexisting risk factors. Studies have reported that some children will be vulnerable to more negative functioning following exposure to traumatic events based on preexisting risk factors. Children who function at a higher level prior to experiencing a traumatic event will have significantly lower levels of depression following a traumatic event (Goslin, Stover, Berkowitz, & Marans, 2013). Children with higher levels of self-esteem who can more effectively self-regulate stressful events are less likely to display long-lasting trauma-related disorders. It has also been reported that supportive families can significantly mitigate the effects of potentially traumatic events (Goslin, et al., 2013; Kiser, Medoff, & Black, 2010). Regular family routines that are interpreted by a youth as supportive, such as eating dinner together, can help reduce the effects of external stressors. In a review of 543 articles of longitudinal studies of post-traumatic stress, DiGangi and colleagues (2013) found six pre-trauma predictors of PTSD: (1) lower cognitive abilities, (2) general negative cognitive bias when coping

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6with difficult life circumstances, (3) preexisting personality disorders (e.g., neuroticism, negative affect, and hostility), (4) psychopathology, (5) psychophysiological factors (especially arousal-related factors), and (6) socio-ecological factors (e.g., poverty, work and school stress, home-related stresses). While much more research needs to be completed on preexisting risk, it seems clear that a traumatic event by itself will not always lead to PTSD and other trauma-related disorders.Single vs. multiple traumas. As suggested above, traumatic stress does not affect every person equally. An accident causing serious physical injury may lead to PTSD or another trauma reaction, but with strong medical, emotional, and family support the prognosis for healing and recovering from the traumatic event is positive. On the other hand, multiple traumatic events are more likely to lead to longer-lasting traumatic stress coupled with impaired psychosocial functioning and developmental deficits. Healing and recovery may require longer and more intensive treatment in trauma-informed care environments.It appears that trauma-related disorders arise from a combination of one™s biological and psychological makeup, family and peer relationships, other environmental factors, events.Chronic exposure to trauma. Persons who are chronically exposed to traumatic events or who are polyvictims (i.e., victims of multiple traumas of varying types) are more likely to develop complex trauma-related disorders. For example, children who are chronic victims of physical, sexual, or emotional abuse are more likely to experience complex trauma disorders. Their prognosis for healing and recovery is likely to be more negative, and they will need comprehensive trauma-informed care provided by skilled professionals. Similarly, youth who are victims of multiple types of traumatic events are at higher risk for complex trauma. These events can include loss of a parent to death or imprisonment; abuse; bullying; rape; and exposure to family, community, and school violence. The compounding of chronic exposure to traumatic events with preexisting risk can lead to debilitating complex trauma reactions.Intentional vs. unintentional victimization. There are likely differing reactions to unintentional or non- interpersonal traumatic events than from intentional or interpersonal events (Bennet, Kerig, Chaplo, McGee, & Baucom, 2014). For example, an accident or severe illness leading to a disabling condition will be less likely to lead to reactions such as emotional numbing or aggression than interpersonal traumas such as rape or abuse. Unintentional victimization is less likely to violate trust relationships and to create deficits in attachments with family members than intentional abuse. As such, while both may require trauma-informed care, the nature, intensity, and duration of that care will likely be different. Trauma-related disorders may lead to a wide variety of behavioral and clinical manifestations. It should be remembered that reactions will differ by individual. The above factors will contribute to those differential reactions, as well. For example, there may be differences between genders, ethno-cultural and racial differences may affect reactions, and sexual and gender orientation may place manifestations.Because this is still a vibrant area of research, it is vital that probation departments and their partners stay abreast of research and practice advances. Some behaviors (not an justice professionals may encounter in youth who are experiencing traumatic stress are described on the following page.

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