Although many youth who come in contact with education, health care, first responder, child welfare, and juvenile justice systems have experienced significant

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Building a Multi -System Trauma -Informed Collaborative ii Authors Jason Brennen, Chapin Hall at the University of Chicago ( , 773 -256 -5197) Jennifer Axelrod, Chapin Hall at the University of Chicago Kathleen Guarino, American Institutes for Research Simon Gonsoulin, American Institutes for Research Recommended citation Brennen, J., Guarino, K., Axelrod, J., & Gonsoulin, S . (2019 ). Building a multi -system trauma -informed collaborative: A guide for adopting a cross -system, trauma -informed approach among child -serving agencies and their partners . Chicago, IL: Chapin Hall at the University of Chicago & Washington, DC: American Instit utes for Research. Disclaimer This project was supported by Grant # 2016 -CV-BXK001 awarded by the Office of Juvenile Justice and Delinquency Prevention, U.S. Department of Justice. The opinions, findings, and conclusions or recommendations expressed in this publication are those of the authors and do not necessarily reflect those of the Department of Justice. Acknowledgments We are grateful for the support of the U.S. Department of Justice™s Office of Juvenile Justice and Delinquency Prevention (OJJDP) in funding the training and techn ical assistance efforts of the Multi -System Trauma -Informed Care (MSTIC) initiative. In particular, we would like to acknowledge our partnership with Catherine Pierce and Carmen Santiago Roberts from OJJDP during this award. We would also like to recognize the strong commitment of our participating state teams from Illinois, Connecticut, and Washington in this endeavor. We sincerely appreciate t he guidance we received from our advisory board , including our co -chairs, Chapin Hall™s Anne Farrell and AIR™s David Osher , as well as the work of our expert consultants throughout this engagement . We would also like to acknowledge the contributions of our colleagues Dana Weiner, Forrest Moore , and Cara Karter, who helped shape the MSTIC init iative and develop some of the tools in this guide.

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The U.S. Department of Justice™s Office of Juvenile Justice and Delinquency Prevention (OJJDP) is a component of the Office of Justice Programs, which also includes the Bureau of Justice Assistance ; the Bureau of Justice Statistics; the National Institute of Justice; the Office for Victims of Crime; and the Office of Sex Offender Sentencing, Monito ring, Apprehending, Registering, and Tracking. OJJDP provides national leadership, coordination, and resources to prevent and respond to juvenile delinquency and victimization. OJJDP supports the efforts of states, tribes, and communities to develop and implement effective and equitable juvenile justice systems that enhance public safety, ensure youth are held appropriately accountable to both crime victims and communities, and empower youth to live productive, law -abiding lives. Office of Juvenile Justice and Delinquency Prevention 810 Seventh Street NW Washington, DC 20531 ojjdp .gov Chapin Hall is an independent policy research center at the University of Chicago that provides public and private decision -makers with rigorous research and achievable solutions to support them in improving the lives of children, families , and communities . Chapin Hall partners with policymakers, practitioners, and philanthropists at the forefront of research and policy development by applying a unique blend of scientific research, real -world experience, and policy expertise to construct actionable informat ion, practical tools, and, ultimately, positive change for children and families. Chapin Hall at the University of Chicago 1313 East 60th Street Chicago, IL 60637 American Institutes for Research (AIR) is one of the world’s largest behaviora l and social science research and evaluation organizations. The intellectual diversity of 1,800 employees brings together experts from many fields in the search for innovative answers to challenges that span the human life course. AIR™s mission is to conduct and apply the best behavioral and social science research and evaluation towards improving people’s lives, with a special emphasis on the disadvantaged. American Institutes for Research (AIR) 1000 Thomas Jefferson Street NW Washington, DC 20007

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Building a Multi -System Trauma -Informed Collaborative v Foreword Trauma is a widespread, harmful, and costly public health problem, and its effects are particularly detrimental to children and adolescents. Although many youth who come in contact with education, health care, fi rst responder, child welfare, and juvenile justice systems have experienced significant psychological trauma, these s ectors often lack systematic approach es to address the impact of trauma on the children they serve. Each approaches trauma differently ; has different levels of awareness, knowledge, and skill about trauma ; and varies in perceptions of the utility of gathering information about trauma (Ko et al. , 2008) . These child -serving systems also differ in their responsibilities for meeting children™s needs. The goal for all systems, however, is to improve outcomes for children by enacting evidence -based standards that ensure a fithrough any doorfl approach t o addressing trauma. Trauma -informed systems are necessary to ensure not only that children and families interacting with an agency have ready access to effective trauma -specific interventions but that staff interactions , physical environments, and support ing policies and practices are aligned to a comprehensive model of care that supports resilience . At a time when children and families are navigating the coronavirus pandemic, and the long -term effects remain uncertain, the need for systems that recognize, understand, and effectively respond to adversity and trauma is particularly salient. In 2010, the U.S. Department of Justice™s Office of Juvenile Justice and Delinquency Prevention (OJJDP) supported the first federally sponsored efforts to bring together child -serving system partners to develop strategic plans designed to serve youth and families at risk for or impacted by violence and other adverse childhood experiences. First starting as a series of city, county, and tribal demonstration projects and la ter as state -level initiatives, these awards provided valuable training and technical assistance to senior policymakers and other partners during their strategic planning and implementation periods. This guide summarizes the learnings from our engagements with the most recent cohort of state -level teams. It offers a framework for system -level and cross -system strategic planning and implementation processes for supporting trauma -informed systems change. The guide is intended for an audience of state or local policymakers, public agency administrators, trauma experts, provider partners, and other stakeholders who seek to advance trauma -informed care within and across their child -serving systems.

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Building a Multi -System Trauma -Informed Collaborative vi Contents Forew ord .. .. v Introduction .. 1 Section One: Understanding Trauma and Its Effects . .. 5 Types and Prevalence of Trauma Across Child -Serving Systems .. . 5 Effects of Childhood Trauma .. 8 A Call for Trauma -Informed Child -Serving Systems 9 Section Two: Defining a Multi -System Trauma -Informed Approach .11 Multi -System Trauma -Informed Approac h Framework . 13 Section Three: Implementing a Multi -System Trauma -Informed Approach ..20 Initiate a Multi -System Collaborative Effort 21 Prepare to Adopt Cross -Sector Trauma -Informed Strategies 28 Implement Trauma -Informed Action Plans .. .. 33 Sustain a Multi -System Trauma -Informed Approach 38 Section Four: Next Steps for the Field 41 1. Incentivize and Enable Innovative Collaborations Across Sectors 41 2. Develop Better Ways to Measure and Benchmark the Impact of Trauma -Informed Care at the Organizational, System, and Cross -System Level .. 42 3. Advance System and Cross -System Policies and Practices Through Legislative Action . 42 4. Strengthen Opportunities to Study and Share Population -Based Data to Better Determine Existing Needs and Treatment Benefits .. 43 5. Further Study Innovative Trauma -Focused Interventions for Prevention and Treatment .. .. .. .. 44 6. Integrate Proven Evidence -Based Trauma -Focused Interventions into Existing State and F ederal Funding Streams .. .. 45 7. Promote Public Awareness .. 45 Conclusion . .. .. 47 References .. . .48 Appendix A: Resources for Implementing Trauma -Informed Strategies 56 Appendix B: Sample Multi -System Readiness Tool .63 Appendix C: MSTIC Agency Reflection Tool . . 66 Appendix D: Trauma -Informed Care Capacity Assessment Scales and Tools ..71 Appendix E: Sample Multi -System Collaborative Charter .73 Appendix F: Implementation and Continuous Quality Improv ement Resources .76 Appendix G: Sample Action Plan . 78

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Building a Multi -System Trauma -Informed Collaborative 2 Purpose of the Guide Launching a coordinated multi -system strategy for addressing child trauma is a complex and long -term effort. It requires a sustained and dedicated commitment by stakeholders within and across service sectors. Establishing a vision and plan for these efforts will help to overcome a collaborative™s challenges by charting a shared cours e of action and maintaining focus and commitment among the leadership team. Informed by current work in the field of trauma -informed care, along with lessons from the MSTIC initiative, this guide: Provides an overview of the types, prevalence, and effects of trauma and its implications for child -serving s ystems. Offers a framework for a coordinated trauma -informed approach within or across health care, child welfare, juvenile justice, education, early child development, first responder, and other child -serv ing systems . Includes a staged process for launching a multi -system trauma -informed collaborative and supporting the adoption of a cross -sector trauma -informed approach. The MSTIC initiative used a collective impact approach, with engagement from the exec utive branch of government and the intent to develop a cross -system trauma -informed collaborative among state agencies. While developed in this context and focused on state systems involving child -serving agencies, we believe that this guide has relevance for those engaged in a variety of collaborative efforts to address trauma and promote resilience across service sectors and communities. The process outlined here includes guidelines and benchmarks for supporting collaborative approaches for addressing tra uma that can be applied and adapted to suit a variety of efforts, including those that are initially less formal in structure, those that serve other populations beyond children and youth, and those that do not involve state agencies or encompass state -based efforts. Equally, although this guide is meant to provide an organizing framework for cross -system efforts, it is immediately translatable to those looking to support within -system s transfo rmational change. It should also be noted that existing collaboratives may already have a trauma -informed framework in place to ground their efforts. The framework provided here is not intended to replace other models already in use; rather, it is intended to support or augment them . Defining Our Terms Health and human service sectors addressing childhood adversity and trauma have a professional vocabulary. Throughout this guide we will use these terms as we explore developing multi -sector trauma -informed collaboratives. Adverse Childhood Experiences (ACEs) : Originating from the initial study by Kaiser Permanente and the Centers for Disease Control and Prevention in the mid -1990s , adverse childhood experiences are defined as events occur ring before the age of 18 that are linked with a variety of poor health and social

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Building a Multi -System Trauma -Informed Collaborative 3 outcomes later in life (Felitti et al., 1998). The original set of ACEs fall into three main categories: abuse, neglect, and household dysfunction . Recently, experts have expanded the categories and types of ACEs to include additional experiences such as exposure to group and/or community violence, poverty and related stressors, bullying, racism and discrimination, poor health, and involvement with child welfar e and juvenile justice systems (Cronholm et al., 2015; Ellis & Dietz, 2017 ; Wade, Shea, Rubin, & Wood, 2014). Collective adversities such as the coronavirus pandemic must also be considered. Trauma: The term trauma is used to describe an event, series of events, or set of circumstances that is experienced as physically or emotionally harmful or life -threatening, overwhelms one™s ability to cope, and has adverse effects on a person™s mental, physical, social, emotional, or spiritual well -being (SAMHSA, 2014). Exposure to traumatic experiences can alter how people view themselves and others by challenging their beliefs that the world is a safe place, that other people can be trusted, and that they are worthy of care and protection. Not all adverse experiences are traumatic for every person. Whether an event or set of circumstances is experienced as traumatic is influenced by many factors , including our internal coping resources, our external supports, and broader community, cultural, and societal factors that shape how we understand and respond to our experiences. The adverse childhood experiences outlined previously are potentially traumatic for youth. Specific types of traumatic experiences are defined further in Section One. Toxic Stress: The term toxic str ess refers to the strong, frequent, and prolonged activation of a child™s stress response system caused by exposure to chronic, severe adversity and trauma without adequate support, such as recurrent abuse, chronic neglect or deprivation, and ongoing expos ure to threat and violence within families or communities (National Scientific Council on the Developing Child, 2014). Posttraumatic Stress Disorder (PTSD) : PTSD as defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM -5) is a mental health problem that some people develop after experiencing a traumatic event or events. A person may be diagnosed with PTSD if they experience the following set of symptoms that significantly impair their daily functioning for longer than 1 month following a traumatic event : Re-experiencing (in the form of memories , recurrent dreams or nightmares, flashbacks, or other intense reactions to trauma reminders) . Avoidance of distressing memories, thoughts, feelings, or external remi nders of the event. High levels of a rousal marked by aggressive, reckless, or self -destructive behavior; sleep disturbances; hypervigilance; and other related problems. Negative cognitions and mood, including myriad feelings such as a persistent and distor ted sense of blame of self or others, estrangement from others, markedly diminished interest in activities, and/or an inability to remember key aspects of the event. Resilience: Resilience refers to a positive, adaptive response to significant adversity (Shonkoff et al ., 2015). Children and youth who demonstrate resilience are able to adapt successfully to stressful situations and maintain healthy functioning. The field continues to focus its study on what set of intrinsic, family, and community protective factors are most impactful in fostering resilience in the face of adversity and exposure to trauma.

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Building a Multi -System Trauma -Informed Collaborative 4 Secondary Traumatic Stress (STS) or Vicarious Trauma : These terms refer to the natural consequent behaviors and emotions that often result from knowing about a traumatizing event experienced by another and the stress resulting from helping, or wanting to help, a traumatized or suffering person. Its symptoms can mimic those of posttraumatic stress disorder. Individuals in caretaker roles or in huma n service s and health care workers may be particularly susceptible to secondary trauma. Trauma -Specific Services: The term trauma -specific services (or interventions ) refers to evidence -based and promising prevention, intervention, or treatment services t hat address symptoms of traumatic stress and related challenges that developed during or after trauma (SAMHSA, 2014). Trauma -Informed Care/Approach: The terms trauma -informed care and trauma -informed approach refer to a universal approach to addressing tr auma and promoting resilience through policies, procedures, practices, and programs adopted by the entire workforce, at all levels or roles, and in all parts of the system, for all people receiving services. The term trauma -informed care is often mistakenl y used interchangeably with trauma -specific clinical interventions . However, as will be discussed throughout this Guide, a trauma -informed approach encompasses a much more comprehensive model within and across systems that often requires that systems engag e in certain fiscal, policy, and workforce development reform efforts as well. Social Determinants of Health : The term describes the conditions in which people are born, grow, live, work , and age that shape health. The determining factors include socioeco nomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care. Addressing social determinants of health is important for improving health and reducing longstanding disparities in h ealth and health care . Collective Impact: The term describes the commitment of various parties coming together on a common agenda to impact a specific social problem. Collective impact is based on organizations and systems forming cross -sector coalitions t o make meaningful and sustainable progress on social issues.

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Building a Multi -System Trauma -Informed Collaborative 5 Section One : Understanding Trauma and Its Effects Types and Prevalence of Trauma Across Child -Serving Systems Children and youth may face a range of adverse and traumatic experiences over the course of development. Adverse childhood experiences (ACEs) include family violence, abuse, parent separation or divorce, family mental health and substance use problems or i ncarceration, as well as environmental adversities , such as exposure to group and/or community violence, poverty and related stressors, bullying, systemic racism and related violence and discrimination, poor health, involvement with child welfare and juven ile justice systems , and collective adversities such as the coronavirus pandemic (Felitti et al., 1998; Cronholm et al., 2015; Ellis & Dietz, 2017 ; Wade, Shea, Rubin, & Wood, 2014). Childhood adversi ty may become traumatic for youth, especially if it is chronic in nature and/ or experienced without adequate adult support. The term trauma is used to describe an event, series of events, or set of circumstances that is experienced as physically or emotionally harmful or life -threatening and that has lasting adverse effects on a person™s mental, physical, social, emotional, or spiritual well -being (SAMHSA, 2014). Traumatic experiences come in many forms . They range from one -time eve nts to experiences that are chronic or even generational. Types of Trauma Acute trauma: Traumatic events that occur at a particular time and place and are usually short -lived, such as witnessing or experiencing a n act of violence, sudden loss of a loved on e, a serious accident, a natural disaster , or an epidemic or pandemic . Chronic trauma: Traumatic experiences that occur repeatedly over long periods of time. Examples include chronic exposure to violence; long -term illness; chronic experiences of poverty and deprivation; an extended epidemic or pandemic and/or the long -term effects; and ongoing and systemic experiences of racism, discrimination, and marginalization related to race, ethnicity, and sexual orientation or gender identity. Complex trauma: Desc ribes both (a) exposure to multiple traumatic events early in life Šoften within the context of a child™s relationship with a caregiver who would ordinarily be a trusted source of support Šand (b) the wide -ranging and long -term effects of these experiences o ver the course of development (National Child Traumatic Stress Network, 2013a) . Examples include physical, emotional, and sexual abuse; neglect or family rejection; witnessing unsafe and violent behavior by trusted adults , including caregivers ; or experiencing other traumatic events without adult support . Historical trauma: Refers to the collective and cumulative trauma experienced by a particular group across generations (National Child Traumatic Stress Network, 2013b) . Examples of historical trau ma include mass genocide , violent colonization and assimilation policies , mass internment or displacement , slavery , targeted violence , structural racism , and homophobia (National Child Traumatic Stress Network,

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