Nationally, childhood traumatic exposure is so widespread that latest estimates indicate two out of three youth will experience a traumatic event by age 17 (National Child Traumatic Stress Network (NCTSN), Schools Committee, 2017). Trauma exposure may include community/school violence, maltreatment, traumatic grief, natural disasters, war- or medical-related incidents, and can range from isolated events to chronic occurrences (NCTSN, 2016). Research informs us that the devastating impacts of traumatic exposure not only threatens the healthy development of its victims (post-traumatic stress), but also their loved ones, caregivers and peers who may witness or learn about such events and experience traumatic reactions or secondary traumatic stress. Communities are also impacted by these traumas, particularly those that endure a disproportionate number of traumatic events often secondary to poverty, community violence and other low social mobility indicators.
Wicked Problem Description:
The cumulative effect of chronic traumatic exposure is a threat to our community’s Culture of Health and health equity, and has a number of lifespan consequences, including behavioral/physical health in the forms of posttraumatic stress and depressive disorders, suicide attempts, obesity, diabetes and cardiovascular disease, perpetuating health disparities (Substance Abuse and Mental Health Services Administration (SAMHSA), 2014). Dire consequences like the school-to-prison pipeline has far reaching economic and psychological costs at the individual, family, community and societal levels. A quarter of Black boys are projected to experience incarceration in their lifetime (Kessler, 2015). Tragically, the mean number of trauma exposures for youth who have been detained in juvenile detention is 14, the majority of which are black and brown (Abram et al., 2004). Other negative consequences of traumatic stress include impacts to brain structures and function akin to brain damage. For example, the prefrontal cortex, amygdala, hippocampus and other areas have been found greatly diminished in size and function (De Bellis & Zisk, 2014). Further, brain functions like fight-flight-freeze are often competing with essential processes and contribute to emotional/behavioral dysregulation. Because youth spend the majority of their time in school and require optimal functioning in mind, body and spirit to succeed academically as well as in other school-related competencies (behavioral, emotional, social), traumatic stress is a wicked problem indeed.
Our wicked problem calls for strategic collective action utilizing a multi-disciplinary, multi-pronged approach. PROMISE for Success: A Trauma-Informed (T-I) and Trauma-Responsive (T-R) Community Intervention is integrative of our Clinical Scholars collective cross-sector expertise with community engagement/collaborative frameworks (community participatory action, positive youth development). PROMISE is also reflective of the best available T-I/T-R evidence-based practices and implementation science.
PROMISE is consistent with the following core elements of T-I Schools: a) feelings of physical, social and emotional safety; b) shared understanding of the impacts of trauma and adversity; c) effective community collaboration; d) positive culturally responsive discipline practices; and e) access to comprehensive school-based behavioral health services (NCTSN Schools Committee, 2017; SAMHSA, 2014).
PROMISE will be implemented in an urban, Southeastern Michigan community, specifically a school and youth/family social services and healthcare agencies, with high adverse childhood experiences (ACEs), poverty, community violence, premature death and other traumatic- and grief-related circumstances.
PROMISE consists of a T-I/T-R multi-tiered approach. Primary aims for each Tier (T) are as follows: T1: create safe environments and promote health; T2: early intervention and identification of individuals at-risk for post/secondary traumatic stress; and T3: intensive support and services for those exhibiting clinically significant traumatic stress symptoms. Key strategies at T1 is promoting a positive community/school climate and implementing community/school wide interventions (e.g., Positive Behavioral Interventions and Supports/PBIS), T2 screening and brief interventions, T3 delivering trauma-specific treatments (e.g., Trauma and Grief Component Therapy for Adolescents/TGCT-A).
Expected outcomes are increased community awareness, increased stakeholders T-I knowledge and implementation of T-R practices; decreased trauma- and grief-related clinically significant post/secondary traumatic stress symptoms and related secondary adversities (e.g., behavior-related office referrals, staff burnout); and improved attendance and academic performance. Goals, activities and milestones across the project period are detailed below.
Carryout Project Start-up/Launch
- Submit Institutional Review Board (IRB) and school district research proposals
- Attend key trainings (PBIS, TGCT-A)
- Identify Advisory Council members and establish PROMISE meeting schedules for all stakeholder groups
- Develop manual of operating procedures
- Devise screening plan/intervention schedule
- Fall 2019, identification of one PROMISE champion within each stakeholder group to co-facilitate efforts
- Winter 2019, receive IRB/school district approvals
- Monthly, incorporation of stakeholders’ feedback to refine implementation plans
Create Safe Environments and Promote Health (Tier 1)
- Develop community ACEs training plan in coordination with school-based behavioral health providers
- Conduct community/school-based trauma training seminars
- Determine mindfulness and other whole-school healthy activities
- Identify spaces for T-I/T-R remodeling
- Winter 2019, launch school/community interventions
- Annually, at least 4 health promotion activities implemented by stakeholder group
- Annually, tailor at least 4 spaces to more T-I/T-R environments
Provide Early Intervention for Post/Secondary Traumatic Stress (Tier 2)
- Screen students, staff, stakeholders post/secondary traumatic stress symptoms
- Implement prevention/early intervention strategies
- Screen 20% of target groups
- Annually, at least 4 early intervention activities delivered to stakeholder groups
Deliver Trauma Specific Treatment (Tier 3)
- Develop T-I community referral list
- Conduct school-based TGCT-A
- Conduct pre/post multi-informant assessments
- Quarterly, conduct at least 2 intervention groups
- Quarterly, conduct at least 1 T-I care community learning collaborative
A cross-sector, multi-disciplinary collaborative team with greater than 20 years’ experience will lead team PROMISE. Clinical scholars’ backgrounds include clinical psychology, social work, public health and medicine. Institutional partners include Michigan Medicine, University of Michigan, Washtenaw County Health Department and school district officials.
A program evaluation will occur utilizing a multi-informant, mixed methods approach, incorporating survey, interview, tracking and record review data, collected prospectively over the three-year project period. Data will be analyzed annually with formative evaluation reports shared with stakeholders. A summative report will occur at the end of Year 3. To enhance sustainability behavioral health assessment tools freely accessible will be utilized. We anticipate screening at least 180 students (30% of the student body) over the project period. Multiple TGCT-A groups will be offered each semester with students, caregivers and teachers completion of pre- and post-behavioral health assessments. The aforementioned academic indicators will also be tracked for intervention youth as well as school wide via a PBIS data management system. Pre/post-assessments of school/community-based stakeholders T-I knowledge will occur at trainings and follow-ups. Implementation of stakeholders T-R practices will also be assessed and tracked.