CreatingTrauma-InformedSchoolsforRuralAppalachia-ThePartnershipsProgramforEnhancingResiliencyConfidenceandWorkforceDevelopmentinEarlyChildhoodEducation.pdf

ORIGINAL PAPER

Creating Trauma-Informed Schools for Rural Appalachia: ThePartnerships Program for Enhancing Resiliency, Confidenceand Workforce Development in Early Childhood Education

Sherry Shamblin1 • Dawn Graham2• Joseph A. Bianco2

Published online: 29 January 2016

� Springer Science+Business Media New York 2016

Abstract Poverty lack of resources and pervasive

adversity threaten the healthy social and emotional devel-

opment of many children living in rural Appalachia.

Despite these traumatic stressors, however, Appalachian

residents have proven surprisingly resilient and responsive

to intervention. This article describes the twin efforts of the

Partnerships Program for Early Childhood Mental Health

and Project LAUNCH, a community-university-state ini-

tiative, to transform school systems by establishing

enduring partnerships within and across schools and

agencies, pooling and disseminating critical resources, and

strengthening the skills, confidence and capacity of the

early childhood education workforce. This article describes

the three-tiered framework of services implemented at the

schools, with special emphasis on its trauma-informed

training for educators combined with trauma-specific

mental health interventions delivered on site. Despite a

modest sample size, results indicate significant pre-im-

provement/post-improvement in teacher confidence and

hopefulness in positively impacting challenging child

behaviors; a decrease in the negative attributes of the

preschool learning environment; and increased teacher

ratings of child resilience as measured by the Devereux

Early Child Assessment. Program limitations and future

directions for creating trauma-informed Appalachian

schools are discussed.

Keywords Trauma-informed care � Schools �Partnerships � Resilience � Early childhood mental health

From birth to age five, children undergo unprecedented

neurobiological development. During these early childhood

years, the ‘‘architecture’’ of the brain and central nervous

system develops and consolidates, laying a lifelong foun-

dation for social, emotional and cognitive development

(Perry, 2004). Environments that consistently expose

children to adversity, trauma and chronic toxic stress can

irreparably alter brain physiology and place them at risk of

poor academic, mental health and medical outcomes

throughout their lives (Anda et al., 2006; Briggs-Gowan,

Carter, Clark, Augustyn, McCarthy, & Ford, 2010; Perry,

2004). Exposure to functional environments and supportive

attachment figures, however, can buffer the effects of

childhood adversity. Strong preschool systems staffed by

knowledgeable, trauma-informed personnel can supply the

relational protective factors that may be diminished or

absent in a child’s home environment. Preschool teachers

can promote emotional regulation and help children control

behavioral impulses that could later interfere with learning

(Buss, Warren & Horten, 2015; Phillips & Shonkof, 2000).

Unfortunately, regional disparities can prevent some

school systems from fully promoting the healthy social and

emotional development of the children they serve. In poor,

underserved and resource-challenged regions such as rural

Appalachia, teachers are typically stretched beyond

capacity. In the rural Appalachian counties of Southeastern

Ohio, for example, approximately 29 % of children live in

poverty (Ohio Department of Education, 2014). In addi-

tion, rates for various mental illnesses range from 24 to

41 % compared to national averages of 16 %. Substance

abuse rates among adults are 30 % greater than non-rural

& Sherry Shamblin

[email protected]

1 Behavioral Health, Hopewell Health Centers, 90 Hospital

Drive, Athens, OH 45701, USA

2 Department of Social Medicine, Ohio University Heritage

College of Osteopathic Medicine, Athens, OH, USA

123

School Mental Health (2016) 8:189–200

DOI 10.1007/s12310-016-9181-4

parts of Appalachia (Zhang et al., 2008). An estimated 3 %

of children in the region have documented and substanti-

ated cases of child abuse (Ohio Department of Health,

2014).

Despite the pervasive poverty and health disparities

Appalachian residents face, access to mental health ser-

vices is severely limited. The region’s 1:3333 ratio of

mental health providers to residents classifies it as a fed-

erally designated shortage area (Robert Wood Johnson,

2014). In addition to a scarcity of providers, access to care

is often impeded by limited or unreliable transportation,

minimal childcare options, lack of health insurance or cash

for co-payments, a cultural preference for self-reliance over

help seeking and pervasive concerns about stigma and

privacy (Zhang et al., 2008). These barriers challenge

service providers to identify non-traditional, culturally

consonant delivery models that minimize cost and maxi-

mize outcomes.

Taken together, the economic constraints, limited

resources and pervasive adversity in rural Appalachian

regions place children at risk of poor outcomes later in

life. Successful service paradigms for rural and Appa-

lachian areas include ‘‘one-stop shopping’’ models, such

as behavioral health services integrated within primary

care medical clinics and community-based outreach

program. For school-aged children and their teachers,

Early Childhood Mental Health Consultation (ECMHC)

models hold particular promise for rural and impover-

ished regions (Brennan, Bradley, Allen, & Perry, 2008;

Perry, Allen, Brennan, & Bradley, 2010). Supportive

services that build capacity and confidence in teachers

and contribute to trauma-informed school environments

are key.

In this paper, we argue that the unique needs and cul-

tural values of some rural and Appalachian regions

necessitate a departure from traditional approaches to

trauma-informed care. These regions are already ‘‘trauma-

informed’’ in the literal sense; their everyday realities are

shaped by chronic economic hardship, pervasive psy-

chosocial adversity and fragmentation of services. From

this perspective, creating trauma-informed systems

involves more than generating trauma-awareness or pro-

viding trauma-specific services at first. Instead, the basic

developmental needs of the organization must be assessed

and made whole. Creating collaborative, flexible and

responsive relationships between service providers and

schools provides the nurturance, support and healthy

attachments required for ideal learning environments for

teachers and students alike. We assert that the key to

developing this relational foundation lies in adapting the

principles and practices of ECMHC.

Theoretical Framework: ECMHCas the Foundation for Trauma-Informed Schools

Early Childhood Mental Health Consultation (ECMHC) is

a problem-solving, capacity-building intervention imple-

mented within a collaborative relationship between a pro-

fessional consultant with mental health expertise and one

or more caregivers, typically an early care and educational

professional and a family member. Instead of direct inter-

vention aimed at individual children with problems, ECMH

consultants focus on building the capacity of early child-

hood staff and caregivers who then go on to work (Cohen

& Kaufman, 2000). The primary goal of ECMHC is to

‘‘strengthen the capacity of teachers to promote positive

social and emotional development as well as prevent,

identify, and reduce the impact of mental health problems

among young children’’ (Kaufman, Perry, Irvine, Duran,

Hepburn, & Anthony, 2012, p. 2).

Although models of ECMHC vary, the key character-

istics of the most successful programs include individual-

ized interventions tailored to the unique needs and

strengths of participants; comprehensive scope of services

at a variety of intervention levels; coordinated services

encompassing multiple child serving systems; focus on

developmental needs; and focus on enhancing strengths

such as skill development and promoting resiliency, rather

than identifying and fixing deficits (Simpson, Jivanjee,

Koroloff, Doerfler, & Garcia, 2001).

The Partnerships Program for Early ChildhoodMental Health (The Partnerships Program)

As Fig. 1 demonstrates, we characterize trauma-informed

school systems as those in which children are resilient in

the face of stress and adversity, equipped with skills to

regulate their behavior and feel safe enough in the class-

room to learn rather than to act out. Teachers in trauma-

informed school systems are confident in their abilities to

meet children’s needs, even when those needs are chal-

lenged by external stressors and adversity. Moreover, they

embody and model healthy, attuned and responsive rela-

tionships with their children.

This article presents a model of an integrated, trauma-

informed school program that applies the relational,

capacity-building practices of ECMHC with trauma-

specific workforce development interventions. More

specifically, we discuss the methods, process evaluation

and short-term outcomes of the Partnerships Program, a

version of Hopewell Health Center’s ECMHC Program. At

its core, the Partnerships Program views relationship

190 School Mental Health (2016) 8:189–200

123

building as both a guiding principle and a method of ser-

vice delivery. Consistent with ECMHC principles, the

Partnerships Program rests on the assumption that the

partnership process catalyzes trauma-informed systems of

care. Accordingly, the case study presented below focuses

heavily on the process and outcomes of strategic affiliation

between the Partnerships Program and the workforce

development arm of community-university-state child

health initiative (Project LAUNCH).

Program Description

Partnerships for Early Childhood Mental Health, an Early

Childhood Mental Health Consultation program, collabo-

rated with Project LAUNCH. The Partnerships Program

utilizes embedded consultants in schools to increase

capacity and positive supports for teachers combined with

on-site mental health interventions delivered to children.

Consultants employ a relationship-based approach to

training, team building, modeling and wellness activities

for teachers so they are better able to promote healthy

social–emotional development in their students. Through

Project LAUNCH, the Partnerships consultants and par-

ticipating teachers were able to leverage university, state

and national resources for comprehensive workforce

development focused on implementing trauma-informed

practices and trauma-specific interventions designed to

increase resilience and buffer the effects of early adversity

by increasing the competence and confidence of teachers to

form supportive attachment relationships with the young

children in their care. The interaction of Partnerships

Program staff and school personnel via the Project

LAUNCH workforce development activities created an

evolution of the model from a simple focus on health

promotion/prevention to incorporate components that

would also reduce the impact of trauma.

Because the development of resilience in children is

interconnected to positive caregiver relationships, two broad

goals guided the Partnerships Program’s efforts to create a

trauma-informed school system: (1) increasing teacher

competence and confidence in meeting the social–emotional

needs of students and reducing challenging behaviors in the

classroom; and (2) increasing resilience in children in the

form of increased initiative, attachment and self-control.

Fig. 1 Logic model for creating trauma-informed schools in rural Appalachia through Early Childhood Mental Health Consultation services

(Partnerships Program) and trauma-specific workforce development (Project LAUNCH)

School Mental Health (2016) 8:189–200 191

123

Contributing Partners

Hopewell Health Centers

The Partnerships Program developed out of Hopewell

Health Centers (HHC), a 501-3-(c), nonprofit and a Joint

Commission accredited Federally Qualified Health Center.

HHC has sixteen sites across 8 counties in Southeast Ohio

and serves 30,000 patients a year. HHC’s CARF accredited

Community Mental Health Center (CMHC) sites provide

individual/group counseling, case management and psy-

chiatry services to approximately 6000 clients (2400 of

whom are children). HHC has developed extensive part-

nerships with schools by providing on-site services for 20

school districts representing 31,861 students.

Project LAUNCH

Project LAUNCH (Linking Action to Unmet Needs) is a

SAMHSA-funded multi-year community-university-state

partnership program consisting of several cross-disci-

plinary initiatives designed to promote the wellness of

young children from birth to age eight. Services offered

through LAUNCH include a Family Navigator program, an

Interdisciplinary Assessment Team, School Outreach Ser-

vices, Co-located Behavioral Health and Primary Care

providers, and, in conjunction with the Partnerships Pro-

gram, ECMHC services. While LAUNCH encompassed

many overlapping initiatives, the current paper focuses on

the interventions and services that intersected with the

Partnerships Program to promote a trauma-informed cul-

ture within school systems.

HAPCAP Head Start

Hocking-Athens-Perry Community Action Agency oper-

ates Head Start Centers in three counties in Southeast Ohio.

As part of their federal requirements, they must have a

mental health specialist make classroom observations and

provide recommendations for teachers to support healthy

social–emotional development and for individual children

who may need follow-up services. Hopewell Health Cen-

ters and HAPCAP Head Start have worked together for

over 13 years with HHC early childhood consultants pro-

viding these classroom observations and consultation ‘‘by

request’’ for challenging classroom situations and individ-

ual children who need follow-up interventions.

Scope of Service Delivery: Consultation Services

and Workforce Development

In the Partnerships Program’s comprehensive model,

trained consultants offer three tiers of early childhood

mental health services—universal consultation, targeted

consultation and intensive services in tandem with work-

force development trainings provided by Project LAUNCH

(see Table 1).

The first tier, universal consultation, focuses on strate-

gies that help teachers support the healthy social–emotional

development of all students in their classrooms. The goals

at this level of service are to implement a social–emotional

curriculum that meets the resilience needs of the children

in a class and to support the professional development of

teachers. The consultant works to build the capacity of the

teacher through training/mentoring and delivers a social–

emotional curriculum to the children. Consultants help

teachers understand trauma-informed care principles and

teach them an evidence-based practice based on Parent–

Child Interaction Therapy, called CARE skills. The con-

sultant also works with the teacher to implement an evi-

dence-based curriculum—either Second Steps or the

Incredible Years—based on school resources and

preferences.

The second tier, targeted consultation, provides strate-

gies that teachers can use for individual children who

present with challenging classroom behaviors. The goals of

targeted consultation are to decrease challenging classroom

behaviors for identified children who have not responded to

typical classroom interventions and to initiate home–school

communication strategies. Toward this end, the consultants

and teachers jointly develop behavior plans to support

positive classroom experiences for individually identified

children with challenging behaviors. For a child who has

experienced trauma, the consultant can work with a teacher

on specific strategies to support the child in the classroom

environment.

The final tier, intensive services, addresses mental health

issues that need individual follow-up. The consultant/spe-

cialist provides on-site mental health assessment and

treatment to children and their families in order to identify

specialized behavioral needs of children with mental health

disorders. Based on the assessment results, consultants will

work with families to provide suitable evidence-based

treatment on or off site. For children who have experienced

trauma, the consultant will implement Trauma-Focused

Cognitive Behavior Therapy and/or Parent–Child Interac-

tion Therapy based on the individual circumstances of each

child.

Workforce Development

Since its inception, staff and coordinators from Project

LAUNCH had been working closely with Hopewell’s

ECMHC director to determine mutual goals for leveraging

shared resources and partnering formally to support the

needs of preschool teachers and children. Workforce

192 School Mental Health (2016) 8:189–200

123

development activities occurred at various times through-

out the year, depending on availability of trainers and other

logistical factors, and were available to preschool teachers

as well as other child service providers. Trainings included

the Georgetown University Model of Early Childhood

Mental Health Consultation; Parent–Child Interaction

Therapy (PCIT); DECA administration training; the Child

Trauma Academy’s Neurosequential Model of Therapeu-

tics (NMT) training, taught by Bruce Perry, MD; and

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT).

Program Evaluation Goals

The goals of this program evaluation were to assess the

impact of consultation services and the workforce devel-

opment activities toward meeting the identified outcomes

in our logic model: (1) improved confidence, self-efficacy

and capacity to support social–emotional development for

participating teachers and (2) increased resilience for par-

ticipating children.

Program Evaluation Methods

Program Evaluation Procedures

Although both Project LAUNCH and Hopewell Health

Center’s ECMHC program had been delivering services to

schools since 2009, the procedures and outcome data

reported here represent a single academic year

(2011–2012) of activities. This year was selected for a

variety of reasons. First, in 2009, Hopewell began offering

ECMHC services to preschools through a HRSA Outreach

Grant but Project LAUNCH was just beginning. The

Table 1 Partnerships program assessment and intervention procedures by tier of service

Tier of

service

Stages of service

Assessment stage Planning stage Intervention stage Evaluation stage

Universal

consultation

Teacher completes: Teacher

Opinion Survey (TOS),

Classroom DECA’s, Interest

Survey

ECMHC completes Preschool

Mental Health Climate Scale,

(PMHCS), DECA Profile,

Consultation Report

Consultant and teacher review

consultation report and write

annual consultation plan

Plans made for consultant’s

implementation of social skills

curriculum. Teacher self-

identifies consultation requests

as needed, plan updated as

needed

Weekly: Consultant conducts

social skills curriculum and

provides follow- up materials

for teacher

Monthly Conduct teacher

training/skill building on

teacher-selected topics

Daily: respond to teacher

requests/needs

Fall/Winter/

Spring: Change

in DECAs

Fall/Spring:

TOS, PMHCS.

Teacher–

Consultant

Collaboration

Survey

Spring: Teacher

Satisfaction

Survey

Targeted

consultation

Child identified by score on

classroom DECA. Teacher

concerns or parent concerns

Parent, teacher, and consultant

meet to review classroom

behavior assessment and write

targeted consultation plan

Social skills training/coaching by

consultant

Fall/Winter/

Spring: Change

in parent and

teacher DECAs

DECA completed by caregiver Plan is reviewed/updated mid-

year or as needed based on

child’s progress on identified

goals

Special classroom materials for

teacher (i.e., Social Stories and

Schedule cards)

Spring: Parent

Satisfaction

Survey

Consultant completes classroom

behavior assessment

Behavioral supports for parents

to use at home to provide

consistency of behavioral

strategies

Ongoing:

Completion of

goals on plan

Monthly progress report for

teacher/parent completed by

consultant

Intensive

services

Consultant and parent complete the

Hopewell HHS Diagnostic

Assessment. Additional

assessments as needed. Review

relevant assessments from

school/other providers

Consultant and parent with

teacher input complete TCMHC

Individual Service plan

Individual/Family/Group

treatment services: Parent–

Child Interaction. Therapy.

Trauma-Focused CBT. Parent–

child psychotherapy.

developmental individual

differences relationship floor

time, applied behavior,

Incredible Years

Completion of

goals on

treatment plan

School Mental Health (2016) 8:189–200 193

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ECMHC services to additional schools through Project

LAUNCH did not begin until 2010. Choosing the

2011–2012 school year ensured that all schools receiving

services had worked through the challenges of an initial

‘‘start-up’’ year. This allowed the program evaluation to

analyze the results of schools funded through the HRSA

Outreach Grant (who had received 2 previous years of

service) with the Project LAUNCH schools (who had only

received 1 previous year of service). By the 2011–2012

school year, the combination of services offered and the

cumulative achievements of the Partnerships Program and

LAUNCH during this year constitute the ‘‘purest’’ form of

our logic model for a trauma-informed, rural Appalachian

school system (see Fig. 1). Moreover, the intersection of

the Hopewell ECMHC program and Project LAUNCH was

greatest in this year; the integration of services and eval-

uation between the two programs was planned at the start

of the year, thus making the blended Partnerships Program

described in this paper; and (3) the ECMHC program

embedded consultants in the classroom this year (having

offered as-needed classroom consultation in the past). At

the same time, data collection from other local ECMHC

models provided the opportunity to compare outcomes for

the Partnership Program’s embedded consultation model

versus consultant-as-needed services.

This program evaluation study received full approval

from the Ohio University Institutional Review Board.

Program Evaluation Participants

Consistent with the theoretical principles and values of

the Partnerships Program Model, ‘‘participants’’ encom-

pass not only the children and teachers receiving

ECMH/trauma-informed services, but the full scope of

participating staff, consultants and organizations involved

in program planning, coordination and implementation.

As Table 2 demonstrates, 11 preschool classrooms across

five elementary schools participated in the 2011–2012

academic year (6 funded through the HRSA Outreach

Grant and 5 funded through Project LAUNCH). A total of

11 teachers (6 funded through the HRSA Outreach Grant

and 5 through Project LAUNCH) received consultation

and workforce development services to enhance their

capacity to teach the 217 students under their care (100

funded through the HRSA Outreach Grant and 117 fun-

ded through Project LAUNCH). Three ECMH consultants

provided services, under the direction of the lead author, a

licensed Professional Clinical Counselor with Supervisory

credentials (PCC-S). In contrast, the By-Request-Model

implemented at Hopewell involved 550 Head Start chil-

dren in 28 classrooms involving 28 teachers and home

visitors.

Outcome Variables and Measures

Teacher Confidence and Competence

We used the Teacher Opinion Scale (TOS; Geller & Lynch,

1999), a 12-item Likert-type self-report measure, to assess

changes in teacher confidence and competence pre- and post-

intervention. It is not a standardized tool but is used to look at

differences in responses across time for individual teachers.

Items are assessed on a 5-point scale (1 = strongly disagree,

3 = neutral, 5 = strong agree) and include statements such

as ‘‘I can help my preschool children learn skills they need to

cope with adversity in their lives,’’ I feel a sense of hope-

lessness about the future of the children I work with,’’ and ‘‘I

frequently feel overwhelmed by my job.’’ Teachers in the

Partnerships Program completed the TOS at baseline and in

the spring for their post-intervention assessment. In the

current study, the TOS demonstrated acceptable reliability

(Fall: Cronbach alpha = .64, Spring: = .73). More infor-

mation about the TOS can be obtained fromWingspan, LLC

(www.wingspanworks.com).

Quality of the Preschool Environment

We used the Preschool Mental Health Climate Scale

(PMHCS; Gilliam, 2008), a 5-point Likert-type observation

rating system completed by ECMH consultants, to assess the

classroom environment and teacher practices, including the

use of transition, the quality of teacher–child interactions,

validation of child feelings and resolution of child conflicts.

It is also not a standardized tool but relies on a review of

changes across time in scores for individual teachers. The

PMHCS yields two scores: Positive Attributes, assessing

teacher strategies that encourage adaptive child behaviors

and support social–emotional development; and Negative

Attributes, which assess teacher behaviors that may inad-

vertently increase challenging behaviors among children

(Cronbach alpha for Fall = .83, Spring = .91). More

information and a copy of the PMHCS can be obtained at

www.childstudycenter.yale.edu.

Functional Assessment of Children

We used the Devereux Early Childhood Assessment (DECA;

LeBuffe & Naglieri, 1999) as a global measure of the social,

emotional and behavioral functioning of participating chil-

dren. The DECA is a standardized, 37-item behavior rating

sale for teachers to assess resilience in three- to six-year-old

children. Child behaviors are rated on a 5-point frequency of

occurrence scale (ranging from ‘‘Never’’ to ‘‘Very Fre-

quently’’). The DECA yields a Total Protective Factors Score

that is based on three Resilience factors: Initiative, Attach-

ment and Self-Control. TheDECA also contains a Behavioral

194 School Mental Health (2016) 8:189–200

123

Concerns Scale, which has not been included in the results of

this study because it is a ‘‘screener’’ and is not a resilience

subscale and does not contribute to the ‘‘Total Protective

Factors’’ score. All raw scores are converted to T-scores.

Areas of concern are indicated byT-scores that are 1 SD away

from the average (C60 for Behavioral Concerns and B40 for

the Initiative, Attachment and Self-control subscales). Inter-

nal reliability for the DECA’s standardization sample is high,

with each of the alpha coefficients for the total score and each

of the subscales meeting or exceeding the .80 ‘‘desirable

standard’’ establishedbyBracken (1987).Cronbach scores for

the current sample indicated good reliability for all three

subscales and administrations: Initiative subscale = .85

(Fall) and .92 (Spring); Self-Control subscale = .88 (Fall)

and .92 (Spring); and the Attachment subscale = .78 (Fall)

and .88 (Spring). Prior research has demonstrated that the

DECAis related tomeasuresof daily stress,with childrenwho

experience more stress tending to have decreased scores on

the Total Protective Factors Score and each of the subscales–

Initiative, Attachment and Self-Control (Work, Cowen, &

Wyman, 1990; Chandler, 1981; Kanner, Coyne, Schaefer, &

Lazarus, 1981).

Teacher Satisfaction and Relationship with Consultant

(Hepburn et al., 2007)

In order to gain additional understanding on program

processes, a descriptive analysis was conducted using

sixteen items from the Georgetown University ECMHC

Satisfaction survey (i.e., those assessing the quality of the

teacher–consultant relationship and overall satisfaction

with services). Items were based on consultation services

(‘‘I have a good relationship with my consultant,’’ ‘‘Con-

sultant respects my knowledge and perspectives on chil-

dren’s issues,’’ ‘‘the consultant is part of the team,’’ etc.)

and rated by teachers on level of agreement (1 = strongly

agree; 2 = agree, 3 = somewhat agree; 4 = somewhat

disagree; 5 = strongly disagree).

Data Analysis

Descriptive statistics were calculated for all child and

teacher outcome measures at baseline (in the fall of the

academic year) and post-intervention (in the spring).

Paired-sample t test analyzed differences in the fall and

spring administrations for the Teacher Opinion Scales and

the Preschool Mental Health Climate Scales. Multi-level

linear regression analyses examined potential differences

among the Partnerships Program and Project LAUNCH’s

use of an embedded ECMH consultant and the as-needed

ECMH consultant used Head Start. To account for the

nested nature of the data (i.e., individual children belonged

to specific classrooms within specific schools), three levels

were examined: individual child, classroom and school. All

statistical results were conducted using the Statistical

Package for the Social Sciences (SPSS), version 19.

Table 2 Participants in the Partnerships Program for Early Childhood Mental Health Program 2011–2012 overview

Model Type N Tools completed Schedule of

completion

Partnerships Program Model (Outreach-funded preschools) Pre-K classrooms 6 X X

Teachers 6 TOS Fall, Spring

DECA Fall, Spring

Teacher satisfaction Spring

Students 100 X X

ECMH Consultants 2 PCMHCS Fall, Spring

Supervisor .3 X X

Partnerships Program Model

(Project LAUNCH-funded preschools)

Pre-K Classrooms 5 X X

Teachers 5 TOS Fall, Spring

DECA Fall, Spring

Teacher satisfaction Spring

Students 117 X X

ECMH consultants 2 PCMHCS Fall, Spring

Supervisor .3 X X

Consultation by request (services to Head Starts) Head Start classrooms 28 X X

Teachers 28 DECA Fall, Spring

Students 550 X X

ECMH consultants 1 X X

Supervisor .3 X X

School Mental Health (2016) 8:189–200 195

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Results

As a preliminary step in the data analysis, descriptive

statistics were calculated for all teacher and child outcome

measures. Teacher demographic characteristics were not

collected or controlled for in the current analyses because

of the relatively homogeneity of race/ethnicity in the area

(100 % of the teachers participating were Caucasian/Ap-

palachian) and because of our interest in program outcomes

over individual characteristics.

Teacher Outcomes: Self-Reported Competence

and Confidence

Table 3 presents descriptive data and mean differences in

study teacher outcome measures. Paired-sample t tests

were calculated for the fall and spring administrations for

the Teacher Opinion Scale (TOS). TOS scores were sig-

nificantly higher post-assessment (M = 42.00, SD = 3.16)

than pre-assessment (M = 39.6, SD = 2.94), t(11) = 2.50,

p = .030, two-tailed.

Paired-sample t tests were also calculated for the pre-/-

post-administrations of the PreschoolMental Health Climate

Scales. For the Positive Attributes scale, the spring mean

score (M = 4.28. SD = .38) did not differ significantly from

the fall scores (M = 4.29, SD = 58), t(10) = .116,

p = .910, two-tailed. The 95 % confidence intervals (CI) for

the difference between means had a lower bound of -.258

and an upper bound of .286. For the Negative Attributes

scale, post-assessment scores (M = 1.15; SD = .196)

demonstrated statistically significant reduction from the pre-

intervention scores (M = 1.38; SD = .287), t (11) p = .004.

The 95 % confidence intervals (CI) for the difference

between themeans had a lower bound of-.367 and an upper

bound of -.091.

Child Outcomes: Resilience and Problematic

Classroom Behaviors

Table 4 presents linear multi-level regression analyses of

DECA scores to determine the impact of the Partnerships

Program’s (n = 65 children) and Project LAUNCH’s

(n = 81) embedded consultation services versus Head

Start’s as-needed consulting service (n = 550 children).

Controlling for class size and composition (gender, age of

students), pre-assessment DECA scores did not differ sig-

nificantly on any subscales for the three programs

(p[ .10). Post-assessment scores, controlling for the same

child characteristics, demonstrated significantly higher

Resilience scores (as measured by the Initiative, Attach-

ment and Self-Control subscales) for the spring Partner-

ships Program children compared to children in the other

two ECMH programs (p .001).

Teacher Satisfaction and Relationship with ECMHC

Consultant

Eight of the eleven teacher participants completed satis-

faction surveys. All items averaged 2 or below, indicating

agreement or strong agreement with the dimensions of

satisfaction measured. One item, ‘‘Our mental health ser-

vices and approach are in need of improvement,’’ averaged

higher than others (M = 2.75, SD = 1.2), indicating that

mild agreement with this statement.

Discussion

The Partnerships for Early Childhood Mental Health Pro-

gram, augmented by Project LAUNCH’s parallel trauma-

informed workforce development programs, has developed

an ECMH consultation model based on the limited avail-

able literature for this burgeoning field and ongoing feed-

back from its participants and staff. The result has been the

creation of a school–community system of care that meets

the needs of all preschool students—including those who

may have experienced trauma. The system of care created

was founded on several principles: a recognition of the

importance of blending/combining trauma-informed

workforce development for school personnel along with

easy access to ongoing trauma expertise and trauma-

specific interventions for identified children; a focus on

Table 3 Descriptive statistics

and mean differences in teacher

outcome measures pre- and

post-intervention (N = 11)

Outcome Fall (pre) Spring (post) t (11)*

M SD Range M SD Range

TOS 39.6 2.94 34–43 42.00 3.16 37–49 2.5**

PMHCS

Positive teacher attributes 4.29 .38 1.10–4.82 4.28 .59 2.98–4.84 .12

Negative teacher attributes 1.15 1.96 .88–1.56 1.38 .29 1.10–1.90 3.70***

TOS Teacher Opinion Scale, PMHCS Preschool Mental Health Climate Scale

* t tests were conducted for 11 participants for the TOS but only 10 participants for the PMHCS due to

missing data from one classroom. ** p .05; *** p .01

196 School Mental Health (2016) 8:189–200

123

relationship building by embedding mental health within

schools; and cultural adaptations of evidence-based models

to meet local needs, values and norms.

The Partnerships Program demonstrated an increase in

teacher-reported feelings of competence and confidence,

especially regarding their ability to cope with and change

challenging behaviors in their classrooms. An additional

teacher outcome was a decrease in teacher use of negative

behavior management strategies. Results from program

satisfaction surveys indicate a high level of teacher

appreciation of services provided. The essential relation-

ship-based features of the Partnerships Program Model

(quality relationships, embedded consultation, perceived

quality of teacher–consultant partnership and mutual pro-

fessional respect) were among the highest rated satisfaction

items endorsed by teachers and school staff/personnel. In

addition, the program received high satisfaction ratings in

its effects on increasing teacher skills and reducing stress in

the classroom.

These positive teacher outcomes are an important

component in the creation of a trauma-informed system of

care in that they link directly to a teacher’s ability to create

safe classroom environments for all children and to shift

responses to challenging child behaviors from a punitive

approach to one of compassion that works to provide the

necessary positive supports for children who have experi-

enced trauma. Such supports may include providing ‘‘calm

down’’ corners, coaching affect regulation, providing

consistency through daily schedules and class meetings,

well-planned transitions, identifying and dealing with

triggers, labeling and identifying feelings, among many

others. Such responses have been found to be helpful not

only with students who have a trauma history, but have

been found to be beneficial to all children (Wolpow,

Johnson, Hertel, & Kincaid, 2011).

By directly focusing on positive impacts for teachers,

the Partnerships Program has made strides in accomplish-

ing its second goal—increased resiliency for participating

children. The program demonstrated modest but significant

positive outcomes in promoting child resilience in the

classroom. DECA results for the Partnerships Program’s

embedded consultation model (both the Outreach-funded

and the Project LAUNCH-funded schools) outperformed

those in classrooms receiving as-needed consultation ser-

vices in other local preschools (Head Start classes). This

held true for relational resilience (as measured by the

attachment and initiative subscales) and well as for class-

room behavior (as measured by increased scores on child

Table 4 Analysis of post-

DECA scores: linear multi-level

regression results for All DECA

variables (mean ± standard

error)

Initiative Self-Control Attachment Protective factor

Intercept

Outreach 51.2 ± 2.48** 53.51 ± 2.38** 49.61 ± 2.43** 51.51 ± 2.58**

Launch versus outreach -6.57 ± 3.58 -3.26 ± 3.45 -2.73 ± 3.42 -5.78 ± 3.71

Head Start versus outreach 1.15 ± 2.7 1.46 ± 2.58 -0.39 ± 2.64 0.28 ± 2.81

Level-3 covariates

Classroom size 0.02 ± 0.25 0.09 ± 0.23 -0.09 ± 0.27 -0.01 ± 0.26

% Girls 0.11 ± 0.05* 0.11 ± 0.04* 0.12 ± 0.05* 0.12 ± 0.05*

Mean age 5.99 ± 3.29 7.01 ± 3* 4.71 ± 3.43 6.75 ± 3.36

% English ineptitude -0.48 ± 0.16** -0.58 ± 0.15** -0.47 ± 0.17* -0.58 ± 0.17**

Slope

Outreach 4.43 ± 0.88** 2.93 ± 0.83** 4.87 ± 0.91** 4.15 ± 0.95**

Launch versus outreach -2.56 ± 1.3* -1.12 ± 1.23 -4.1 ± 1.24** -2.58 ± 1.38

Head Start versus outreach -3.14 ± 0.94** -2.41 ± 0.88* -3.96 ± 0.96** -3.05 ± 1.01**

Random effects (standard deviation)

School intercept NS NS NS NS

School slope NS NS NS NS

School correlation NA NA NA NA

Classroom intercept 4.13 3.82 3.85 4.31

Classroom slope 1.56 1.31 1.45 1.69

Classroom correlation -0.50 -0.60 -0.16 -0.53

Child intercept 5.39 5.95 4.63 5.39

Child slope NS NS NS NS

Child correlation NA NA NA NA

Residual 2.21 3.29 3.49 2.14

School Mental Health (2016) 8:189–200 197

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self-control). Further, the Outreach-funded classes, that had

been the recipient of the Partnerships Program’s embedded

consultation for 2 years longer than the Project LAUNCH-

funded schools, showed the greatest increases in DECA

scores. This further suggests that the Partnerships Program

has impacted resiliency of participating children.

Limitations

The Partnerships Program is highly tailored to meet the

needs of impoverished rural, Appalachian schools. In this

regard, its methods and approaches may not generalize to

other areas. We suspect, however, that the central approach

of creating trauma-informed school systems by strength-

ening professional partnerships and relationships has uni-

versal utility. Recognizing that community members can

support or impede schools in creating trauma-informed

systems of care, others have developed recommendations

and strategies for developing school–community relation-

ships such as the ones developed by the Partnerships Pro-

gram and Project LAUNCH (Cole, O’Brien, Gadd,

Ristuccia, Wallace, & Gregory 2013; SAMHSA, 2014a, b).

This program was conducted as a service for community

preschools. As such, it lacks the carefully controlled rigors

of larger-scale, randomized controlled designs. The small

number of participating schools, classrooms and teachers

and limited outcome measures collected (in order to reduce

workload for participating teachers) further limits the

generalizability of this study.

Although the study may lack large-scale generalizabil-

ity, it documents a real-world application of trauma-in-

formed care concepts. For proponents of trauma-informed

care systems to further their movement, it is critical for

projects to undergo program evaluation and document the

results. By adding to the literature in this way, projects can

help researchers discover feasible strategies and verify

ecological validity of recorded approaches to identify those

that warrant controlled trials of effectiveness. The in-the-

trenches approach undertaken by the Partnerships Program

lends credence to the program’s feasibility for implemen-

tation in other communities seeking to replicate its

approach of building capacity in schools by developing the

educator workforce and partnering with other agencies/

initiatives to leverage resources and maximize outcomes.

Implications and Future Directions

This case study approach reinforces the literature describ-

ing the critical components necessary to create trauma-

informed organizations and the developmental stages

common to this implementation. Because of the well-ar-

ticulated processes and positive outcomes, the Partnerships

Program’s combination of relational capacity-building and

trauma-informed workforce development initiatives may

serve as an exemplar for programs in similar contexts,

particularly those located in rural Appalachian settings.

This study also demonstrates ways to weave didactic

training, consultation and interventions in schools to create

a system of care that is responsive to the trauma experi-

ences of students.

In addition to benefits for the Partnerships Program, this

study has also contributed to the larger ECMHC field.

Dissemination of this study and its findings serve as a

documented example of the way ECMH consultation is

conducted in rural Appalachia Ohio.

Early childhood represents a critical time in social–

emotional development. For rural, impoverished and

under-resourced areas, specialized programs are needed to

address the complex needs of young children, their par-

ents/caregivers and the providers who work with them. In

communities that are rich in adversity but lack centralized

mental health infrastructures, it is especially important to

develop culturally consonant programs for children and

teachers that restore and promote resilience, confidence and

competence—that is, the psychosocial basis of healthy

development that traumatic stress threatens.

The Partnerships Program was created to address the

social–emotional needs of preschool children living in rural

Appalachia Ohio so that they would have increased resi-

lience to combat the many risk factors associated with

growing up in a region of high poverty. Throughout its

years of development, the program has worked to complete

this mission by developing relationships with schools, early

childhood professionals and state-local initiatives, such as

Project LAUNCH. The Project LAUNCH Initiative ended

in 2014, but it had lasting impact for the Partnerships

Program in terms of the addition of trauma-informed care

components at the universal consultation level and trauma-

specific, evidence-based treatments at the targeted and

intensive level of consultation. Further the resources

obtained from Project LAUNCH allowed the Partnerships

Program to conduct an effective program evaluation that

garnered the findings discussed in this article. The Part-

nerships Program has continued to refine their model of

service delivery and expand it throughout the Southeast

Ohio. The Partnerships Program now has embedded con-

sultants delivering a comprehensive, trauma-informed

consultation model in five counties—representing 18

school districts and approximately 10,000 preschool chil-

dren. Head Starts Programs, Preschools and Other Early

Childhood Professionals in an additional 13 counties now

receive the ‘‘consultation by request’’ services from con-

sultants—approximately 60 additional school districts and

225 Head Start Centers and Child Care Centers have access

to this service and represent 34,000 children under the age

of 5 years old (Kids Count Data Center, 2015; Ohio

198 School Mental Health (2016) 8:189–200

123

Department of Jobs and Family Services, 2013; Ohio

School Boards, 2015; U.S. Census Bureau Fact Finder,

2014). These data suggest that the Partnerships Program

has potential for significant impact on young children in

Appalachia Ohio.

Because it is housed in an integrated health care agency,

the Partnerships Program is also exploring how their model

might be adapted to provide consultation in primary care

settings and unify health care with education systems to

benefit young children. The team is embracing a population

health management strategy to the promotion of Early

Childhood Whole Health & Wellness. Current partnerships

will expand across disciplines into public health, job and

family services, court systems, mental health primary care

and public education. Through the use of consultation

strategies, the team aims to promote communication and

partnership within communities to enhance access to care

for families.

Program sustainability planning never ends, but the

Partnerships Program has successfully diversified revenue

streams to not only maintain current level of services, but

also expand throughout the region. Multiple factors

influence sustainability, including the funding options,

evidence of the program’s effectiveness and evaluation of

the program’s return on investment. The Partnerships

Program has successfully leveraged program evaluation

results to have school partners, and Head Start programs

provide small contracts for consultation services. The

bigger success has been in using evaluation results to

obtain funding from Ohio Mental Health and Addiction

Services. Finally, Medicaid and other 3rd-party reim-

bursement are used to sustain the targeted and intensive

consultation services.

Conclusion

‘‘The counterbalance of trauma is resiliency, the ability of

an individual or community to withstand and rebound from

stress (Wolpow et al., 2011, p. 14).’’ By positively

impacting the resilience of children through the develop-

ment of compassionate teacher relationships, the Partner-

ships Program, Project LAUNCH’s Workforce Initiative

and participating schools have potentially made contribu-

tions toward diminishing the effects of trauma and of

regional disparities with the hope that children in the region

are better able to learn and thrive. This was accomplished

in the context of a community–school partnership which

created synergy—allowing each partner to accomplish

goals they could not accomplish alone given a shortage of

manpower and material resources. This is consistent with

an ecological view of trauma and resiliency that includes

the interconnectedness of students, their families and their

communities. This view also suggests that traumatic events

and regional stressors related to poverty impact not only

the resilient capacities of individuals, but also the ability of

the entire community to foster health and resiliency among

all its members (Harvey, 1996). By networking together,

the Partnerships Program, Project LAUNCH and schools

have become stronger than they could ever have become

working in isolation. This collaboration, born out of

necessity in impoverished rural Appalachia, can serve as a

powerful example of what can be accomplished for any

school located within any community when individuals

work together to develop a trauma-informed system of care

for children.

References

Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C.

H., Perry, B. D., et al. (2006). The enduring effects of abuse and

related adverse experiences in childhood. European Archives of

Psychiatry and Clinical Neuroscience, 256(3), 174–186.

Bracken, B. A. (1987). Limitations of preschool instruments and

standards for minimal levels of technical adequacy. Journal of

Psychoeducational Assessment, 5, 313–326.

Brennan, E., Bradley, J., Allen, M., & Perry, D. (2008). The evidence

base for early childhood mental health consultation in early

childhood settings: Research synthesis addressing staff out-

comes. Early Education and Development, 19(6), 982–1022.

doi:10.1080/10409280801975834.

Briggs-Gowan, M., Carter, A., Clark, R., Augustyn, M., McCarthy,

K., & Ford, J. (2010). Exposure to potentially traumatic events in

early childhood: Differential links to emergent psychopathology.

Journal of Child Psychology and Psychiatry and Allied Disci-

plines, 51(10), 1132–1140. doi:10.1111/j.1469-7610.2010.

02256.x.

Buss, K., Warren, J., & Horton, E. (2015). Trauma and treatment in

early childhood: A review of the historical and emerging

literature for counselors. The Professional Counselor Digest,

8(2), 6–8.

Chandler, L. (1981). The source of stress inventory. Psychology in

Schools, 18(2), 164–168.

Cohen, E., & Kaufman, R. (2000). Early childhood mental health

consultation, DHHS Pub. No. CMHC-SVP0151. Rockville,

MD: Center for Mental Health Services, Substance Abuse and

Mental Health Administration.

Cole, S., O’Brien, J., Gadd, M., Ristuccia, J., Wallace, D., & Gregory,

M. (2013). Helping traumatized children learn: Supportive

school environments for children traumatized by family violence.

Boston, MA: Massachusetts Advocates for Children Trauma and

Learning Policy Initiative.

Geller, S., & Lynch, K. (1999). Teacher opinion survey. Richmond:

Virginia Commonwealth University Intellectual Property Foun-

dation and Wingspan LLC.

Gilliam, W. (2008). Preschool mental health climate scale. Unpub-

lished survey. Harvard University.

Harvey, M. R. (1996). An ecological view of psychological trauma.

Journal of Traumatic Stress, 9(1), 3–22.

Hepburn, K., Kaufman, R., Perry, D., Allen, M., Brennan, E., &

Green, B. (2007). Early childhood mental health consultation:

An evaluation tool kit.Washington, DC: Georgetown University,

Technical Assistance Center for Children’s Mental Health; Johns

School Mental Health (2016) 8:189–200 199

123

Hopkins University, Women’s and Children’s Health Policy

Center; and Portland State University, OR, Research and

Training Center on Family Support and Children’s Mental

Health.

Kanner, A., Coyne, J., Schaefer, C., & Lazarus, R. (1981). Compar-

ison of two modes of stress management: Daily hassles and

uplifts versus major life events. Journal of Behavioral Medicine,

4(1), 1–37.

Kaufman, R., Perry, D., Irvine, M., Duran, F., Hepburn, K., &

Anthony, B. (2012). Creating practice-based principles for

effective early childhood mental health consultation services.

Washington, DC: Georgetown University.

Kids Count Data Center (2015). www.datacenter.kidscount.org.

LeBuffe, P., & Naglieri, J. (1999). Devereux early childhood

assessment: User’s guide. Lewisville, NC: Kaplan Press.

Ohio Department of Education (2014). School report cards. http://

education.ohio.gov/Topics/Data/Accountability-Resources.

Ohio Department of Health (2014). County health profiles. http://

www.odh.ohio.gov/odhPrograms/cfhs/cf_hlth/cha/hsprofiles.

aspx.

Ohio Department of Jobs and Family Service (2013). Appalachian

counties profile statistical and demographic data. https://jfs.

ohio.gov/county/cntypro/pdf13/Appalachian.stm.

Ohio School Boards (2015). www.ohioschoolboards.org

Perry, B. (2004). Maltreatment and the developing child: How early

childhood experience shapes child and culture. Inagural lecture

for the Margaret McCain Lecture Series, September 23, 2004.

Printed Copy.

Perry, D., Allen, M., & Brennan, E. (2010). The evidence base for

mental health consultation in early childhood settings: A

research synthesis addressing children’s behavioral outcomes.

Early Education and Development, 21(6), 795–824. doi:10.1080/

10409280903475444.

Phillips, D. A., & Shonkoff, J. P. (Eds.). (2000). From neurons to

neighborhoods: The science of early childhood development.

Washington, DC: National Academies Press.

Robert Wood Johnson (2014). County Health Rankings & Roadmaps.

http://www.countyhealthrankings.org/.

Simpson, J. S., Jivanjee, P., Koroloff, N., Doerfler, A., & Garcia, M.

(2001). Promising practices in early childhood mental health.

Systems of care: Promising practices in children’s mental

health, 2000 Series, Volume III. Washington, DC: Center for

Effective Collaboration and Practice, American Institutes of

Research. Retrieved from http://www.mentalhealth.samhsa.gov/

cmhs/ChildrensCampaign/practices.asp.

Substance Abuse and Mental Health Services Administration.

(2014a). SAMHSA’s Concept of Trauma and Guidance for a

Trauma-Informed Approach. HHS Publication No. (SMA)

14-4884. Rockville, MD: Substance Abuse and Mental Health

Services Administration, 2014.

Substance Abuse and Mental Health Services Administration.

(2014b). Trauma-Informed Care in Behavioral Health Services.

Treatment Improvement Protocol (TIP) Series 57. HHS Publi-

cation No. (SMA) 13-4801. Rockville, MD: Substance Abuse

and Mental Health Services Administration.

United States Census Bureau (2014). http://factfinder.census.gov

Wolpow, R., Johnson, M., Hertel, R., & Kincaid, S. (2011). The heart

of learning and teaching: Compassion, resiliency, and academic

success. Washington State Office of Superintendent of Public

Instruction (OSPI) Compassionate Schools. Olympia, WA.

http://www.k12.wa.us/CompassionateSchools/Resources.aspx.

Work, W., Cowen, E., Parker, G., & Wyman, P. (1990). Stress

resilient children in an urban setting. Journal of Primary

Prevention, 11(1), 3–17.

Zhang, Z., Infante, A., Meit, M., English, N., Dunn, M., & Bowen, K.

(2008). An analysis of mental health and substance abuse

disparities & access to treatment services in the Appalachian

Region. Final Report presented to the Appalachian Regional

Commission. Appalachian Regional Commission and National

Opinion Center.

200 School Mental Health (2016) 8:189–200

123