Consider discussion around the elements of community resilience. In this discussion consider the elements of community resilience and their significance to managing pote

ORIGINAL PAPER

Creating Trauma-Informed Schools for Rural Appalachia: The Partnerships Program for Enhancing Resiliency, Confidence and 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: ECMHC as 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 Childhood Mental 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