The APSAC Advisor is a peer reviewed quarterly news journal for professionals in the field of child abuse and neglect.
The APSAC Advisor provides succinct, data-based, practice-oriented articles that keep interdisciplinary professionals
informed of the latest developments in policy and practice the field of child maltreatment. It is designed to highlight
best practices in the field and publish original articles and current information about child maltreatment for professionals
from a variety of backgrounds including medicine, law, law enforcement, social work, child protective services, psychology,
public health and prevention in the U.S.
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2018 Number 3
Introduction to the Issue: Creating Trauma-Informed Systems of Care
Introduction to the Issue: Creating Trauma-Informed Systems of Care
The Partners for Change Project is a collaboration between the Dartmouth Trauma Interventions Research Center (DTIRC) and the New Hampshire Division for Children, Youth, and Families (NH DCYF), with a shared goal of improving the social and emotional well-being of children served by the state’s child welfare agency. Implementation involved training child welfare staff on the use of screening and assessment to inform case planning, coordination of trauma-informed services, and resource parent training in trauma. Our target population included youth from both child protection and juvenile justice sectors. Our most striking challenge has been contending with a cascade of contextual stressors including a devastating opioid crisis, staff shortages and leadership instability. We discuss how we navigated these stressors to optimize project uptake, offer a DCYF staff member’s perspective on enacting these practices in a system “under siege,” and present “lessons learned”.
Lessons From an Evaluation of a Trauma-Informed Care Initiative in Child Welfare
Evaluating trauma-informed care (TIC) initiatives in child welfare (CW) is a complex undertaking. Numerous challenges emerge throughout the evaluation process, from defining and operationalizing the construct of TIC, to assessing the effectiveness of intervention components separately and in aggregate, to detecting associations between TIC and child, family, and system outcomes. This article highlights lessons learned through a mixed method, multi-source, longitudinal evaluation of the Massachusetts Child Trauma Project (MCTP). While results indicated positive outcomes across intervention domains, we also encountered a number of evaluation challenges along the way. We describe three particular issues that emerged - measuring TIC outcomes, lack of consistent engagement among service providers and families, and turnover among providers - as well as our strategies for addressing them.
The following article provides a practice perspective on the Initial Implementation stage (Fixsen, Blasé, Timbers, & Wolf, 2001) of a collaborative case planning protocol between child welfare and mental health agencies using the Child and Adolescent Needs and Strengths (CANS) tool. Woven throughout the article is a fictional case example used to highlight barriers and illustrate potential solutions to cross-sector implementation. Although some barriers have been quickly and easily overcome, others present ongoing challenges. Nonetheless, many key staff at the local and state level are engaged, supportive, and committed to this implementation and the state continues to make steady progress toward trauma-informed, collaborative case planning around the CANS. Indeed, as barriers arise, they continue to be addressed and resolved using the same innovative and collaborative spirit that is at the heart of the CANS protocol itself. The fictional case exemplifies how collaborative teaming, when using the CANS to its full potential, can support the needs of children who have experienced trauma and maltreatment, as well as the adults who care for them.
Implementation of Trauma Screening in Three Tribal Communities
Implementation of a trauma-screening instrument into child welfare practice is one component of engaging in trauma-informed practice (Klain & White, 2013). The results of trauma screening can be used to enhance trauma-informed service delivery by responding to the unique needs and challenges faced by youth who have experienced trauma. The Transforming Tribal Child Protective Services project, a collaboration between of the National Native Children’s Trauma Center and Bureau of Indian Affairs (BIA) Rocky Mountain Region, selected, adapted, and began implementation of a trauma-screening instrument in three tribal communities. This article details the process by which the project approached implementation of a screening instrument as well as the challenges faced along the way. Importantly, these findings and lessons learned include commentary from BIA project partners regarding their experience of selecting, adapting, and implementing trauma screening into their practice. Steps for moving forward with implementing trauma screening into tribal child welfare practice are discussed.
New Hampshire’s child welfare system introduced family-level screening tools to assess attachment, belongingness, caregiver commitment, and caregiver ability to reflect on one’s own and the child’s experiences. The caregiver screens were done in conjunction with child-level screens capturing trauma exposure, PTSD, and well-being installed through a related project, along with other practice improvements targeting child welfare and mental health staff. Project leaders were challenged by slow uptake of the family functioning screens compared with the child-level screens, and few families were identified as having needs. To better understand the potential barriers to uptake and potential solutions, the team plans to analyze the screening tool data and conduct additional focus groups with staff and parents.
Screening for Mental Health Needs in Child Welfare: Do We Also Need to Screen for Trauma?
Children involved in the child welfare system have high rates of mental health and trauma-related problems, yet many children with an identified need do not receive mental health services. In California, a recent initiative resulting from a class action lawsuit established the requirement for all counties statewide to implement screening procedures to identify mental health needs among children involved with child welfare services in order to increase access to mental health assessment and treatment services. In this article, we describe results from the implementation of a screening approach in a county child welfare agency in California to highlight the importance of screening for trauma-related concerns in conjunction with screening for general mental health needs. Implications for the delivery of services for children involved in the child welfare system are discussed.
What Is Foster Parents' Role in Trauma-Informed Child Welfare Practice?
Although foster parents are the cornerstone of the foster care system, they often lie outside of formal structures and decision-making processes at both the child and agency level. This can cause problems when agencies seek to implement trauma-informed practices, which are intended to support the care of children but can instead be experienced as burdensome. This article provides examples of how foster parents were actively involved in the planning and implementation of trauma-informed practices in New York City-based Treatment Family Foster Care programs, discusses challenges and benefits of foster parent involvement in such activities, and provides recommendations for deeper foster parent engagement and collaboration in the design and implementation of trauma-informed child welfare practices.
In response to concerns that foster parents’ reports on child mental health symptoms within the first 30-60 days post-placement may not be valid, the Washington State Creating Connections project team conducted a cross-informant study of the interrater reliability of a key screening measure, the Pediatric Symptom Checklist-17. Additionally, in an effort to gather information about how child mental health status changes over time when children remain in care, we initiated a centrally managed “ongoing mental health screening program” to re-assess children and youth who remain in the system for six months or longer. Results indicated that youth self-report ratings were slightly more associated with their foster parents’ ratings than biological parents’ for internalizing and externalizing subscales. Between baseline and 6-month follow-up, approximately 31% of children and youth showed improvement, 10% deteriorated, 25% remained consistently below clinical criteria, and 34% remained consistently above clinical criteria. We conclude with lessons learned and implications for the field. Commentary is provided by project partners at the Washington State Department of Social and Health Services, Children’s Administration.
One of the most daunting challenges of creating system-level change is maintaining progress over time and through leadership transitions. However, during multi-year implementation projects for child-serving social service systems, such as child welfare and children’s behavioral health, leadership change is the norm. These changes can create shifts in priorities, perceptions, and decision making, often creating new currents for the organizational context in which the change is implemented. With very limited research to guide policy makers, system leaders, and implementation intermediaries, there is a great deal still to understand about this frequent occurrence and how it serves to facilitate or hinder implementation progress. As an initial step to further explore this topic, we propose a model for considering crucial contributing factors for an implementation project when leadership change occurs. We then offer a case study based on a multi-year, trauma-informed care project implemented within several child welfare and behavioral health systems to apply the model and explore the outputs in the model. Finally, we discuss next steps for implementation intermediaries, policy makers, and social service system leaders to address the impact of leadership change.
Policy Change to Support Trauma-Informed Care in Child Welfare
Although research on trauma-informed care in child welfare is increasing and guidelines have been developed to help agency administrators design trauma-informed organizational cultures and services, very little is known about creating internal trauma-informed policies and procedures and how they can support and sustain practice components of trauma-informed care. This article describes the challenges created by lack of information about trauma in a public child welfare agency’s internal policies and procedures at the beginning of a statewide initiative to implement trauma-informed care principles into practice. An additional challenge was created by lack of a defined agency process to develop policies and procedures or modify existing ones. Using guidelines established for designing trauma-informed child welfare systems, the authors describe the planning and implementation process for developing trauma-informed child welfare policies to support the implementation of trauma-informed care in a state child welfare agency. They present results of a 3-year process that included the review and modification of 23 major child welfare policies and procedures to support practice changes being simultaneously implemented. Lessons learned are described and recommendations made for developing policies and procedures to support trauma-informed care in child welfare.
Creating Trauma-Informed Systems of Care: Reflections on the Special Issue
Few would disagree that the abuse and neglect of our nation's children is truly one of the most concerning public health problems of our time. They physical, emotional, psychological, and economic burdens of abuse and neglect are staggering, yet are also preventable. Building coordinated systems of care for family support, inclusive of early intervention services (e.g., home visitation) are key to moving upstream to ensure that abuse and neglect never occur. Creating systems and processes for transitioning children and families across the service continuum (and and various levels of intensity) depending upon need is essential in our pursuit of preventing trauma and adversity.
APSAC Advisor 30(3): Full Issue