Diligent Recruitment Webinar Series December 4, 2012

1. Measuring Trauma in Child Welfare PopulationsRuth Hubbell McKey, Ph.D.Elliott Graham, Ph.D.James Bell Associates, Inc. Diligent Recruitment Webinar Series December 4, 2012

2. CWS and Trauma: Some Background • Children in the child welfare system experience a variety of traumatic events. • For example, child abuse, neglect, exposure to family or community violence, removal, and separation from parents and siblings. • Child welfare must coordinate with mental health systems to ensure children receive the services they need.

3. What is Child Traumatic Stress? • Child traumatic stress refers to the physical and emotional responses of a child to events that threaten the life or physical integrity of the child or of someone critically important to the child (such as a parent or sibling). • Traumatic events overwhelm a child’s capacity to cope and elicit feelings of terror, powerlessness, and out-of-control physiological arousal. • (Wilson, 2009)

4. Types of Traumatic Stress • Acute trauma is a single traumatic event that is limited in time. • Chronic trauma refers to the experience of multiple traumatic events. • Complex trauma describes both exposure to chronic trauma—usually caused by adults entrusted with the child’s care—and the impact of such exposure on the child.

5. Effects of Trauma Exposure • Attachment: Social isolation, problems with empathy • Biology: Hypersensitivity to physical contact, unexplained medical problems • Mood Regulation: Difficulty controlling and describing feelings • Disassociation: Feelings of detachment & depersonalization • Behavior Control: Poor impulse control, aggressiveness, self-destructive behavior • Cognition: Problems with concentration, completing tasks, planning, language development • Self Concept: Low self-esteem, shame, guilt

6. Childhood Trauma and Other Diagnoses • Other common diagnoses for children in the child welfare system include: • Reactive Attachment Disorder • Attention Deficit Hyperactivity Disorder • Oppositional Defiant Disorder • Bipolar Disorder • Conduct Disorder • Many children with these diagnoses have a complex trauma history.

7. Trauma and the Influence of Culture • Social and cultural realities strongly influence children’s risk for and experience of trauma. • Many children who enter the child welfare system are from groups that experience: • Discrimination • Negative stereotyping • Poverty • High rates of exposure to community violence • These children may have more severe trauma symptomatology for longer periods of time.

8. Trauma and the Influence of Culture • People of different cultural, national, linguistic, spiritual, and ethnic backgrounds may define “trauma” differently and use different expressions to describe their experiences. • Child welfare workers’ own backgrounds can influence their perceptions of child traumatic stress and how to intervene. • Some components of trauma response are common across cultural backgrounds; others vary by culture. • Strong cultural identity and community/family connections can increase resilience to trauma or can increase children’s risk for and experience of trauma. • Example: Shame is a culturally universal response to child sexual abuse, but the victim’s experience of shame and the way it is handled by others (including family members) varies with culture.

9. Trauma and Child Developmental Stages • Child traumatic stress reactions vary by developmental stage. • Children exposed to trauma expend significant energy responding to, coping with, and coming to terms with the event. • This may reduce a child’s capacity to master age-appropriate developmental stages. • The longer traumatic stress goes untreated, the farther a child tends to stray from appropriate developmental pathways.

10. Trauma and Young Children • Young children who experience trauma may: • Become passive, quiet, easily alarmed • Become fearful, esp. regarding separations and new situations • Experience confusion around assessing threats and finding protection, esp. when a parent or caretaker is the aggressor • Regress to earlier developmental behaviors (e.g., baby talk, bed-wetting, crying) • Experience strong startle reactions, night terrors, or aggressive outbursts

11. Trauma and School-Aged Children • School-aged children who experience trauma may: • Have unwanted and intrusive thoughts and images • Become preoccupied with frightening moments from the traumatic experience • Replay the traumatic event in their minds to figure out what could have prevented it or how it could have been different • Develop intense, specific new fears linked to the original event • Alternate between shy/withdrawn behavior and unusually aggressive behavior • Become so fearful of recurrence that they avoid previously enjoyable activities • Have thoughts of revenge • Experience sleep disturbances that interfere with concentration and attention

12. Trauma and Adolescents • Trauma experienced by adolescents may lead to: • Anxiety and depression • Intense anger • Low self-esteem and feelings of helplessness • Aggressive or disruptive behavior • Sleep disturbances masked by late-night studying, television watching, or partying • Drug and alcohol use as a coping mechanism • Over- or under-estimation of danger • Expectations of maltreatment or abandonment • Difficulties with trust • Increased risk of re-victimization, esp. if the adolescent has lived with chronic or complex trauma

14. Diligent Recruitment and Trauma: Why It Matters • Reunification: Children who went home and stayed home had a four-fold increase in internalizing behaviorproblemsfrom baseline to 18-month follow-up. Although the percentage of children with behavior problems at 36-month follow-up decreased, twice as many children still met or exceeded clinical levels compared to baseline (Bellamy, 2008). • Kinship Care: Kinship placements were not predictive of better mental health outcomes regardless of the amount of time in kinship care (Fechter-Leggett & O’Brien, 2010). • Adoption: In assessments of children at 2, 4, and 8 years following adoption, adopted foster youth were more behaviorally impaired than their non-FC counterparts, although a number of non-FC youth displayed behavior problems as well (Simmel, Barth, & Brooks, 2007).

15. Diligent Recruitment and Trauma: Why It Matters • Out-of-home placement is a significant traumatic event for most children. • Trauma symptoms and associated behaviors often persist even after children go home, are placed with kin, or are adopted. • Resource families must learn to recognize and address trauma symptoms and behaviors expressed by children in their care. • Especially relevant to resource family retention.

16. Trauma Screening and Assessment • CWS-involved children should be: • Screened for trauma • Assessed for trauma • Provided a psychological evaluation (sometimes this is the trauma assessment)

17. Measures for Trauma Screening and Assessment • Measures used for this should be: • Reliable — Consistent in their use across time and settings • Valid — Accurate in measuring the psychological/functioning domain of interest • Have standardized norms — be tested with a sufficient population to provide guidance for interpretation of the measure • However, the psychometrics for many tools have not been developed.

18. Trauma Screenings • A brief measure administered to all children by CW staff at initial contact to determine exposure to potentially traumatic events/experiences or to identify possible traumatic stress symptoms/reactions (e.g., behavioral, educational, self-concept difficulties). • Trauma screenings are not diagnostic. • They do indicate if a child should be referred for a trauma assessment.

19. Trauma Assessment • Comprehensive process of evaluation conducted by a trained mental health provider. • Determines if symptoms of trauma are present. • Determines the severity of the symptoms and impact on child’s functioning. • More comprehensive and detailed than screening. • Examines trauma and developmental history; traumatic stress symptoms; broader mental health symptoms; caregiver/family needs; environmental issues; resources and strengths. • May include observations, administration of measures, and clinical interviews with child, caregivers, others.

20. Psychological Evaluation • Comprehensive diagnostic process of all functional domains (cognitive, developmental, social/emotional and personality). • Completed by licensed psychologist based on referral. • Measures used relate to reason for referral, but may also include standard psychological battery.

21. Trauma Screening Tools • Child and Adolescent Needs and Strengths (CANS) —Kisel, Blaustein, et al., 2009 • Age range 0-18. • Short version used as screener, longer version as assessment. • Gathers basic information on traumatic experiences and whether adjustment to trauma affects child’s functioning. • Collected from multiple sources.

22. Trauma Screening Tools (cont.) • Child Welfare Trauma Referral Tool — • (CWT) Taylor, Steinberg, and Wilson, 2006 • Age range 0-18. • Completed by caseworker. • Questions about the child’s history and presenting problems lead to identification of traumatic experiences.

23. Trauma Screening Tools (cont.) • Trauma Symptom Checklist for Children (and Young Children) (TSCC) — Briere, 1996 • Ages 8-16 for child version; Ages 3-12 for young children version. • Self-report for child version; Caregiver report for young children version. • 90-items; can also be used as an assessment. • Evaluates acute and chronic post-traumatic symptomatology in children who have experienced traumatic events. • Based on theories of development and child trauma. Provides information on other symptoms such as anxiety, depression, anger, and abnormal sexual behavior.

24. Trauma Screening Tools (cont.) • UCLA Post Traumatic Stress Disorder Reaction Index (UCLA-PTSD) • — • Pynoos, et al., 2004 • Age range 0-18. • Caregiver, child, or adolescent report depending on age. • 48-item semi-structured interview to assess a child’s exposure to 26 types of traumatic events. • Assesses PTSD diagnostic criteria.

25. Trauma Screening Tools (cont.) • Strengths and Difficulties Questionnaire (SDQ) — • Goodman, 1997 • Brief behavioral screening tool including 5 areas: (emotional symptoms, conduct problems, hyperactivity/inattention, peer problems, prosocial behavior) to yield a total difficulties score. • Parent, teacher, and child versions.

26. Trauma Assessment Tools • Trauma assessment may include checklists, assessments, interviews, and other measures. • Most of these instruments will be used in combination to complete a full trauma assessment.

27. Trauma Assessment Tools • Child and Adolescent Needs and Strengths (CANS)— Kisel, Blaustein, et al., 2009 • Long version can be used as an assessment (short version used as a screener).

28. Trauma Assessment Tools (cont.) • Child Behavior Checklist (CBCL) — • Achenbach and Rescoria, 2001 • Versions for young and older children. • Provides ratings for 20 competences and 120 problem items. • Includes open-ended items covering physical problems, concerns, and strengths. • Yields scores on internalizing, externalizing, and total problems. • Very widely used.

29. Trauma Assessment Tools (cont.) • Ages and Stages Questionnaires (ASQ) 2nd Ed. — • Bricker et al., 1999 • www.agesandstages.com • Developmental and social-emotional assessment for children from one month to 5 ½ years. • Examines strengths, trouble spots, developmental milestones. • Based on parent report.

30. Trauma Assessment Tools (cont.) • Trauma Symptom Checklist for Children (TSCC) — • Briere, 1996 • Age range 8-16. • Measures severity of post-traumatic stress and related psychological symptomatology in children who have experienced traumatic events (e.g., physical or sexual abuse, natural disasters, other major loss). • Based on child self-report.

31. National Child Traumatic Stress Network (NCTSN): Core Data Set • Developed to standardize data collected on CWS children related to clinical evaluation, evidence-based interventions, service use, and provider training. • Consists of forms and assessment measures that collect data on demographics, trauma exposure, client functioning, treatment services, and provider training. • Collected on over 10,000 children nationally. Includes: • TSCC • UCLA PTSD • CBCL • Youth Services Survey • Other tools, surveys, interviews, and focus group guides

32. For more information on these and other measures go to: • The Measures Review database at the NCTSN website (www.NCTSN.org) • -or- • Website of Psychological Resources, Inc. (www.parinc.com)

33. References Barto, B., Barnett, E., & Ake, G. (2012). The application of trauma screening/assessment in child welfare settings. Part II: direct level. NCTSN Training Series. Retrieved from www.NCTSN.org. Bellamy, J. (2008). Behavioral problems following reunification of children in long-term foster care. Children and Youth Services Review, 30, 216-228. Conradi, L., Wherry, J., & Kisiel, C. (2011). Linking child welfare and mental health using trauma-informed screening and assessment practices. Child Welfare , 90 (6), 129-147. Chadwick Trauma-Informed Systems Project: www.ctisp.org. Fechter-Leggett, M. O., & O’Brien, K. (2010). The effects of kinship care on adult mental health outcomes of alumni of foster care. Children and Youth Services Review, 32 (2), 206-213.

34. References (cont.) National Child Traumatic Stress Network (2012). NCCTS leadership: The core data set. Retrieved from www.NCTSN.org. Pynoos R., Fairbank, J. A., & James-Brown, C. (2011). Effectively addressing the impact of child traumatic stress in child welfare. Child Welfare, 90 (6), 7-11. Putnam, F., Perry, M., Putnam, K., & Harris, W. (2008). Childhood antecedents of clinical complexity. Presentation the Annual Meeting of the International Society for Traumatic Stress Studies, Nov 15, 2008, Chicago, IL. Simmel, C., Barth, R. P., & Brooks, D. (2007). Adopted youths psychosocial functioning: A longitudinal perspective. Child and Family Social Work, 12 (4), 336-348. Wilson, C. (2009). Understanding how trauma impacts children in child welfare and what to do about it. Presentation at the Department of Children and Family Services Conference, Cleveland, OH. Retrieved from: www.chadwickcenter.org/resources/resources.htm.

35. Questions and Discussion Ruth Hubbell McKey, Ph.D. Elliott Graham, Ph.D. James Bell Associates 3033 Wilson Blvd, Suite 650 Arlington, VA 22201 General Number: 703-528-3230 Direct Dial: 703-247-2653 (Ruth) 703-842-0958 (Elliott)