The Importance Of A Trauma-Informed Child Welfare System

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ISSUE BRIEFS MAY 2020The Importance of a TraumaInformed Child Welfare SystemTrauma refers to a deeply stressful experienceor its short and long-term impacts. Becauseexposure to trauma can cause a host of problemswith lifelong consequences, early screening andintervention is essential. Child maltreatment cancause traumatic stress in some children, whileothers are more resilient and show few, if any,lasting effects. Widespread recognition of trauma'sharmful impacts and the related consequencesfor children, families, and society has resulted inFederal, State, and local initiatives over the lastdecade to promote trauma-informed care.This issue brief outlines the essential componentsof a trauma-informed child welfare system andfeatures examples from State and local programsthat are incorporating trauma-informed practice.After providing a brief overview of trauma and itseffects, the brief explores trauma-informed practiceand the importance of strengthening familiesand communities to help them develop resilienceand heal. The brief concludes by highlighting theimportance of cross-systems collaboration increating a trauma-informed child welfare systemthat improves child and family well-being.WHAT'S INSIDETrauma and its effectsWhat is trauma-informed practice?Transitioning to a trauma-informed childwelfare systemBuilding resilience: The role of protectivefactorsCross-system collaborationConclusionAdditional resourcesReferencesChildren's Bureau/ACYF/ACF/HHS 800.394.3366 Email: info@childwelfare.gov https://www.childwelfare.gov1

Some of the information in this issue briefis based on interviews with practitionersand thought leaders who have been at theforefront of implementing and evaluatingtrauma-informed child welfare practice,including U.S. Department of Health andHuman Services (HHS) grantees fundedthrough the Children's Bureau and theSubstance Abuse and Mental Health ServicesAdministration (SAMHSA).Historical trauma affects populationswho have experienced cumulative andcollective trauma over multiple generations(e.g., American Indians, African Americans,immigrant groups, families experiencingintergenerational poverty) (Brave Heart,1998). Children within these families mayexhibit signs and symptoms of trauma—TRAUMA AND ITS EFFECTSsuch as depression, grief, guilt, and/orAccording to SAMHSA, "individual traumaresults from an event, series of events, or setof circumstances that is experienced by anindividual as physically or emotionally harmfulor life threatening and that has lasting adverseeffects on the individual's functioning andmental, physical, social, emotional, or spiritualwell-being" (HHS, SAMHSA, 2014, p. 7). Traumathat follows a single event and that is limitedin time (such as a car accident, shooting, orearthquake) is called acute trauma. Complextrauma occurs when children are exposed tomultiple traumatic events over time that aresevere, pervasive, and interpersonal in nature(such as repeated abuse and neglect) andthat cause long-term harmful consequences(National Child Traumatic Stress Network[NCTSN], 2014). Complex trauma mayinterfere with a child's ability to form secureattachments to caregivers and many otheraspects of healthy physical and mentaldevelopment.experienced traumatic events.Children's responses to trauma are affected bymany factors, including their age at the timeof the event, the severity of the traumaticevent, their caregivers' reactions, and aprior history of trauma and other behavioralhealth conditions (NCTSN, n.d.-a). Traumaticanxiety—even if they have not personallyexperiences can cause a "fight, flight, orfreeze" response that affects children's bodiesand brains and overwhelms their naturalability to cope. Chronic exposure to traumacan create toxic stress, which interferes withnormal child development and can causelong-term harm to children's physical, social,emotional, or spiritual well-being. This canimpair a child's emotional responses; ability tothink, learn, and concentrate; impulse control;self-image; attachments to caregivers; andrelationships with others. Across the life span,for example, complex traumatic experienceshave been linked to issues such as addiction,depression and anxiety, and risk-takingbehavior (NCTSN, n.d.-c). These in turncan lead to a greater likelihood of chronicill health, including obesity, diabetes, heartdisease, cancer, and stroke (Harvard Women'sHealth Watch, 2019).A recognition of the potentially lifelongconsequences of trauma from adversechildhood experiences (ACEs) is at the coreof Federal and State child maltreatmentprevention policies and initiatives. ChildChildren’s Bureau/ACYF/ACF/HHS 800.394.3366 Email: info@childwelfare.gov https://www.childwelfare.gov2

Welfare Information Gateway's AdverseChildhood Experiences webpage discussesimpacts from traumatic stress and offers awide variety of prevention and informationresources. Information Gateway's factsheet,Long-Term Consequences of Child Abuse andNeglect, explores these impacts further.For detailed information and resources, seeSAMHSA's manual, Concept of Trauma andGuidance for a Trauma-Informed Approach,and the HHS Administration for ChildrenFamilies (ACF) toolkit titled Resource Guide toTrauma-Informed Human Services.WHAT IS TRAUMA-INFORMEDPRACTICE?Trauma-informed practice involves anongoing awareness of how traumaticexperiences may affect children, families,and the human services professionals whoserve them (NCTSN, 2016). Trauma-informedchild welfare staff recognize how clients mayperceive practices and services. They areaware of how certain actions and physicalspaces have the potential to retraumatizeor trigger behaviors in the families theyserve (HHS, ACF, n.d.). Trauma-informedpractice likewise acknowledges the realityof secondary traumatic stress (STS) andincorporates efforts to address and mitigateit so staff can be grounded and effective intheir interactions with families or clients andfamilies.NCTSN (n.d.-b, para. 1) defines a traumainformed system as one in which programsand agencies "infuse and sustain traumaawareness, knowledge, and skills into theirorganizational cultures, practices, andpolicies" and use the best available scienceto "maximize physical and psychologicalsafety, facilitate the recovery of the child andfamily, and support their ability to thrive." Itis an ongoing commitment that involves theday-to-day work of the entire system. Childwelfare systems that are trauma informedare better able to address children's safety,permanency, and well-being needs. Serviceimprovements include more childrenreceiving the trauma screenings, assessments,and evidence-based treatments (EBTs) theyneed. These improvements, in turn, mayproduce better outcomes for children andfamilies, including the following (HHS, 2013): Fewer children requiring crisis services,such as emergency department visits orresidential treatment Decreased prescriptions for psychotropicmedications Fewer foster home placements, includingreentries Overall improved child functioning andwell-beingSAMHSA notes that a trauma-informedpractice achieves the following (HHS,SAMHSA, 2014): Realizes the impact of trauma Recognizes the signs and symptoms oftrauma in clients, families, staff, and others Responds by fully integrating knowledgeabout trauma into policies, procedures, andpractice Resists the retraumatization of children andthe adults who care for themChildren’s Bureau/ACYF/ACF/HHS 800.394.3366 Email: info@childwelfare.gov https://www.childwelfare.gov3

SAMHSA also notes that trauma-informedcare recognizes the importance of safety;trustworthiness and transparency; peersupport; collaboration and mutuality;empowerment, voice, and choice; andcultural, historical, and gender issues (HHS,SAMHSA, 2014).TRANSITIONING TO A TRAUMAINFORMED CHILD WELFARESYSTEMMoving to a trauma-informed approachrequires a major commitment from childserving systems. The Children's Bureauawarded three clusters of grants in 2011,2012, and 2013 to help child welfare agenciesbecome more trauma-informed at theindividual and systems levels to improvesafety, permanency, and well-being forchildren and families. These grants includeIntegrating Trauma-Informed and TraumaFocused Practice in Child Protective ServiceDelivery (HHS-2011-ACF-ACYF-CO-0169),Initiative to Improve Access to Needs-Driven,Evidence-Based/Evidence-Informed Mentaland Behavioral Health Services in ChildWelfare (HHS-2012-ACF-ACYF-CO-0279), andPromoting Well-Being and Adoption AfterTrauma (HHS-2013-ACF-ACYF-CO-0637).The grants explored key elements in buildinga trauma-informed child welfare system,including routine screening and assessment,workforce development, acknowledgementand treatment of STS, measurement-drivencase planning and referral to evidencesupported treatment, changes to data systems,and sustainability. This section explores someof the basic components of a trauma-informedsystem and related grantee work.SCREENING AND ASSESSMENTScreening and assessment are fundamental toidentifying children and families with traumahistories and, if necessary, securing effectivetreatment as soon as possible. The goals oftrauma screening and assessment include thefollowing: To learn about a child's trauma history,identify current symptoms and functionaldelays and identify children who needfurther assessment and possible treatment To conduct a more detailed clinicalevaluation for children whose traumascreen indicates a trauma history combinedwith psychological symptoms and/orfunctional delays, which will form the basisfor treatment planning To gather data about a child's strengths andneeds via a functional assessment, measureimprovement in skills and competenciesand inform ongoing case planning To measure outcomes to ensure thatservices are achieving desired effects at thechild level, and, if not, to inform changes tothe treatment plan To identify changes needed at the systemlevel to improve the effectiveness of theservice arraySeveral considerations are involved inselecting the appropriate screening andassessment instruments including thefollowing:Length. Initial screenings should be as briefas possible. If the initial trauma screeningis positive, a mental health clinician shouldfollow up with a thorough assessment.Children’s Bureau/ACYF/ACF/HHS 800.394.3366 Email: info@childwelfare.gov https://www.childwelfare.gov4

Screening for trauma exposure versusscreening for symptoms. Tools that facilitateconnections between the two will helpidentify more appropriate referrals.Administration and data-sharing. Agenciesand partners should assess the ease withwhich data can be shared. Is the screeningadministered by paper and pencil or bycomputer entry that links to an existingdata system? Is the tool self-scoring? Is theinformation taken from the parent, the child,or case records?Costs. Items to consider include the initialpurchase of the tool, required training, andexpenses associated with data collectionand/or analysis.Psychometric properties. How accuratelydoes the tool measure what it purports tomeasure? How many false positives or falsenegatives are likely?State Examples of Screening and AssessmentWorkIn Connecticut, statewide trauma screeningwas implemented as a major part of itsCollaborative on Effective Practices forTrauma (CONCEPT), a Federal grant in theIntegrating Trauma-Informed and TraumaFocused Practice in Child Protective ServiceDelivery cluster designed to improveoutcomes for trauma-exposed children. Thegrant resulted in the statewide use of a briefscreening tool, the Child Trauma Screen,developed by Connecticut's Department ofChildren and Families (DCF) in collaborationwith the Child Health and DevelopmentInstitute (CHDI) and Yale University.The screening tool is used during themultidisciplinary evaluations that take placewhen children come into DCF care.In North Carolina, the Judicial College atthe University of North Carolina's School ofGovernment is training judges to becomemore trauma informed. One unintendedconsequence of widespread training hasemerged, however. As judges learned aboutone highly evidence-based treatment forchild trauma, Trauma-Focused CognitiveBehavioral Therapy (TF-CBT), some begancourt-ordering children and youth in thechild welfare system to receive that specifictreatment. Now, the North Carolina ChildTreatment Program (NC CTP) and otherstakeholders are working to ensure thatchildren and youth receive a trauma-informedclinical assessment and the most appropriatetreatment, since no single treatment willwork for every child. NC CTP trains cliniciansin several EBTs, including TF-CBT, parentchild interaction therapy, child-parentpsychotherapy, structured psychotherapy foradolescents responding to chronic stress, andCBT for children and youth with problematicsexual behavior (M. Blythe, personalcommunication, October 14, 2019).For additional resources on screeningchildren for trauma and related assessmenttools, visit the following webpages: Screening and Assessment of Child Trauma(Information Gateway) Screening and Assessment (NCTSN) Screening Tools (SAMHSA)Children’s Bureau/ACYF/ACF/HHS 800.394.3366 Email: info@childwelfare.gov https://www.childwelfare.gov5

WORKFORCE DEVELOPMENTThe development of a trauma-informedworkforce is an essential first step inimplementing an effective trauma-informedsystem. It is important to integrate a traumaperspective in the organization's day-to-dayactivities so that all levels of agency staff—receptionists, caseworkers, supervisors,managers, administrators, and other programstaff—consider this as foundational to theirwork. This includes training for foster andadoptive parents.Moving to a trauma-informed approachrequires the workforce to make paradigmshifts in the areas listed below: Perspective. Becoming a trauma-informedsystem involves shifting the conversationfrom asking "What's wrong with you?"to "What happened to you?" Traumaticstress is often misunderstood andmisdiagnosed as a behavioral problem byfoster parents, child welfare workers, andother professionals. Applying a traumainformed lens involves close considerationof an individual's trauma experience as anunderlying explanation for behavioral oremotional issues. Goals. The focus of child welfare servicesis often on substantiating a case of abuseor neglect and ensuring a child's physicalsafety. With trauma-informed care, thegoal includes helping children heal fromthe impact of the trauma and improvingtheir social and emotional well-being whilepreventing additional trauma. Importance of collaboration. When childwelfare agencies successfully work withother service systems through improvedcommunication, collaboration on joint goals,data sharing, and strategic use of fundingstreams, they are more likely to enhancewell-being and maximize access to services. Focus on early intervention. A traumainformed child welfare system reflectsthe understanding that focusing moreresources on the identification of traumaand early intervention services may preventor mitigate some of the long-term effects. Approach to families. It is important tobe clear with families about the boundarybetween their involuntary participation inthe child welfare system (i.e., when thereis a substantiation of maltreatment) andwhat may be their voluntary participation inservices to promote healing from trauma. Awareness of intergenerational trauma.It also is important to understand that,like their children, caregivers' challengingbehaviors may be most productively viewedas maladaptive responses to their owntrauma. Role of child welfare professionals. Withthe shift in attention toward well-beingand healing, the child welfare professional'srole changes. Staff will spend more timescreening for trauma, facilitating effectivemental health treatment, and followingup to ensure appropriate progress isbeing made toward those treatmentgoals, including monitoring the use ofpsychotropic medication.Children’s Bureau/ACYF/ACF/HHS 800.394.3366 Email: info@childwelfare.gov https://www.childwelfare.gov6

Awareness of STS. Hearing about children'sand families' trauma histories may result inSTS among professionals and caregivers.Left untreated, this can decreaseeffectiveness and lead to excessive burnoutor turnover. This often occurs in addition toworkers' experiences with primary trauma(e.g., witnessing violence, participating ina removal, being threatened) or their ownpersonal trauma histories. Being traumainformed requires attention to trauma'seffects on all participants in the system,including caregivers and service providers.As agencies move toward establishing atrauma-informed workforce, they will need toestablish practices and protocols that addressthe following challenges cited by the U. S.Government Accountability Office (2019): High rates of child welfare staff turnover Insufficient funding and staff time to spendon trauma initiatives Lack of trained cliniciansThe National Child Welfare WorkforceInstitute (NCWWI) offers several trainingresources on trauma-informed practice,STS, and staff burnout. Some of the practicesbelow provide examples of how jurisdictionsare working to overcome these barriers.Trauma Systems TherapyIn child welfare, there has been a shift towarda more holistic approach to trauma-informedcare and a recognition that everyone in anorganization—regardless of their rank orlevel—should be trained in helping individualswho experience trauma feel more comfortableand confident. Saint Francis Ministries, anonprofit organization serving children andfamilies in Kansas, Nebraska, Oklahoma,Arkansas, Texas, and Central America, hasimplemented a Trauma System Therapy (TST)approach to become more trauma informed.TST is both a clinical and organizationalmodel that coordinates care and addressesthe social environments of traumatizedchildren. Saint Francis has made a systemwidecommitment to becoming trauma informedthat includes the following (P. Cornwell,personal communication, November 8, 2019): An organizational plan with timelines andspecifics for pilot testing (location, numbersof children to serve, staff involved, etc.) Measurements of completion (training,number of children eligible, number ofindividuals treated, etc.) Implementation teams, which representexecutive-level leadership, midlevelmanagement, clinical staff, andmultidisciplinary treatment staff, thatreport to the organization's leadership "Trauma champions" within each ofthe teams to become TST trainers andcoaches/consultants who train across theorganization as additional program sitesemerge and as new staff are hired Application of trauma-informed care ona larger scale through an organizationwide committee that assesses a varietyof safety-related measures, the reviewof stress and burnout surveys from staff,and the implementation of environmentalculture surveys that help the organizationunderstand its progress in becoming moretrauma responsiveChildren’s Bureau/ACYF/ACF/HHS 800.394.3366 Email: info@childwelfare.gov https://www.childwelfare.gov7

Creation of groups to address staff burnoutand STS Engagement of evaluators to assess theorganization's trauma-informed practicesand processes and ensure sustainabilityFor more on TST, visit the NCTSN website.WORKFORCE TRAININGIt is essential that child welfare professionalsrecognize trauma and provide early andappropriate interventions for childrenand families who have experienced childabuse, neglect, or other acts of violence.Trauma training should be introducedfrom the beginning of each staff member'semployment. In addition to the basics aboutwhat trauma is, its impact on the brain, andhow it affects children (including the role oftriggers and reminders), training topics shouldinclude the following: How to screen children for trauma Children's need for physical andpsychological safety Resiliency case planning (i.e., using servicesto build a child's resilience and sense ofcompetency) When, how, and where to refer children fo

for children, families, and society has resulted in Federal, State, and local initiatives over the last decade to promote trauma-informed care. This issue brief outlines the essential components of a trauma-informed child welfare system and features examples from State and local

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