Section 4: Trauma in the Child Welfare System

A significant number of children who enter the child welfare system have experienced trauma that can have profound and lasting negative effects throughout their lives. In fact, there is mounting evidence that chronic, adverse conditions in a child’s background can lead to ongoing issues with social, cognitive, emotional, and behavioral well-being. These might include maladaptive behaviors, cognitive difficulties, problematic relationships, and mental health issues. In addition, children who enter the child welfare system after experiencing trauma are vulnerable, without proper interventions, to being further traumatized by the very system that was designed to protect and heal them.

It is possible for child welfare agencies to have a significant positive impact on the challenges presented by trauma-affected children through appropriate assessments, interventions, and services. Implementing these, however, requires an understanding of how trauma can affect children across various well-being domains. It also requires an understanding of the various tools available for assessing trauma as well as of the many strategies and interventions available to help trauma-affected children and families. Research throughout the past decade has shown that there is no age at which appropriate interventions with a child will not have at least some degree of success in lessening the effects of trauma.

This e-training module, which is divided into four main sections, provides basic information on how to deal with trauma in the child welfare system. The first section, Trauma Overview, provides background information about child maltreatment and how it can negatively affect children. It also describes complex trauma and its effect on a child’s well-being.

Section Two, Trauma-Based Screenings and Assessments, discusses the important role of screenings and assessments for trauma within the child welfare system, provides general information about trauma-informed screenings and assessments, and provides some specific examples of some screening/assessment tools.

Section Three, Trauma-Informed Systems, presents ideas for agencies to consider in creating a more trauma-informed environment. It discusses the critical importance of evidence-based, trauma-focused practice interventions by professionals and concludes with a discussion of strategies that agencies can put into place to become more trauma-informed.

Finally, Section Four, Additional Resources, includes a link to the documentary video Children and Families Having a Choice and a Voice, which provides basic trauma information and lessons learned from a 5-year demonstration grant program to test whether children with severe emotional disturbances who meet the requirements to receive services from a psychiatric residential treatment facility could be successfully served in a cost-effective manner with their families in the community. The section also provides a comprehensive list of Web-accessible books, articles, and other source material related to trauma in the child welfare system.

Trauma Overview

To fully understand the negative role that  trauma can play within the child welfare system, one must first understand the impact of child maltreatment upon children who enter the system.  While states have varying legal definitions, the term "child maltreatment" typically refers to a child who is physically, sexually, or emotionally abused or neglected; exploited; or exposed to domestic violence by a parent or caregiver.  These types of maltreatment can lead to childhood trauma.

Trauma itself can be defined as "simple" or "complex." Simple trauma refers to a single, isolated, definable traumatic event.  Even a single incident of maltreatment can be traumatic and lead to a wide range of potentially negative short-term psychological and behavioral responses from the child that include fear, dissociation, inability to regulate emotions, loss of trust, attachment disorders, and many other issues.

However, evidence also suggests that different types of abuse and neglect rarely occur in isolation. In other words, maltreated children often experience multiple types of abuse or neglect, which in turn results in even greater maladjustment and negative outcomes.  Complex trauma, also referred to as “chronic interpersonal trauma,” refers to a child’s experience of multiple traumatic events or maltreatment that often occur within the context of the child’s caregiving situation.  This chronic maltreatment can result in a lack of secure bonding between the child and his or her primary caregiver, which in turn can cause significant negative effects across multiple well-being domains.  However, children vary enormously in how they are affected by complex trauma, due in large part to a variety of protective and coping factors that each child may or may not possess.

For years, child welfare agencies have provided treatments to maltreated children that focus primarily on a child's mental health.  However, these traditional therapeutic treatments are often ill-designed to deal with victims of trauma and often fail to provide needed long-term support and flexible approaches.  To be effective in their work with maltreated children, agencies must be aware of the differences between treatments traditionally focused on mental health and treatments that are truly part of a trauma-informed system

The Administration on Children, Youth, and Families (ACYF) has developed a Framework for Social and Emotional Well-Being that establishes four well-being domains across which a child’s functioning can be assessed.  This framework helps provide child welfare agencies with an understanding of how to more effectively work with children whose lives have been affected by trauma.

Impact of Child Maltreatment

There is a well-recognized relationship between child maltreatment and a variety of negative emotional, developmental, and health consequences.  However, relatively new evidence also indicates that childhood trauma can actually alter the physiology of a child’s brain, which may lead to significant negative impacts on the child’s neurological development and mental health, and thus the child’s social, emotional/behavioral, cognitive, and physical/developmental domains.  These effects can diminish a child's relational competence and lead to the development of behavioral problems, which together can diminish the child’s capacity to maintain effective interpersonal relationships, progress academically and vocationally, and become a productive member of his or her community.  Furthermore, psychotropic medications may be inappropriately used to treat these effects.

Neurological Development

To understand how maltreatment can affect a child's neurological development, it is important to first understand that the brain is organized into and develops within four distinct regions.  These regions range from least to most complex, and each region develops, organizes, and becomes fully functional at different stages of a child's development.

One of the more critical functions of the lower, or "micro-level," brain regions is the creation of neural networks that facilitate simultaneous communication across the regions.  Impairment of these neural networks can result in a myriad of dysfunctions that extend from the lower regions to the higher, or "macro-level," regions.  Thus, brain development in the higher regions that control functions like perception, reasoning, emotion, and problem-solving is dependent on development in the lower regions.

Many of the micro-level brain processes, including the critical development of neural networks, are dependent on an optimal level of activation, which in part comes from the environment or experience of the child.  When the child has adverse experiences, such as loss, threat, neglect, or abuse, the brain’s developmental processes can be disrupted in the micro-level areas and the neural connections can wither.  This, in turn, can have a cascading negative effect on the macro-level regions of the brain.  Depending on the degree and duration of the adverse experience, these effects can be significant and hamper the child’s functioning well into adulthood.

Early childhood, during which neurons are organized to form the complex workings of the brain, is a critical time for brain development.  This development includes essential neurological processes that establish patterns of behavioral and emotional functioning during subsequent stages of life.  Since a child's early experiences and environment can significantly affect the development of specific areas of the brain, the impact of neglect and the impact of abuse on a child's brain can seriously affect his or her ability to regulate emotions and become emotionally connected with others in the future.

Impact of Neglect

Whether it is a lack of emotional or physical nurturance, neglect can negatively affect the child's neurological development.  If a caregiver is depressed, chronically stressed, inconsistent, or absent, this can adversely affect the brain’s neural networks that help the child to regulate stress and benefit from healthy, nurturing support.  Essentially, these early experiences between the caregiver and child create a template for the child’s brain, setting up associations that help determine the child’s balance between resilience and vulnerability.  Bonding and healthy caregiver/child interaction are critical in ensuring normal brain development; thus, the negative impact of neglect on the developing brain, beginning in the lower regions and expanding into the higher regions, can significantly impede a child’s ability to develop socially and emotionally, and to meet developmental milestones.

For example, one of an infant's primary tasks is to determine how to have his or her needs met.  Infants constantly assess whether their cries for comfort and food are answered or ignored.  When infants feel safe and secure and their needs for food and soothing are met, their brains are free to explore, focus on the objects and people in the world around them, and develop socially and cognitively.  If, however, responses to them are inconsistent or harsh, infants will concentrate their energy and brainwork on survival or ensuring that their needs are met.  As a result, it becomes increasingly difficult for them to interact with surrounding people and objects, as their mental and emotional resources are focused on other tasks and their brains shut out the stimulation needed to develop healthy cognitive and social skills.

Impact of Abuse

Abuse, like neglect, can severely affect a child's neurological development.  While mild or moderate levels of stress for a child within a supportive and nurturing environment can promote adaptive coping skills, abuse or severe neglect can expose children to chronic and abnormal levels of stress, which in turn can lead to elevated levels of cortisol, a stress hormone.  These levels can become toxic and stunt the tissue growth of the hippocampus, an area of the brain that affects the child’s ability to respond to future stress, regulate emotion, and retain memory.

Heightened stress can also impede the development of the prefrontal cortex, a part of the brain that controls critical functions like focusing, planning, self-regulation, and decision-making.  All of these functions are essential for children to successfully navigate their way later in life, academically, in relationships, and in the workplace. 

Mental Health

Children who have been maltreated, particularly those who have experienced complex trauma, may experience higher rates of mental health issues and more mental health diagnoses than other children.  Some of the most common diagnoses of maltreated children include:

  • Post-traumatic stress disorder (PTSD)
  • Attention deficit/hyperactivity disorder (ADHD)
  • Major depressive disorder (MDD)
  • Conduct disorder (CD)/oppositional defiant disorder (ODD)

Since many of the children entering the child welfare system meet the diagnostic criteria for mental health disorders before they enter foster care, it is important that child welfare agencies promote mental health screening and assessment early in the child’s involvement with the system.  It is equally important to remember that there is currently no single diagnosis for the full range of issues that can be experienced by children affected by complex trauma.  Behavioral health specialists may instead use one or several mental health diagnoses in an attempt to categorize the array of difficulties shown by many traumatized children.  However, traditional mental health treatments may not aid traumatized children to better control behaviors and improve social relationships.

For example, in a comprehensive analysis of trauma-informed assessments administered to children who entered foster care in Illinois between 2005 and 2011, the researchers found that it was possible for children to have a mental illness and, at the same time, display trauma symptoms.  The primary concern identified was that children did not receive trauma-focused treatment when they were either misdiagnosed with a mental illness or did not meet the criteria for PTSD.  In both cases, the critical need to effectively address the trauma symptoms was neglected.

Child welfare agencies must focus on developing effective trauma-based screenings and assessments to capture trauma history and symptoms in children whom they serve, rather than relying solely on mental health screening and diagnoses to pinpoint behavioral and mental health needs.  To be effective in this task, the relationship between trauma and mental health, and how decisions about treatment are affected by this interplay, must be understood.  Otherwise, a traumatized child's condition may be treated in isolation, thereby ignoring the disarray of the traumatized child’s condition as a whole. 

Relational Competence

Relational competence refers to a child’s ability to engage in beneficial caregiver and peer relationships, and navigate other social interactions.  Trauma-affected and vulnerable children frequently have difficulty forming and sustaining relationships.  This may be due to the absence of an early nurturing relationship with their primary caregiver.  Nurturing relationships provide the context within which a child learns about reciprocal relationships.  Also, in early adolescence, the neurological development of the brain areas most crucial to successfully forming interpersonal relationships may be hindered by traumatic stressors.

If, however, children in the child welfare system are able to form and sustain supportive relationships with peers and adults, and other protective and coping factors are strengthened, their ability to cope with trauma can be greatly enhanced.  Child welfare agencies should strive, through effective trauma-based screenings and assessments and trauma-informed systems, to strengthen the child’s capacity to successfully build meaningful relationships with others, including the child’s caregivers, by emphasizing the development and employment of critical interpersonal skills like cooperation, seeing another’s perspective, boundaries, and empathy.

While this skill-building is taking place, agencies, caregivers, and others must continually strive to enhance the child’s protective and coping factors by surrounding the child with caring, supportive adults; listening to the child; keeping the child’s world as predictable as possible; and ensuring that the child has a secure attachment relationship.  The goal is not only to enhance the child’s self-esteem, but to make the child feel as psychologically and physically safe as possible.

Behavioral Problems

The National Survey of Child and Adolescent Well-Being (NASCAW) study showed that behavioral problems warranting mental health or behavioral services are common in children who have been maltreated or traumatized.  Many of these children lack sufficient ability to regulate their emotions or impulsivity and may also have difficulty describing their feelings.  They may be unable to articulate their wishes and desires in a socially acceptable way, and may manifest behavioral problems externally through bullying, fighting, or opposition; or internally through withdrawal, anxiety, or fear in the face of non-threatening events, or crying easily.

Caregivers of traumatized children with behavioral issues in the child welfare system frequently have difficulty coping with these children in the home.  They do not understand why a child fails to respond to their affection, support, and structure with improved behaviors.  The caregiver may eventually ask for the removal of a child with behavioral problems, particularly if the child is defiant and aggressive.  This may further compound the child’s social and emotional difficulties, and make permanency even more elusive.

Psychotropic Medications

The use of psychotropic medications for children has risen over the past 10-15 years, although there is currently no definitive, comprehensive information that shows the prevalence of psychotropic medication use among children in the child welfare system.  However, published studies do indicate that there are higher rates of psychotropic medication use among children involved in child welfare than in the general population; older children, males, and children in residential or group settings are the most likely to have psychotropic medications prescribed.

Unfortunately, the full effect of these medications on a child's growth, development, and maturing neurological system remains unknown.  What is known is that psychotropic medications can have a variety of side effects, including lethargy, withdrawal, weight gain, poor appetite, irritability, and sleep disturbances.  They can also cause hallucinations, intrusive thoughts, and paranoia.

There are growing concerns that some children in foster care are prescribed too many psychotropic medications, that their dosages exceed approved recommendations, and that they are being prescribed psychotropic medication at too young an age.  There has, in fact, been a dramatic rise over the past 20 years in the use of antipsychotic medications with foster children.  A seven-state study found that the rate of antipsychotic medication use among foster children was almost nine times that of other Medicaid-covered children, even though foster children made up only three percent of the population of children on Medicaid.  An additional concern is that because there is no clear diagnostic label for complex trauma, a default to a mental health diagnosis is resulting in the inappropriate over-use of psychotropic medication for traumatized children.

Despite these concerns, the high rates of psychotropic medication use among children in foster care may indicate, at least in part, the high level of emotional and behavioral needs of this population.  Psychotropic medication may be necessary to effectively treat children or adolescents struggling with a mental illness, and can be helpful when children are so overwhelmed by their own behavior that their symptoms cannot be managed in other ways.  However, if untreated emotional trauma underlies the presenting symptoms, use of medication as a primary treatment may be ineffective or even exacerbate existing problems, and the stabilization needed to effectively support growth and healing will not occur.

Pending Developments in Psychotropic Medication

Some States have made attempts to regulate, at least to some extent, the use of psychotropic medication for behavior and mood management among foster children, encouraging caregivers to become more skilled in dealing with children’s challenging behaviors. Agencies are promoting more effective, evidence-based treatments for these children, coupled with trauma-focused training and education for staff and foster parents about caring for and managing behaviors of children with significant emotional and behavioral needs. The issues surrounding psychotropic medication use for children in foster care are being addressed through several Federal initiatives outlined in the ACYF Information Memorandum, Promoting the Safe, Appropriate, and Effective Use of Psychotropic Medication for Children in Foster Case (ACYF-IM-12-03).

Complex Trauma

The National Child Traumatic Stress Network (NCTSN), located at www.nctsnet.org, has defined complex trauma, also called "chronic interpersonal trauma," as a child’s experiences of multiple and sequential traumatic events within the context of the caregiving system.  Typically, these traumatic events incorporate two or more types of child maltreatment that begin in early childhood. 

Complex trauma typically involves the lack of a secure bond, or attachment, between a child and his or her caregiver.  The relationship between complex trauma and attachment is complicated.  A disruptive attachment pattern can be the source of complex trauma; conversely, traumatic events can disrupt the normal attachment process.  Because a caregiver bond is normally the fundamental source of stability and security in a child’s life, the lack of a primary attachment can result in the child’s inability to self-regulate emotion and relate beneficially to others.

Children exposed to complex trauma often experience lifelong problems that place them at risk for multiple dysfunctions, including:

  • Substance abuse or other addictions
  • Psychiatric disorders
  • Chronic physical illnesses
  • Poor parenting of their own children
  • Relationship and workplace problems
  • Involvement with the criminal justice system

Needless to say, the impact of complex trauma can be severe, diverse, and persistent across several domains of functioning, with difficulties extending from childhood through adolescence and into adulthood.  It is also critically important to understand the negative impact that complex trauma can have upon a child's neurological development.  In his booklet, Effects of Traumatic Events on Children, Dr. Bruce Perry emphasizes the need for understanding how trauma affects brain development and subsequent cognitive, social, and emotional development, and the implications for assessment and treatment of maltreated children.

Protective and Coping Factors

While exposure to complex trauma can adversely affect child development across multiple domains of functioning, the degree of the trauma's impact can change as the child is exposed to different stressors and developmental challenges.  Various protective and coping factors, including the child’s supportive relationships, self-esteem, and social competency, will affect how each child fares when exposed to trauma.  These factors, whether they are individual factors or family and environmental factors, can help buffer the effects of trauma, strengthening the child’s resilience and competence across various domains of functioning.

Understanding these protective and coping factors is critical to the child welfare practitioner’s ability to respond appropriately to children exposed to trauma, and is key to implementation of trauma-informed practice.  It is the responsibility of caregivers, child welfare practitioners, and other professionals to instill and/or enhance these factors in trauma-affected children to the greatest degree possible and set them on a pathway to healing.

Individual Factors

There are a variety of critical individual protective and coping factors, or traits, that relate to a child’s resilience and ability to cope with adverse events such as maltreatment and trauma.  Many maltreated children possess some of these traits to some degree.  They include:

  • Social supports, or well-developed interpersonal skills, and the ability to secure and maintain a circle of nurturing, supportive adults. Research suggests that strong interpersonal relationships may provide the best defense in coping with stress or trauma.
  • Involvement in validating experiences. Children who participate in experiences such as art, music, outdoor activities, and volunteering, are provided opportunities for success and validation, which helps build feelings of worthiness and lessen the effects of trauma.
  • Healthy self-esteem. A good self-concept and regular experiences of positive emotions promote resistance and resilience to the effects of trauma.
  • Adaptability. Flexibility in perspective, beliefs, and emotions is a protective factor against adverse experiences.
  • Aptitude. Resourcefulness and intellectual mastery can help mitigate the effects of trauma.
  • The ability to think rationally. This ability, which enables children to make sense of the actions of others and brings logical, clear ideas about their experiences to the forefront, is a factor in mitigating trauma.
  • Positive temperament. A positive temperment provides the ability to see things in as favorable a light as possible and helps children cope with the effects of trauma.
  • Positive beliefs about the world. Children who perceive the world as fair, safe, and predictable are generally better able to withstand the effects of trauma.
  • Degree of mastery and autonomy. When children feel that they have a sense of power and control over their lives, they can better deal with traumatic events.

It is important to remember that these protective factors interact differently in different children, and that some trauma-affected children can function fairly competently in some social and emotional areas but not in others.

Family and Environmental Factors

Unlike a child's individual factors, which are protective and coping factors intrinsic to the child, family and environmental protective and coping factors refer to factors that are generally outside of the child's control, such as the available extended support network.  These factors, which relate to a child’s resilience and ability to withstand trauma, include:

  • Positive attachment and connections to emotionally supportive and competent adults within the family or community. Parents or other significant adults who can provide emotional support and understanding can significantly increase a child's ability to cope effectively with trauma.
  • Socioeconomic resources. Children from families with adequate resources are much more likely to have fewer stressors than children from families with inadequate resources, and it is also likely that parents with adequate resources will be more able to provide support and resources that children need to mitigate trauma.
  • Ties to extended family. These ties can provide a child with additional supportive resources from a trusted network of adults and help mitigate the effects of trauma.
  • Caregiver/parental capacity to provide the child with a secure base and a secure attachment relationship. A child with a secure attachment will have more cognitive and emotional resources for dealing with trauma than a child with insecure attachments.
  • Caregivers/parents who are able to effectively manage their own response to the child’s trauma. Caregivers who stay calm, supportive of the child, and focused on meeting the child’s needs rather than their own provide an important defense against the negative effects of the child's trauma.
  • Caregivers/parents who believe and validate the child’s experience. Knowing that someone understands and cares about what has happened to them greatly increases the child’s ability to cope with adversity.
  • Availability of community supports. Accessible community social organizations that promote healthy child development are valuable resources to children dealing with adverse situations.
  • Communities that send a clear message of behavior and events that are acceptable. Children and caregivers who recognize clear boundaries of acceptable and non-acceptable behavior feel more supported in dealing with trauma.

These family and environmental protections help mitigate the effects of maltreatment and trauma experiences for a child.  However, like individual protections, the family and community supports are present in different degrees for different children, and their interplay in a specific child is complex and varied.

ACYF Framework for Social and Emotional Well-Being

There are various constructs, or frameworks, that have been designed to present, in an easily understood fashion, how both healthy and impaired functioning affects children across multiple domains of their lives and relates directly to how they interact with others and function on a daily basis.  Many of these frameworks describe "domains of functioning" that have some commonality or overlap with other constructs.

The framework developed by the Administration on Children, Youth, and Families (ACYF) focuses on social and emotional well-being.  The framework, which is adapted from the research of Lou, Anthony, Stone, Vu, & Austin (2008), establishes four well-being domains across which a child's functioning can be assessed, and provides for flexibility and refinement, depending on the age and developmental level of the child.  For instance, independent living skills are indicators of well-being only for older youth.  The framework’s purpose is to present a way for child welfare agencies to understand and promote well-being that is aligned with ACYF’s overall focus on system change, and, as such:

  • Engages in continuous quality improvement (CQI) of child/youth functioning
  • Takes a proactive approach to social and emotional needs
  • Uses developmentally specific interventions
  • Focuses on child and family outcomes
  • Promotes healthy relationships for children and youth

In their research, Lou et al. found that some of the existing well-being frameworks were either too focused on deficits or did not account for the child’s resilience or environmental supports.  ACYF’s framework addresses these concerns, incorporating two intermediate outcome domains, “environmental supports” and “personal characteristics,” into the overall framework to illustrate factors that may influence a child’s ability, positively or negatively, to cope with trauma.  Environmental supports include family income, family social capital, and community factors such as neighborhood.  Personal characteristics include the child's temperament, cognitive ability, identity development, and self-concept.  The various factors within these two intermediary domains are related to the child’s protective and coping factors.

Well-Being Domains

The four Well-Being Domains of the ACYF framework are:

  • Cognitive functioning, which includes competencies such as language development, approaches to learning, problem-solving skills, academic achievement, school engagement, and school attachment
  • Physical health and development, which incorporates the normative standards for growth and development, gross and fine motor skills, overall health, and risk-avoidance behavior related to health
  • Emotional/behavioral functioning, which includes competencies such as self-control, emotional management and expression, internalizing and externalizing behaviors, trauma symptoms, self-esteem, emotional intelligence, self-efficacy, motivation, prosocial behavior, positive outlook, and coping
  • Social functioning, which is defined by social competencies, attachment and caregiver relationships, social skills, and adaptive behavior

The components that make up these domains directly relate to how children live their day-to-day lives, or how they deal with frustrations, cope with tasks and responsibilities, and interact with others.  In addition, the ACYF framework assesses functioning across the domains according to the child’s age and developmental stage, as per these four stages:

  • Infancy (0-2)
  • Early childhood (3-5)
  • Middle childhood (6-12)
  • Adolescence (13-18)

Cognitive Functioning

The effects of maltreatment can linger long after the neglect or abuse occurs.  Because caregivers have such a critical role in fostering children’s cognitive development, the sensory deprivation caused by caregiver neglect appears to be particularly detrimental to the cognitive development of young children.  Many neglected infants and toddlers demonstrate delays in language development, as well as deficits in overall intellectual ability.

Research has consistently found that maltreatment increases the risk of low academic achievement and problematic school performance.  School performance is also significantly associated with a child's ability to regulate emotional responses and interact competently with peers and authority figures, abilities that are adversely affected by complex trauma.  This may be manifested in the child as over-reliance on teachers for completion of tasks, reluctance to try challenging or new tasks, and poor relationships with classmates.

In early elementary school, maltreated children may show short attention spans and an inability to concentrate and organize thoughts or conform to the structure of the school setting.  In middle school, children affected by complex trauma are more likely to face disciplinary actions.  By adolescence, maltreated children may show problems with abstract reasoning and problem solving.  Also, because of their ongoing behavioral issues, they may experience more frequent disciplinary action.  Consequently, they may disengage academically.

Physical Health and Development

Aside from the obvious effects of serious injuries, like broken bones or brain injuries, and possible resulting disabilities from physical abuse, the physical pain from other types of abuse will eventually pass.  However, maltreated children frequently experience additional kinds of physical issues, such as failure to thrive (delayed weight gain and growth) and even brain damage, stunted growth, and mental retardation from chronic malnutrition.  Because neglected and emotionally abused children must focus their mental energies on having their primary needs met, they cannot spend adequate time in motor activities and explorations.  Consequently, delays in their physical development are not uncommon.

report completed by the U.S. Department of Health and Human Services indicated that maltreated children from birth to 36 months are at substantial risk of experiencing developmental problems.  The level of risk for developmental delay remains high even years after the initial maltreatment.  Infants and toddlers who are neglected may exhibit poor muscle tone, delays in fine and gross motor skills, poor coordination and muscle control, and delays in reaching developmental milestones.  They may be difficult to soothe and may have small stature.  They may also be chronically ill; many have upper respiratory infections and digestive problems.

Trauma-affected children, particularly preschoolers, may also regress in their development and lose skills they had previously mastered.  For example, toilet-trained children may suddenly lose their ability to control their bladders and have to re-learn toileting control.  Maltreated children of school age may show general delays in physical development, with awkward gait and motor movement, poor coordination and muscle tone, speech and language difficulties, and low levels of strength as compared to their peers.  They may also lack the coordination and skills necessary for perceptual-motor activities, such as playground activities or sports.  As maltreated children enter their adolescent and teen years, they may begin to participate in risky behaviors such as smoking, promiscuous and/or unsafe sex, picking fights, and substance abuse, all of which may further affect their well-being.

The Adverse Childhood Experiences Study (ACE), an ongoing, decade-long collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente’s Department of Preventive Medicine, addresses the effects of childhood experiences on adult health.  Findings show that children who experienced adversity such as neglect, physical and sexual abuse, or exposure to domestic violence may likely have health problems in adulthood as a result.  The study states that there is “a powerful relationship between our emotional experiences as children and our physical and mental health as adults.”  In other words, the effects of childhood trauma and maltreatment that distort children's lives can last for a lifetime.

Behavioral/Emotional Functioning

Children affected by trauma may present a variety of emotional issues.  They may have experienced ongoing assault to their self-esteem from blaming or humiliating messages from a caregiver, or from lack of positive attention in a neglectful environment.  They may feel powerless, vulnerable, exploited, and unlovable.

Because capacities to safely express emotions and to regulate emotional experiences are linked, children exposed to complex trauma may show impairment in both of these skills due to neurological deficits and resort instead to maladaptive coping behaviors such as dissociation or emotional detachment to avoid further pain and anxiety.  Dissociation can occur to varying degrees; in its most intense form, children may emotionally separate from their bodies during a traumatic event and become unaware of their surroundings.  Following the trauma, memories of that experience may trigger the dissociative reaction.  Other maladaptive coping behaviors include avoidance, which is withdrawal from a stressor or situation, and substance use or abuse. 

Children exposed to trauma may also be “internally agitated" and display hyper-vigilance, an exaggerated startle response, a fast heart rate, and increased muscle tone.  They may also have great difficulty maintaining a state of internal calm.  Many traumatized children are diagnosed with Post-Traumatic Stress Disorder (PTSD), which may bring with it any number of these effects as well as panic attacks.  Other common emotional and psychological effects of trauma are attention problems, bed-wetting, concentration problems, sexual reactivity, and acting out.  The traumatized child may suffer from insomnia, depression, eating disorders, inability to concentrate, and self-mutilation.  Additionally, a maltreated child may experience excessive loneliness, paranoia, lack of interest in daily activities, and poor relationships with others.

Because trauma-affected children may have multiple emotional issues and deficits, behavioral problems are not uncommon.  Children who have experienced trauma may react with apathy, defiance, aggression, cruelty, and even rage in their day-to-day lives; they may appear unreceptive to treatment and efforts to intervene, and may be difficult for caregivers and teachers to manage.  These children tend to have more placement changes in care, and caseworkers may be inclined to blame them for taxing caregivers to the point that the child's removal is requested.  Many maltreated children exhibit emotional problems to the extent that a mental health diagnosis is made.  Thus, it is critical that child welfare agencies screen for and assess trauma, and employ evidence-based, trauma-focused treatments for children in care.

Social Functioning

Social functioning is yet another aspect of a child’s life that may be negatively affected by maltreatment.  The ability to become emotionally attuned to others and regulate emotions, otherwise referred to as "social competence," encompasses the capability to take another person's perspective, share experiences and learn from them, and apply that learning to further interactions with others.  This ability to communicate and relate effectively to others is the building block for future interactions with people in all walks of life.

Because of their early negative experiences and possible alterations in neurological development, many maltreated children lack the capacity for basic trust in others and find it difficult to form appropriate friendships.  The traumatized child may feel inferior and incapable around other children and may be overwhelmed by peer expectations of academic, social, and athletic performance.  This can lead to the child becoming detached and withdrawn.  Trauma-affected children may also be impulsive, have emotional outbursts, and experience difficulty in deferring gratification.  Schoolmates may view them with dislike and derision, and they may become scapegoats among peers. 

Some maltreated children, particularly those who have experienced complex trauma, have difficulty learning basic social skills and may either over-comply with or defy authority figures.  They may also be extremely shy and passive or, on the other hand, may employ aggression to solve interpersonal issues.  In addition to their social awkwardness, trauma-affected children may have low self-esteem and be easily victimized by both peers and adults.  These social difficulties, if left untreated, may affect children throughout their adult lives.

Trauma-Based Screenings and Assessments

Screening and assessing for trauma symptoms, especially in regard to determining how trauma affects healthy functioning, are essential in determining a child’s overall social and emotional well-being.  Children usually present to a child welfare agency as a result of a specific incident of maltreatment.  For effective case planning and treatment, it is critical that child welfare practitioners be aware of the child’s history, including the child’s cumulative trauma experiences, in order to ensure a holistic, trauma-informed approach to the child. 

Developing the capacity to screen and assess for trauma in the child welfare system can also address broader policy considerations.  The 2011 Child and Family Services Innovation and Improvement Act, for example, requires states to include in their health care oversight plans a description of how they will screen for and treat foster children for trauma associated with maltreatment.  Consequently, it is very important that an agency’s plan address emotional trauma for children involved in the child welfare system. States should consider integrating trauma-informed screening and assessment tools into their daily practice and carefully consider selecting tools from the wide variety available that meet their specific needs.

As appropriate, trauma assessments should be completed, initially and on an ongoing basis, to determine whether treatment strategies employed are effective and to plan further treatment.

Trauma-Informed Screening and Assessment Tools

There are distinct differences between trauma screening and trauma assessment tools.  Screening tools are brief, used universally, and designed to detect exposure to traumatic events and symptoms.  They help determine whether the child needs a professional, clinical, trauma-focused assessment.  Functional assessments are more comprehensive and capture a range of specific information about the child’s symptoms, functioning, and support systems.  A trauma assessment can determine strengths as well as clinical symptoms of traumatic stress.  It assesses the severity of symptoms, and can determine the impact of trauma (how thoughts, emotions, and behaviors have been changed by trauma) on the child’s functioning in the various well-being domains.

If properly trained, the frontline caseworker within a child welfare setting can administer a screening tool when a child initially enters the system.  Information obtained from that screening can help the caseworker determine whether a more comprehensive trauma-informed assessment is needed.  If the initial screening indicates that additional assessment is needed, the child can be referred to a mental health practitioner for a trauma-informed assessment.  This will provide the agency and caregiver with a fuller understanding of the child’s needs and behaviors; guide the treatment plan; and determine a trauma-focused, evidence-based intervention that will stabilize and help the child heal. 

Selecting a Tool

When selecting a tool, factors to consider include how well it meets the needs of the target population and fits within the agency’s service delivery system.  There are also properties specific to each tool that must be considered.  As part of any selection process for a trauma-informed screening or assessment tool, the National Child and Traumatic Stress Network (NCTSN) recommends examining these specific properties:

  • Validity – the degree to which the tool, including each of its specific items, accurately accomplishes its purpose, or whether the tool measures what it is intended to measure 
  • Reliability – the degree to which the tool is consistent across time and different raters
  • Standardization of Norms – a process in instrument and measure development that allows for comparisons between data from the screening/assessment tool with general populations of the same age group

In addition to the screening tools and functional assessments summarized in the links below, there are also other assessment models/tools available.  These trauma-informed screenings and assessments are similar to other types of assessments in that information is gathered as early as possible or on an ongoing basis from multiple sources such as the child, caregiver, and provider.  However, they differ from traditional types of assessments in that they differentiate trauma effects from mental health disorders, which will be a critical factor in assisting child welfare practitioners to choose an appropriate course of treatment.

The NCTSN Webinar speaker series, Screening and Assessment for Trauma in Child Welfare Settings (Link), contains valuable information about trauma-informed screenings and assessments.  The series contains several modules focused on the rationale for and utility of screening and assessing for trauma, specific tools and measures for conducting screening/assessment, the application of this knowledge and these tools within the direct as well as the systemic levels of child welfare systems, and important developmental considerations for screening and assessment.  Note that you may have to create a free account on the NCTSN website to view this speaker series.

Additional sites with information about trauma-informed screenings and assessments are located on the Additional Resources page of this module.

Screening Tools

The following trauma screening tools were presented in ACYF’s Information Memorandum, Promoting Social and Emotional Well-Being for Children and Youth Receiving Child Welfare Services (ACYF-CB-IM-12-04), available online at: http://www.acf.hhs.gov/programs/cb/laws_policies/policy/im/2012/im1204.pdf), as examples of trauma-informed screening tools.

Child and Adolescent Needs and Strengths (CANS) Trauma Version

The Child and Adolescent Needs (CANS) Trauma Version is one of several CANS instruments (e.g., CANS Mental Health, CANS Comprehensive, etc.).  This instrument measures functioning across domains for traumatic experiences and traumatic stress symptoms, as well as emotional/behavioral issues related to trauma.

For more information on CANS Resources and Training Information, visit the Praed Foundation’s website at http://www.praedfoundation.org/index.html.  For an overview of the CANS Trauma Version and discussion on its uses in a child welfare setting, go to NCTSN’s Screening and Assessment for Trauma in Child Welfare Settings Speaker Series (http://learn.nctsn.org/course/category.php?id=3).  Information on the CANS Trauma Version can be found in the module, Trauma Screening and Assessment Measures for Child Welfare.  Note that while registration with the NCTSN Learning Center is required to view this module, there is no cost.

Childhood Trauma Questionnaire (CTQ)

The Childhood Trauma Questionnaire (CTQ) is a 28-item self-report inventory that provides brief, reliable, and valid screening for histories of abuse and neglect in children ages 12 and older.  The CTQ contains five subscales, three focused on assessing abuse (Emotional, Physical, and Sexual), and two focused on assessing neglect (Emotional and Physical).  Each subscale, in turn, has five items, and there is a three-item Minimization-Denial subscale to check for individuals who may be under-reporting their traumatic experiences.  Interpretive guidelines help identify a likely case of abuse at one of three levels – mild, moderate, or severe.

For more comprehensive information on this tool and instructions on how to order manuals and forms, visit Pearson’s website at: http://www.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=015-8102-339&Mode=summary.

Pediatric Emotional Distress Scale (PEDS)

The Pediatric Emotional Distress Scale (PEDS) is designed to rapidly assess and screen for elevated symptomatology in children following exposure to a stressful and/or traumatic event.  It is not intended to be a diagnostic instrument.  The measure consists of behaviors that have been identified in the literature as associated with experiencing traumatic events and consists of 17 general behavior items and 4 trauma-specific items.  The measure yields scores on the following scales:

  • Anxious/withdrawn
  • Fearful
  • Acting out

Questions related to these scales are measured along a 4-point Likert scale with attributes ranging from “Almost Never” to “Very Often.”  It is designed for children ages 2-10.

For additional information on this tool, visit NCTSN’s website at: http://www.nctsnet.org/content/pediatric-emotional-distress-scale.

Strengths and Difficulties Questionnaire (SDQ)

The Strengths and Difficulties Questionnaire (SDQ) is a brief behavioral-screening instrument for children ages 4-16 that assesses child positive and negative attributes across the following 5 scales:

  • Emotional symptoms
  • Conduct problems
  • Hyperactivity-inattention
  • Peer problems
  • Prosocial behavior

The measure also yields a Total Difficulties score.  In addition to the child self-report version, the SDQ was designed to be administered to parents or teachers in parallel versions.  For more information about and to obtain copies of the tool, go to: http://www.sdqinfo.org/.

Functional Assessments

Functional assessments are tools that measure multiple aspects of a child’s social-emotional functioning, accounting for the major domains of well-being.  These tools capture the child’s issues and challenges as well as strengths, skills, and capacities.  Some functional assessments also capture parenting capacities and changes over time.  One of the distinctions between traditional child welfare assessments and functional assessments is that functional assessments provide a more holistic approach by measuring a wide array of competencies that contribute to well-being rather than just one aspect of well-being.

Functional assessments, if administered at periodic intervals, provide a way to track progress toward the healing of social and emotional well-being issues.  This makes the use of functional assessments a key component of promoting social and emotional well-being for maltreated children, because they can help agency decision-makers at all levels determine the appropriateness of services and identify the most effective interventions for children.

The following are examples of functional assessments with brief descriptions and links to resources for further reading.

Child Behavior Checklist (CBCL)

The Child Behavior Checklist (CBCL) for Ages 6-18 (CBCL/6-18) is a standardized measure based on national norms.  The CBCL/6-18 provides ratings for 20 competence and 120 problem items paralleling the Youth Self-Report (YSR) and the Teacher’s Report Form (TRF).  The CBCL/6-18 includes open-ended items covering physical problems, concerns, and strengths.  The CBCL/6-18 yields scores on internalizing, externalizing, and total problems as well as scores on DSM-IV related scales.

More information on this assessment and how to obtain copies is found at the Achenbach System of Empirically Based Assessment website: http://www.aseba.org/.

Social Skills Rating System (SSRS)

The Social Skills Rating System (SSRS) includes three behavior rating forms; a teacher, a parent, and a student version.  This rating scale allows teachers to rate the occurrence and importance of specific social skills, problem behaviors, and academic competence.  Students third grade and above rate their own social skills, and parents rate social skills and problem behaviors.

For more information on this tool, the developers, and instructions on how to order manuals/forms, go to: http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=PAassrs&Mode=summary.

Emotional Quotient Inventory Youth Version (EQ-i:YV)

The Emotional Quotient Inventory Youth Version (EQ-i:YV) is a self-report instrument designed to measure emotionally and socially intelligent behavior in children and adolescents 7 to 18 years of age.  The EQ-i:YV is based on the Bar-On conceptual model of emotional-social intelligence.  It consists of 60 items that are distributed across the following 7 scales:

  • Intrapersonal
  • Interpersonal
  • Stress management
  • Adaptability
  • General mood
  • Positive impression
  • Inconsistency index

For more information on the Bar-on Model of Emotional Intelligence, go to http://www.reuvenbaron.org/bar-on-model/conceptual-aspects.php.

Other Assessment Models/Tools

While there is a distinction between screening tools and functional assessments, there is often an overlap in the use of both.  Some tools are used for both screening and assessment, while in other cases, assessment tools are adapted for screening purposes.  Regardless of how these tools are used, screening and assessing for trauma should take place in order to guide treatment planning.

To ensure that the treatment planning and service delivery processes are effective, it is important to ensure that screening and assessment processes are informing both case planning and service delivery.  In their 2008 article, Linking Child Welfare and Mental Health Using Trauma-Informed Screening and Assessment Practices, Conradi, Wherry, and Kisiel lay the groundwork for addressing challenges associated with integrating trauma screenings into the day-to-day practice of child welfare practitioners.

From their review of existing trauma-focused assessment and treatment models, the following models have emerged as feasible tools.

Transactional Model

The Transaction Model comes from Steve Spaccarelli’s research on the impact of child sexual abuse.  This model assesses the child’s trauma experience from the circumstances of the abuse and neglect incident, and also from related factors, such as the process of the child welfare investigation and child factors such as coping styles.  Further information on the Transactional Model can be found in Spaccarelli's 1994 article, Stress, appraisal, and coping in child sexual abuse: A theoretical and empirical review.

Trauma Assessment Pathway Model (TAP)

The Trauma Assessment Pathway Model (TAP) is designed to assess and treat children and adolescents between 2 and 18 years of age who have experienced any type of trauma.  TAP incorporates assessment, triage (prioritizing of needs based on children’s risks and immediate needs), and essential components of trauma treatment into “clinical pathways.”  Within the TAP model, “pathway” refers to a sequence that clinicians follow when performing assessments and triage and making clinical decisions.  The components of these pathways are based on research on complex trauma and the current research on effective treatment modalities.

The TAP model has been increasingly and effectively used in the medical field to standardize the management of medical and mental ailments, improve care, and reduce unnecessary costs.  For more information, visit the TAP training Web site (http://taptraining.net/).

Child and Adolescent Needs and Strengths (CANS) Comprehensive Version

The "comprehensive" version of the Child and Adolescent Needs and Strengths (CANS) instrument is designed to gather and integrate information.  It collects information on a range of domains regarding the child’s functioning and the care-giving system, and incorporates it into the child’s individualized care plan.  As an integration tool, CANS Comprehensive integrates information gathered from multiple sources into one record.  The integration process aims to increase communication across providers, guide service planning and delivery, and more effectively meet the needs of the children and families involved.

For more information on CANS Resources and Training Information, visit the Praed Foundation’s website at http://www.praedfoundation.org/index.html.

 

Additional Resources

The following websites contain additional information on trauma-informed screening and assessment tools.

Measures Review Database

(http://www.nctsnet.org/resources/online-research/measures-review?page=2)

This database, hosted by the National Child Traumatic Stress Network (NCTSN), is a searchable database containing reviews of measures important for the field of child traumatic stress.  All reviews were conducted using a uniform review template to allow comparison across measures.  For each measure, comprehensive clinical and research information is provided so that any user can determine whether a measure is appropriate for a specific individual or group, given factors such as the purpose of the assessment, age, cultural and linguistic group, and trauma type.

The database includes information on the following tools.

  • Childhood and Adolescent Needs and Strengths (CANS)
  • Pediatric Emotional Distress Scale (PEDS)
  • Strengths and Difficulties Questionnaire (SDQ)
  • Child Behavior Checklist (CBCL)

California Evidence-Based Clearinghouse for Child Welfare

http://www.cebc4cw.org/assessment-tools/

This website, hosted by the California Evidence-Based Clearinghouse for Child Welfare (CEBC), provides child welfare professionals with information about selected child welfare-related programs.  The primary task of CEBC is to inform the child welfare community about the research evidence for programs being used or marketed in California.  It provides information on interventions and practices by topic areas, a guide to the CEBC rating system, screening and assessment tools for child welfare, implementation tools, and online training and resources.  It includes information on the following tools:

  • Strength and Difficulties Questionnaire (SDQ)
  • Child Behavior Checklist (CBCL)
  • Child and Adolescent Needs and Strengths (CANS)

For each tool, there is a brief description and summary of the available psychometric research, along with CEBC’s ratings for reliability and validity.

Child Welfare Information Gateway

http://www.childwelfare.gov/systemwide/assessment/family_assess/childneeds/trauma.cfm

The Child Welfare Information Gateway is a service provided by the Children’s Bureau.  This particular page within the Gateway is designed to assist professionals looking for information and resources on screening and assessing trauma in children and youth.  Information posted on this page includes research article abstracts (with information on how to access or request copies) and links to organizations that provide additional resources and information on trauma.

Trauma-Informed Systems

Understanding trauma and its impact on a child’s social and emotional well-being is an important building block toward establishing a more trauma-informed child welfare system—in other words, a system that works to provide physical and psychological safety for a child; listens to the child’s wants and needs; surrounds the child with caring adults; ensures that the child has an attachment with a caregiver; gives the child as much control over his or her life as possible; ensures that the child has a consistent, predictable environment; and in every way possible fosters the child’s various protective and coping factors.

With that understanding, agencies can successfully use ACYF’s framework for social and emotional well-being in their work.  The overarching purpose of this framework is to help agencies understand and support well-being of maltreated children and foster positive system change.  ACYF regards the framework to be a continuation, or logical next step, of its historical emphasis on child and family well-being.  Agencies should not regard trauma-informed child welfare as an initiative that competes with other initiatives but rather employ it as a more accurate, sensitive lens through which current practice is observed and assessed, revealing fresh insights that can be integrated into everyday practice.  Understanding trauma and working from that perspective will enable caseworker staff to better engage families, link them to more appropriate services, and ensure improved long-term outcomes for both children and families.  

Many states are developing or initiating practice models, or conceptual maps, of how agency staff and professionals, resource families, and stakeholders will function and collaborate to meet the needs of families and ensure the safety, permanency, and well-being of children served.  The core elements of a practice model include:

  • Clearly stated mission, values, vision, and standards of practice
  • Strategies for implementing standards of practice
  • A plan for assessing needs and engaging families in services
  • Clearly defined strategies for agencies to achieve outcomes
  • A plan for sustaining practice and system changes

Many states are diligently working toward development or implementation of new practice models.  Some, however, have not yet integrated trauma knowledge and strategies into those models.  In order for frontline staff to truly embrace trauma-informed practice and trauma-focused treatments, it is essential to incorporate trauma knowledge and concepts into existing and future practice models.  Guidelines are available that provide concrete strategies to update a practice model so that it is more trauma-informed; for one example, see Link. 

It is also critical for an agency to focus on evidence-based practice.  By focusing only on promising approaches that have been proven effective through research, testing, or experience, an agency can ensure the best outcomes for the populations it serves.  Furthermore, initiatives to promote social and emotional well-being through trauma-focused treatments that require clinical expertise and guidance should be integrated with a state’s current efforts to promote safety and permanency.  This avoids replacing or compromising any effective existing practices.  The same holds true for trauma-focused interventions that go beyond treatment to include day-to-day casework and caregiver activities and practice, and that promote the child’s protective and coping factors.

Strategies for Agencies

ACYF has identified three general areas of concentration for child welfare agencies as they transition toward a more trauma-informed approach that focuses on children's social and emotional well-being.  These are: 

  • Workforce development. Agency staff, other professionals, and resource families must begin viewing children through a more trauma-focused lens.
  • Effective service provision. The agency must shift its practices and services for trauma-affected children and families to only those proven effective.
  • System changes. The agency must be willing to invest work in making systemic adjustments to ensure that common protocols for the entire continuum of care are developed, that the system is trauma-educated and informed, and that racial/ethnic disproportionality and disparity are addressed.

The effective combination of these three general strategies will enable agencies to move toward a more trauma-informed approach in their daily interactions with children. 

Workforce Development

Agency capacity-building efforts that aim to further promote the social and emotional well-being of children must incorporate ongoing training in trauma awareness for all staff and professionals.  This trauma awareness should include recognition that secondary traumatic stress can have a significant negative effect on frontline staff. 

The agency must also actively engage its resource families (e.g., kinship, foster, and adoptive families) as well as its stakeholders, both internal and external, in trauma capacity-building efforts.  Each group must fully understand that trauma is a defining experience, physically and emotionally.  Trauma can shape children’s sense of self and others, and generate effects that persist throughout adulthood.  These capacity-building efforts should reflect an ongoing commitment by the agency to implement and sustain evidence-based practice.

Staff and Professionals

When caregivers, child welfare staff, teachers, physicians, legal advocates, and service providers lack a full awareness of trauma and related issues that children can present, they are unable to provide the environment those children need to heal and reach their full potential.  A full understanding of the impact of child maltreatment as well as comprehensive trauma education and awareness are necessary steps toward providing a framework for attending to the vulnerability and needs of trauma victims.  Broad initial training should include information on trauma-informed screening tools for frontline staff who should ensure that every child entering the system is screened upon entry so that interventions and treatments are properly informed.

This training should begin with building child welfare practitioners’ capacity to better understand the needs and behaviors of children whom the agency serves.  Traumatized children, who likely have experienced earlier rejections by significant others, may move from placement to placement due to the inability of caregivers to manage their behaviors.  Thus, the children undergo even further blows to their self-esteem, their sense of worthiness, and their ability to develop healthy coping mechanisms; they feel powerless, inadequate, and unlovable.  They blame themselves (as they are blamed by others), and expect to be disliked and rejected.  As these children enter adolescence, they may be seen as “bad kids,” and even professionals may have little sympathy for them.

Child welfare practitioners and other involved professionals require knowledge and education to help them more fully understand the trauma from which these children’s behaviors and attitudes stem.  They need heightened awareness and skills so that they are empathetic and tolerant, respond appropriately to the children, and provide needed support to caregivers in order to preserve a placement.  Most important of all, they need to ensure that proven interventions grounded in evidence-based practice are employed to help children work through their trauma.  By ensuring a safe and stable environment; surrounding children with nurturing, supportive adults; promoting attachment and bonding to a caregiver; and providing them with validating experiences that enhance their self-esteem, the child welfare agency can help children see their world as fair and predictable, and increase their feelings of control and self-mastery.  All of these, in turn, can work to enhance children’s various protective and coping factors.

It is critical to remember, however, that vicarious trauma and secondary trauma can take a huge toll on the child welfare workforce, particularly among caseworkers and supervisors.  Child welfare practitioners are not only exposed to chronic and frequently severe maltreatment of children on an everyday basis, but they may also be confronted with threats or violence due to their work.  Secondary traumatic stress, or emotional and physical responses to working with traumatized children and families, is common among frontline staff.  This secondary trauma can affect caseworkers’ and supervisors’ ability to do their jobs effectively, and many times contributes to caseworker/supervisor inability to remain in the field.

High vacancy rates among caseworkers and supervisors, in turn, can negatively affect agency functioning overall.  This negative impact manifests as unmanageable caseloads, overburdened supervisors, and a lack of institutional knowledge among the majority of staff, which, of course, can ultimately result in poor outcomes for families and children.  Thus, it is essential that agency leaders recognize the impact that secondary trauma can have on the frontline workforce, particularly in the critical area of caseworker/supervisor retention, and implement strategies and policies to address this issue.

Resource Families

Resource families—foster parents, adoptive parents, and relatives— are frequently the ones who have the most impact on a child’s trauma recovery, because they are the ones who spend the greatest amount of time with the child on a day-to-day basis.  Although these families do receive specialized training, the training usually contains little specific information on trauma and how to provide trauma-informed care.  Consequently, these parents are often ill-equipped to handle many of the children placed with them.

The education and support provided to foster parents should focus on helping them comprehend children’s behaviors from a trauma perspective.  It should also focus on helping them learn to cope with and manage those behaviors, which may be extreme.  These resource families should receive specialized, evidence-based training to help them understand the impact of trauma on brain development and behavior, and how to interact with and respond to traumatized children in a way that optimizes the children’s social and emotional well-being.  They should be trained in specific techniques to help mediate stress and create a psychologically secure environment for traumatized children.

In their role as resource parents, it is critical for these caregivers to be aligned with the caseworker in a trauma-informed approach to the child.  It is essential that families provide traumatized children with positive interactions and strengths-based parenting; foster parents should be trained to constantly provide children in their care with positive feedback and validation in order to strengthen the child’s protective and coping factors.  Providing this type of feedback can be very challenging when a child is displaying negative, acting-out behaviors; it takes much creativity, commitment, and skill on the part of both caregivers and caseworkers to find strengths in the behaviors of a difficult child, particularly over a sustained period of time.

Another critical concern is that the child remains with the resource family until permanency is achieved.  Children are further damaged by multiple moves through the child welfare system.  While the reasons for placement instability are many and complex, children’s behavioral problems and resource parents’ lack of ability to deal with the behaviors are commonly cited.  Foster parents should understand that their foster child’s behaviors are adaptive and reflect what the child has been through, and may also reflect the lack of neurological development necessary to regulate emotions and control behaviors.  Those involved with the child should be asking of that child, “What have you been through?” instead of, “Why are you behaving this way?”  The parents must be offered a new framework for understanding the child’s responses and attitudes, and should be shown appropriate techniques and responses to help them manage the child’s behaviors on a day-to-day basis.

Above all, the importance of a commitment to maintaining the child in the home while the child works through his or her trauma should be stressed and supported.  States may need to provide a high level of support or assistance 24 hours a day, seven days a week, to families (particularly new families) struggling with traumatized children.  For example, to preserve a placement, it may be necessary for the agency to come in the middle of the night to aid a family that has been trying for hours to de-escalate the tantrums and rage of a 12-year-old foster child.  Placement stability is critical to avoid re-traumatizing a child, and education around that issue is paramount.

Stakeholders

Child welfare system stakeholders should be trained in the impact of child maltreatment, complex trauma, and the importance of focusing on the social and emotional well-being of children in the system. This is true for both internal stakeholders; staff; resource parents; and external stakeholders, including law enforcement officials, service providers, CASA, Citizen Review Boards, Tribes, advisory councils, and the courts, who are connected to the child welfare service delivery continuum. Courts in particular play a close and critical role in promoting positive outcomes for children, and should be provided information and kept abreast of well-being needs and evidence-based practice to meet those needs.

Training for stakeholders, which may be funded for some groups at least partially with title IV-E training funds, will involve ongoing education on the impact of child maltreatment and the need to focus on social and emotional well-being with a different lens. It is critical that everyone involved share a common understanding about the effects of trauma on maltreated children and the holistic interventions required to respond, so that a trauma-informed culture and system of care will emerge.

Effective Service Provision

An understanding of the impact of child maltreatment upon children who enter the child welfare system will build the capacity of staff and professionals, resource families, and stakeholders to be more proactive in their work with these children, enabling them to be alert to symptoms and anticipate needed services. In staff, this capacity is necessary not only at caseworker and supervisor level, but also at the leadership level where decisions are made about the complete array of required services.

Providing evidenced-based practices and trauma-focused treatments are critical components of the system change effort that is required for effective trauma-informed practice. This change must involve both reexamining existing services provided by the agency, including its network of providers, and establishing effective trauma-based screening and assessment processes early on for involved children and youth to determine the impacts of maltreatment. The agency should also ensure that it is providing culturally relevant services to meet the needs of every group it serves, which includes developing a systemic cultural sensitivity and competency.

When the screening and assessment processes show that treatment is needed, child welfare agencies should respond with a well-coordinated service delivery system that employs effective, trauma-focused services and interventions. Additional trauma-based assessments will be needed periodically to determine if children are improving and to inform treatment decision-making on an ongoing basis. Caseworker interaction with children and caseworker interaction with birth parents should also be trauma-informed. Work with children should focus on giving the child a voice; enhancing the child’s self-esteem; promoting the involvement of supportive adults in the child’s life; and making the child’s world as safe, stable, and predictable as possible. This is also true for all case planning activities. 

Reexamining Existing Services

Many child welfare agencies often refer families for psychotherapy and parent training to remedy the problems that originally led to agency involvement. Some agencies have used the same contractors and community providers for many years, considering the provision of services as the marker of success, rather than the effectiveness of services, which has never been adequately determined.

As agencies become more aware of evidence-based practice and evidence-informed services, and of the complex needs of children and parents who have been affected by trauma, it is essential that ineffective or marginal services be replaced with those proven effective. Initially, this may require additional resources, but eventually resources may be reallocated from less effective services to those that are evidence-based.

Scaling back on existing services, particularly those that have been in place for years, may require carefully planned community/provider education and public relations skills on the part of agency leaders. Some community providers may actually be trauma experts who have extensive training in trauma-based screening and assessment and trauma-informed, evidence-based treatments. Other providers may lack any specific trauma training or expertise, but still insist that their existing expertise and licensure enables them to effectively treat even the most acute trauma cases. Agencies must be vigilant and have complete awareness of the abilities and specialties of their provider network so that they can strategically refer children and families for services based on each provider's specific expertise to meet the needs of those referred.

Child welfare administrators should also consider integrating trauma-informed, evidence-based approaches into the practices of residential treatment facilities, as well as ensuring that facility staff and professionals receive specialized trauma training. There are specific questions that can be asked of treatment staff and therapists to help determine whether they are trauma-informed. The mere act of routinely and consistently asking about the qualifications of therapists and others who provide trauma treatment may have a motivating effect on improving the skill level among clinicians and staff.

As services are procured through the contract process, service descriptions in the States’ funding announcements and requests for proposals (RFPs) may need to be rewritten in order to solicit providers of evidence-based and trauma-informed services. Community mental health providers will need to be educated about trauma and its effects on both children and parents, and motivated to increase focus on children’s social and emotional well-being

For services that are the sole responsibility of the agency, such as investigations, adoptions, resource family and foster parent training, and independent and transitional living services, agencies should begin modifying, refining, or redesigning interventions and programs as needed to provide trauma-informed and evidence-based services. They should also ensure that direct, day-to-day casework services are provided in ways that constantly view and respond to the child from a trauma perspective. To this end, policies and procedures should be reviewed and revised to ensure that children are not re-traumatized.

Measuring Service Effectiveness

As States move to more extensive, agency-wide continuous quality improvement (CQI) systems with more focus on use of data for assessment and decision making, there is a need to move beyond mere delivery of services as a gauge of success. Results of current and new interventions and practices must be continually measured and assessed to determine their effectiveness. The data collected from these assessments can help inform decisions about how to allocate scarce resources.

New medical technologies, such as neuroimaging (e.g., magnetic resonance imaging, or MRI), have escalated research into early neurological development. These technologies are providing new insights into the mechanics of brain development and how early experiences affect that development. Also, research on trauma and evidence-based practice is constantly evolving. Staff at all levels should be encouraged to contribute to a continuous learning environment in the agency by staying abreast of current research, questioning the status quo, and trying to improve and be more sensitive in their individual responses to trauma-affected children and families.

Culturally Relevant Services

Native Americans, African Americans, and other racial/ethnic groups have traditionally experienced historical, cultural, and intergenerational trauma, including racism, warfare, and other assaults such as banning traditional languages and healing practices. For children and parents, these assaults can magnify trauma experienced in their present environments. Agency child and family interactions and assessments should reflect cultural awareness and sensitivity and consider the cultural background and communication styles of both the person doing the assessment and the family and child being assessed.

Some evidence-based and trauma-informed treatments for children and families have been adapted so that they are relevant to various cultures (see www.chadwickcenter.com for more information). States should seek information about these services and incorporate them as needed into their service network and individual treatment of families.

Caseworker Interaction With Children

Agency leaders should integrate an understanding of trauma within every agency program, including investigations, in-home and out-of-home care, adoption, youth/independent living, and other applicable programs. Caseworkers should use trauma-informed practice to interact with and respond to children in ways that promote healing rather than intensify the trauma. Agency staff and professionals should be trained to minimize trauma to children during investigations and removals. Using a trauma-informed approach, child welfare investigators can buffer possible adverse effects on the family and child during the investigation, and simultaneously promote family engagement and improve the accuracy of the information they obtain.

Research has shown that it is possible for agencies to increase the protective and coping factors of children to help buffer and even heal the effects of trauma. Organizational environments can be developed that promote greater caregiver skills, and thus more stable placements and more predictable environments for children. Agencies can surround children with as many caring adults as possible, and can help ensure that the child feels safe and cared for both psychologically and physically. An agency that ensures that a child is kept informed, provided choices, and involved in making decisions will empower that child and increase self-esteem. Agencies that involve children in activities where they can learn and contribute will give children a degree of mastery and validate their worth. And lastly, the importance of promoting and ensuring a secure bond with a caregiver, particularly for children whose neurological development has been impaired from trauma, cannot be overstated; such a bond is critical for the child to heal.

When children require placement, every effort should be made to maintain them in the same placement, unless their placement is determined to be harmful. Moving from placement to placement can be damaging for any child; however, the effect is compounded for traumatized children. These children have often experienced abandonment prior to coming into care, and changes in placement can trigger that original abandonment trauma. Additionally, multiple placements frequently result in children ultimately moving to higher levels of care. When there is no other alternative to moving a child, a pre-placement visit is critical to lessen the trauma of the move for the child, even in situations where the visit has to occur the same day as the placement change. 

A strong relationship with a nurturing caregiver can be a child’s most effective barrier against trauma. Despite the agency’s best efforts, however, children involved with child welfare often lack a secure caregiver bond, making them highly vulnerable to the effects of trauma. In the absence of a strong caregiver bond, it is critical to preserve other significant relationships for the child. Agency staff should work to keep siblings together in care, ensure frequent visitation if siblings are separated in care, and encourage and facilitate the involvement, as appropriate, of extended family, friends, and other significant individuals in the child’s life. The agency should also make every effort to maintain a removed child in his or her present neighborhood and school, thereby providing the child with a sense of connectedness, identity, and worth that might otherwise be lost. This can greatly fortify the child’s protective and coping factors and ability to deal with adversity in the system and in his or her life.

Caseworker Interaction With Birth Parents

According to the National Childhood Traumatic Stress Network (NCTSN), accessible online at www.nctsn.org, birth parents’ history and experience with trauma affect not only their ability to provide adequate care for their children, but also their ability to respond to and work with their caseworkers. Many parents of children in the system have experienced trauma in either their childhoods or adulthoods or both, and that history can have a significant impact on their ability to engage in services, maintain a healthy relationship with their child, and protect and help their child heal. Furthermore, parents with unaddressed trauma are more likely to treat their children the way they themselves were treated as children. Though they may strongly desire a healthy attachment with their child, forming that attachment may be difficult for them.

Caseworkers should become knowledgeable about how to work with trauma-affected birthparents and should refer them to appropriate services to help them resolve their trauma. There are several evidence-based adult trauma treatment models, some of which integrate issues relating to mental health, substance abuse, and trauma for a holistic approach. For more information on these models, visit the Child Welfare Information Gateway site at http://www.childwelfare.gov/responding/treatment.cfm#caregivers.

Parents who have insight into their own traumatic backgrounds and have worked to resolve their trauma are much more likely to understand their child’s needs, develop the means to meet those needs, and become more functional and competent parents. As parents become healthier and gain more protective capacities, fewer removals might be necessary, and reunifications of children in care might occur sooner and be more stable and successful. 

In cases where parents are reluctant to engage with agency services, the agency should conduct a careful assessment of parental barriers to engagement, as the reasons for non-engagement may be complex and challenging to overcome. Rather than passively waiting for parents to engage, the agency should make efforts to encourage, facilitate, and support service engagement. Birth parents in need of parent training, mental health, and other services should be provided those evidence-based and evidence-informed services that will help them to not only deal with their own trauma, but enable them to better respond to, nurture, and protect their trauma-affected children.

Case Planning

The agency should emphasize to all staff that children in care should always, at a developmentally appropriate level, be aware of their permanency plan and be involved in identifying strengths and needs, setting goals, assessing progress, and planning for the future. On a daily basis, children and youth should be given information and as many choices as possible in all areas of their lives, to minimize their feelings of helplessness and provide them some sense of control and mastery. Youth in foster care, particularly older youth, should be guiding their own case planning. Trauma-affected youth should be empowered, and their protective and coping factors increased, by providing them all information about their permanency options and the services and supports available to them. They should be provided choices in every aspect of their lives—otherwise, children may feel that their needs, input, and desires are not important, which may further increase their feelings of helplessness and lower their self-esteem.

Caseworkers should have a steady focus on the empowerment of children and youth, and should constantly emphasize their strengths; these actions alone can have profound positive effects. One of the most critical and challenging aspects of case planning for traumatized children is providing every child with opportunities for success and validation, or opportunities to not only grow but to contribute, succeed, and receive positive feedback. Frequently, many possibilities must be explored to find areas where the child connects and has success; the caseworker must know the child well and be creative in finding resources. A few examples of possible activities in which children can be engaged include:
  • art (including theater, dance, and music)
  • sports
  • scouting (camping and nature experiences)
  • community gardening
  • horseback riding
  • religious or cultural experiences
  • helping seniors or those with physical disabilities
  • helping younger children or injured animals

Efforts to discover and provide opportunities for traumatized children to experience success, including the identification of necessary funding, requires going beyond devising “cookie cutter” case plans and often exceeds traditional expectations of the case planning process. Functional assessments should be ongoing to determine the child’s progress in healing, determine what is or is not working, and guide further case planning. The caseworker should also be very involved in the child’s educational planning and achievement.

Caseworker changes should be minimized as much as possible for children. Great care should be taken to ensure that a change does not further traumatize the child by undoing the positive work of previous caseworkers, or by failing to provide the new caseworker with critical information about the child and/or family, such as known trauma triggers. 

Older Youth

The Fostering Connections to Success and Increasing Adoptions Act, signed into law in 2008, allows States the option of extending foster care to youth, and claiming Federal Title IV-E reimbursement, until the youth reaches the age of 21. Research has shown that youth who remain in care beyond age 18 benefit from the supports received by remaining in care; on the whole, youth who remain in care are more likely to participate in post-secondary education, secure higher-paying and more stable employment as adults, and experience more stable housing situations.

Despite child welfare agencies’ best efforts, there are some foster youth who leave the child welfare system without having gained “traditional” permanency (e.g., permanent guardianship, adoption, or a long-term relative or kinship placement). For any youth, the transition from childhood to adulthood is a gradual, complex process that is encouraged and eased by family and community support. Many youth in foster care, however, face significant challenges related to childhood trauma from family separation, neglect or abuse, and/or placement instability. Few have natural family systems to support them emotionally as they prepare for or are exiting care. Although some emancipating youth fare very well, many experience undesirable outcomes due to poor protective and coping factors, lack of preparedness, and an overall inability to navigate the world of adult responsibilities. Without a circle of caring adults, they have no emotional, social, and financial safety net that enables them to safely make mistakes and learn from their experiences.

States should redouble their planning and efforts to find permanent homes for older youth, while at the same time preparing them to live as successful adults. This requires employing a set of targeted services if permanency is not found. Of paramount importance is ensuring that every older youth has caring adults who will help him or her navigate into adulthood. Case planning should vigorously support mentors to fill this role; these mentors may be foster parents, former foster parents, teachers, the birth family, other older youth, and any other safe adult in the youth’s life.

Careful planning should ensure that these support networks for older youth are in place well before emancipation. Older youth should always participate in their own case planning. The supports and services that will follow youth into adulthood should be designed to increase the youth’s protective and coping factors, such as enhanced self-confidence, predictability of their world, physical and psychological safety, and sense of accomplishment. Likewise, it is the responsibility of States to plan, encourage, and support the adults in the youth’s life to remain involved as the youth struggles with the challenges of early adulthood.

Educational Planning and Achievement

Effective case planning should provide for youth to obtain a high school degree, or at least its equivalent, prior to aging out of care. Ensuring that a high school education is obtained will likely involve ongoing, focused educational/graduation case planning that begins no later than eighth grade. It will also involve a close monitoring of the youth’s academic progress, providing all necessary supports (e.g., tutoring, meetings with teachers and counselors, preparation for college entrance exams, etc.), and continual vigorous advocacy with the school system. States should also intensify their efforts to overcome barriers when a youth changes placement, such as out-of-school time, adaptation to a different school, and difficulties in transferring school records.

It is also important that State agencies work with the educational system to develop an understanding of the inter-relatedness of trauma and the educational system. There is often low tolerance from school systems for the behavioral problems that can be manifested by traumatized children, and State agencies should work closely with teachers, counselors, parents, and other involved parties to minimize negative consequences.

Additionally, agencies should plan and work diligently with youth who have aged out of care to promote their participation in post-secondary education, whether that takes place in traditional colleges or in vocational schools. A significant correlation exists between education and avoidance of the criminal justice system. Similarly, education is one of the prime factors that prevents recidivism for individuals who have been incarcerated.

System Changes

Child welfare agencies have numerous opportunities and entry points for integrating trauma-informed practices into their daily work with families and children. A critical challenge, though, involves shifting the child welfare and related systems so that there is recognition of the devastating, pervasive effects of trauma on children and families, and, that there is a set of appropriate, effective responses across the entire continuum of care, particularly in regard to trauma and the educational system.

Although child welfare is at the center of a broad child/family service system, that system will not become fully trauma-informed if child welfare agencies attempt to integrate trauma-informed practices in isolation from others that serve the same population. Because treatment of children and families in the child welfare system requires a community effort, and because traumatized children and their families are often involved with other—perhaps multiple—service providers, agencies are encouraged to develop system-wide protocols and frameworks for effective service provision.

The child welfare agency, in its leadership role, is well-advised to make concerted and ongoing efforts to align the array of public and private agencies and other service providers involved in the child/family service system around a coordinated continuum of trauma-informed care. Doing this will enhance related agencies’ abilities to meet the needs of the common population they serve and to achieve agency goals. States will need to collaborate and coordinate their services with public and private mental health agencies, Medicaid providers, the juvenile justice system, law enforcement agencies, the educational system, and others to build a network of responses and interventions that are evidence-based and evidence-informed for trauma-affected children and families. Child welfare agencies can cross-train with and learn from other community systems that are already working toward being trauma-informed.  Agencies should also strive to address any systemic cultural/racial disproportionality and disparity that may exist within their organizations. 

There are a variety of tools and guidelines to help States assess the needs of specific programs within their agency, their agency as a whole, and their community, which in turn can help determine an agency’s or community’s current ability and readiness for implementing a trauma-informed system. For more information about these tools and guidelines, visit http://www.chadwickcenter.org/CTISP/images/CTISPTICWAdminGuide.pdf.

Trauma and the Educational System

Schools are filled with students who have experienced recent trauma, or whose lives are an ongoing trauma. Children who are traumatized may experience considerable difficulty in the school setting, not only in terms of focus and learning, but in being able to manage their behaviors. In fact, children served by child welfare may spend more waking hours in school than they spend in their homes.

Because many traumatized children have not developed the brain or body tools required to regulate their emotions, they experience a state of chronic anxiety rather than calm. As a result, they are poorly equipped to tolerate and deal with the academic and social demands of the educational setting. As a result, school can become a highly stressful experience that may contain frequent trauma triggers. School will likely remain a stressful environment for these children until a setting conducive to emotional regulation has been provided.

Many children with special needs qualify for and receive specialized educational services through Section 504 of the Rehabilitation Act of 1973, which covers mental and physical disabilities, including learning disabilities, or the Individuals with Disabilities Education Act (IDEA), which covers students who meet requirements of one or more of 13 disabilities. Although "serious emotional disturbance" is one of the qualifiers of IDEA, children who have experienced trauma do not necessarily meet any of the requirements of either Act. Thus, trauma-affected children may receive no special consideration or modifications in the school setting, as they are not viewed as having special needs. Many educators approach these students without the knowledge necessary to help them gain the most from their academic experiences; they may view a traumatized child as a bad child who is disruptive and will not learn, rather than as a child who has many struggles to overcome. However, at the same time, schools that are trauma-educated and responsive can serve as a critical support system for their trauma-affected students.

While child welfare agencies can begin to shift their own practice to more effectively help children work through trauma and heal, the work will always be incomplete if school systems fail to gain similar trauma-related knowledge and skills. Child welfare administrators must develop their own paths for approaching and affecting necessary changes in the educational system. Whether administrators work with teachers, counselors, principals, superintendents, or school boards, it is essential that school personnel be trained on the impact of childhood trauma, understand that they must help traumatized children overcome special barriers to learning and interaction, learn to help children manage their trauma-related reactions, and work to enhance the protective and coping factors of those in their charge.

There are many actions that a trained, sensitive educational system can take to respond to trauma-affected children and alter their environment, depending on the specific needs of a particular child at a given time. These actions range from those fairly easy to implement, to those that require more effort and resources, and include:

  • modified school schedules that match the child’s level of emotional tolerance
  • reduced peer interactions, particularly if the child has been a victim of teasing or taunting
  • daily, consistent one-on-one mentoring by an adult who relates calmly yet firmly, to provide the child with a trusting figure with whom he/she can feel secure
  • a low-stimulus, secure environment to decrease external stimulus and aid the child in maintaining a state of calm
  • a highly structured, consistent environment with a minimum of change to promote the child’s maintenance of a state of regulation
  • additional time to complete assignments, to reduce the child’s anxiety and allow more opportunities for mastery
  • choices for the child, to provide more sense of control
  • a safe place for the child to talk about his or her trauma, and simple, realistic responses to the child’s questions
  • sensitivity to the cues in a child’s environment that may cause a reaction, like an increase in the child’s negative behavior near the anniversary of a traumatic event, for example
  • awareness of other children’s reactions to the traumatized child, non-disclosure of the details of a child’s trauma to classmates, and protection for the child from peers’ curiosity

Implementing appropriate modifications and accommodations in the trauma-affected child’s educational setting will greatly assist that child in maximizing his or her cognitive abilities in an environment that would otherwise be perceived as very stressful. Close monitoring as the child progresses may make it possible to moderate or even eliminate some of the accommodations.

Responding to Systemic Cultural/Racial Disproportionality and Disparity

Racial disproportionality, or the overrepresentation of children of color in foster care, along with disparate outcomes, is an issue with which many States have struggled and continue to struggle. Racial disparity in children’s and families’ experiences with the child welfare system and its services has also, in some instances, been an issue.

The degree of agency sensitivity and attentiveness to cultural issues, along with the cultural background of the child welfare practitioner, can influence how staff perceive child trauma and how best to intervene. Practitioners who are not culturally competent may over-identify maltreatment in races or ethnic minorities different than their own, and may refer a family for services that are not culturally appropriate. The causes of racial disparity and disproportionality, which cross many systems, are complex and deep-rooted. Child welfare agencies and other social and educational systems must work with each other and the vulnerable citizens whose lives are affected to effect lasting change from entrenched patterns of the past that influence responses to trauma and maltreatment.

In order to ensure culturally relevant services, it falls to leadership at every level of the agency, through the use of training, mentoring, modeling, and monitoring, to ensure that the staff is educated about and sensitive to racial and cultural issues. Cultural knowledge and awareness should become pervasive in every aspect of the agency. It is important that practitioners understand the historical context through which institutional racism – and thus disproportionality and disparity – has occurred, and they should be shown how to create solutions and carry out their work through a non-biased trauma lens. Ongoing efforts should be made by management to ensure that agency policies, procedures, training, supervision, and practices are trauma-informed; show a deep level of cultural awareness; and are culturally relevant for the families served.

Trauma-Focused Treatments

According to the Chadwick Center for Children and Families' Creating Trauma-Informed Child Welfare Systems: A Guide for Administrators; common, broad goals of trauma-focused treatment include: 

  • Re-establishing a sense of physical and psychological safety for the child
  • Helping the child (and family) manage emotions, particularly in the presence of trauma reminders
  • Helping the child (and family) gain an understanding of the traumatic experience(s), while recognizing that there may be differences in how the trauma experience is understood by those who were exposed to it

The Chadwick article further defines the following as components to be worked toward in effective treatment.  

  • Emotion expression and regulation skills, or identifying feelings and developing coping mechanisms for managing difficult feelings such as sadness or anger
  • Anxiety management and relaxation skills through practices such as visualization, deep breathing exercises, progressive muscle relaxation, etc.
  • Cognitive processing or reframing, or helping the child not to self-blame, and to identify the connection between thoughts, feelings, and behaviors (the “cognitive triangle”) and replace inaccurate thoughts with more helpful thoughts
  • Strategies that allow exposure to traumatic memories and feelings in tolerable doses so that they can be mastered and integrated into the child’s experience. It is important that children be able to integrate their trauma experiences, so they are one/some of many life experiences rather than the defining experience(s); this includes construction of the “trauma narrative,” or telling the trauma story in tolerable doses, while other techniques are utilized, so that the trauma loses its power.
  • Personal safety training and other empowerment activities, or developing healthy boundaries and learning ways to enhance physical and psychological safety
  • Resilience and closure, or, at treatment termination, helping children identify strengths for future coping, and helping children/families prepare for possible trauma reminders and triggers

The Chadwick Center's findings led the researchers to make several recommendations for child welfare agencies regarding trauma-focused treatment. First, agencies should universally screen and assess for trauma experiences and symptoms; they should review assessment tools carefully to ensure that they are valid, reliable, and sensitive enough to distinguish trauma and mental health symptoms. Secondly, because of the important differences between mental health services and trauma-focused treatment, traditional mental health services should not be provided unless trauma screening has first taken place, with trauma being ruled out.

Child welfare agencies should recognize that the mental health field has related, but somewhat differing goals when working with children and parents. Mental health providers tend to work toward ameliorating the manifestations of a specific condition (or conditions) diagnosed, which is a worthwhile goal, but they may fail to recognize how trauma has pervaded and shaped the child’s or adult’s entire sense of self and safety. Because of this, they may sidestep dealing holistically with the wide array of trauma effects and may limit their effectiveness in developing protective and coping factors through their interventions. It is critical that mental health providers understand what the professionals in child welfare, as well as the child and family, hope to accomplish with a referral for mental health services. Additionally, they should know and understand the goals for the child and family, whether or not there is evidence of trauma in the child’s and family’s history, and what strategies the child welfare agency believes should be considered in treatment planning.

In general, when compared to traditional mental health treatments for diagnoses such as bipolar disorder, attention deficit disorder, and conduct disorder, the researchers found that trauma-focused treatments:

  • Keep a greater focus on context, safety, and support
  • Better address symptoms and risk behaviors as part of a broader set of reactions
  • Develop more strengths and protective factors
  • Focus less on medications
  • Are less stigmatizing

Thus, great care should be taken to distinguish between mental health and trauma symptoms in children, and to ensure that treatments selected are appropriate, consider the child as a whole, and help affected children make new meaning of their trauma history.

Evidence-Based Practice

Evidence-based practice, also referred to as evidence-informed practice, is practice in which effectiveness has been validated through experience or research. The concept began in other fields, including medicine and manufacturing, and is now receiving attention from child welfare agencies. Changes in practice and services are more likely to be successful in yielding positive outcomes if they have been proven through research, testing, or previous implementation.

Selecting or developing new practice, however, is only the first step. Once a new practice or intervention has been identified, care must be taken to ensure that it is implemented with adherence to its evidence-based design. If new practices are not implemented as intended, even if they have been shown by research to be effective, they will likely not succeed or, at best, will have only mixed results.

Another aspect of effective practice is providing trauma-informed services across the child welfare continuum. This may involve modifying the service delivery system so that it incorporates across-the-board screening for trauma symptoms when children enter the system, and, as necessary, ongoing trauma-informed assessments initially and at periodic intervals to determine if services are effective and children are progressing. These processes should be coordinated and integrated with any evidence-based, trauma-focused interventions that are currently used by child welfare agencies and/or trauma informed services delivered by mental health providers. Additionally, they should become part of the State's agency-wide continuous quality improvement (CQI) systems, but regularly measured, evaluated, and adapted as needed for maximum effectiveness.

This section discusses some specific evidence-based practices that agencies may want to consider as they begin to develop their own trauma-informed practices and policies. It also includes a look at some additional resources on evidence-based practice that agencies may find helpful.

Examples of Evidence-Based Practices

Below is a brief survey of three examples of evidence-based or promising practices that are specifically named in ACYF’s Information Memorandum, Promoting Social and Emotional Well-Being for Children and Youth Receiving Child Welfare Services (ACYF-CB-IM-12-04). ACYF cites these as interventions that address the most common “mental health diagnoses, trauma symptoms, and behavioral health needs of children and show measurable improvements or promising results.”

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

TF-CBT is a components-based model of psychotherapy that addresses the unique needs of children with Post-Traumatic Stress Disorder (PTSD) symptoms, depression, behavior problems, and other difficulties related to traumatic life experiences.

TF-CBT’s target population is children and youth ages 3-21, and is suited for those who have significant emotional or behavioral difficulties related to one or more traumatic life events (including complex trauma); children and youth do not have to meet PTSD criteria to receive TF-CBT. TF-CBT treatment has been shown to result in decreased PTSD symptoms, depression, anxiety, externalizing behavioral problems, sexualized behavior problems, shame, and trauma-related cognitions (mental processes) and increased interpersonal trust, and social competence.

For more information on TF-CBT, refer to the National Child Traumatic Stress Network (NCTSN) document, How to Implement Trauma-Focused Cognitive Behavioral Therapy (PDF) and the NCTSN’s Fact Sheet for TF-CBT found at: http://www.nctsnet.org/sites/default/files/assets/pdfs/tfcbt_general.pdf.

Multisystemic Therapy (MST)

Multisystemic Therapy (MST) is an intensive family- and community-based treatment that addresses the multiple factors contributing to serious antisocial behavior in youth; it has a home-based model of service delivery and is targeted to youth 12-17. The multisystemic approach views individuals as being embedded within a complex network of systems, all interconnected, that include individual, family, peer, school, neighborhood, and other factors. MST posits that intervention may be necessary in any one or a combination of these systems.

The major goal of MST is to provide parents with the resources and skills needed to deal with the challenges involved in raising teenagers. Additionally, it strives to empower youth to cope with problems and issues in the various systems. MST works to promote behavior change in youth in their own environment, using a strength-based approach. There are clinical adaptations of MST, with MST-CAN being particularly useful for youth in foster care who are being reunited with birth families.

For more information on MST, refer to the Multisystemic Therapy Web site at http://www.mstservices.com/ and http://www.mstservices.com/MST%20Pilot%20Handout%20FINAL.pdf for MST adaptations.

Parent-Child Interaction Therapy (PCIT)

Parent-Child Interaction Therapy (PCIT) is an evidenced-based treatment model with highly specified, step-by-step, live coached sessions with both the parent/caregiver and the child. Parents/caregivers learn skills through PCIT didactic sessions. Using a transmitter and receiver system, the parent/caregiver is coached in specific skills as he or she interacts in specific play with the child. Generally, the therapist provides the coaching from behind a one-way mirror. The emphasis is on changing negative parent/caregiver-child patterns.

The goals of treatment are:

  • An improvement in the quality of the parent-child relationship or, in the case of residential treatment centers and foster homes, the caregiver-child relationship
  • A decrease in child behavior problems with an increase in prosocial behaviors
  • An increase in parenting/caregiving skills, including positive discipline
  • A decrease in parenting/caregiving stress

For more information on PCIT, visit PCIT International at http://www.pcit.org/ or download the National Child Traumatic Stress Network (NCTSN) Fact Sheet for PCIT found at:http://www.nctsnet.org/sites/default/files/assets/pdfs/pcit_general.pdf.

Additional Resources

There are many publically available resources that support the task of selecting an effective intervention. The following is a list of some of these resources.

  • National Child Traumatic Stress Network (NCTSN) Intervention Fact Sheets (http://www.nctsnet.org/resources/topics/treatments-that-work/promising-practices#q3). NCTSN provides fact sheets on many trauma-focused interventions, which have varying levels of evidence-basis. Fact sheets include information on topics such as target populations, essential components, clinical and anecdotal evidence, research evidence, outcomes, implementation requirements and readiness, training materials and requirements, and more.
  • California Evidence-Based Clearinghouse for Child Welfare (CEBC) (http://www.cebc4cw.org/). The CEBC provides child welfare professionals with information about selected child welfare related programs, focusing primarily on research for programs and interventions being used or marketed in California. The CEBC provides information on interventions by topic areas, one of which is Trauma Treatment for Children and Adolescents. Other information on this site includes a guide to the CEBC rating system, screening and assessment tools, implementation tools, and online training and resources.
  • SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP) (http://www.nrepp.samhsa.gov/). NREPP is a searchable online registry of mental health and substance abuse interventions that have been reviewed and rated by independent reviewers. The purpose of this registry is to assist in identifying scientifically based approaches to preventing and treating mental and/or substance use disorders that can be readily disseminated to the field. The registry allows users to sort and filter interventions by factors such as age, areas of interest, settings, outcome categories, race/ethnicities, gender, study designs, and keyword. While there is no area of interest for trauma-focused interventions per se, the outcome categories include a “trauma/injury” selection that includes some trauma-focused interventions. In addition, some of the interventions listed under the “mental health treatment” area of interest are also considered trauma-focused interventions.
  • Agency for Healthcare and Quality’s (AHRQ) Interventions Addressing Child Exposure to Trauma: Part I-Child Maltreatment (http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=846). This report is the study protocol for the comparative effectiveness review of psychosocial interventions for children exposed to trauma through maltreatment or family violence and is designed to inform healthcare decisions by providing evidence on the effectiveness, benefits, and harms of different treatment options. 

Additional Resources

Children and Families Having a Choice and a Voice

This documentary, produced by JBS and the Georgetown University Center for Child and Human Development's National Technical Assistance Center for Children's Mental Health, provides viewers with a clear picture of the impact home and community-based services are having on families and children. In 2005, Congress authorized a 5-year demonstration grant program to test whether children with serious emotional disturbances who meet the requirements to receive services from a psychiatric residential treatment facility could be successfully served in a cost-effective manner with their families in the community. The Centers for Medicare and Medicaid Services selected nine States to participate in this demonstration. They ultimately provided community alternatives to residential treatment services to more than four thousand children. The demonstration successfully enabled most of the children to maintain or improve their functional status while in the program at less than a third of the cost of serving them in an institution.

The video includes basic trauma information and lessons learned. JBS is working with Georgetown University on the 5-year program, which is formally titled the Community Alternatives to Psychiatric Residential Treatment Facilities Demonstration Grant Program. Section 6063 of the Deficit Reduction Act of 2005 authorized up to $218 million for the demonstration, from fiscal years 2007 through 2011. A second video is planned to address trauma-informed practices.

To view the video, please visit the Georgetown University Center for Child and Human Development's National Technical Assistance Center for Children's Mental Health at: Link.

Online Trauma Resources

In addition, the following trauma-related resources are available online:

  • A Closer Look: Trauma Informed Treatment in Behavioral Health Settings, January 2007, Disability Rights Ohio, Ohio Legal Rights Service, retrieved from Link
  • Adaptation Guidelines for Serving Latino Children and Families Affected byTrauma, The Workgroup on Adapting Latino Services (first edition, 2008), San Diego, California, Chadwick Center for Children and Families, retrieved from Link
  • After Abuse: Early Intervention Services for Infants and Toddlers, 2008, FPG Snapshot, Frank Porter Graham Child Development Institute, University of North Carolina at Chapel Hill, retrieved from Link
  • Anda, R., The Health and Social Impact of Growing Up with Adverse Childhood Experiences [the ACE Study]: The Human and Economic Costs of the Status Quo, retrieved from Link
  • Barth, R., Scarborough, A., Lloyd, E., Losby, J., Casanueva, C., Mann, T., Developmental Status and Early Intervention Service Needs of Maltreated Children, 2008, study commissioned by the U.S. Department of Health and Human Services, completed by Institute for Social and Economic Development, retrieved from Link
  • B. Bryan Post, Education and the Child of Trauma, 2012, the Post Institute, retrieved from Link
  • Conradi, L., Wherry, J., & Kisiel, C. (2011). Linking Child Welfare and Mental Health Using Trauma-Informed Screening and Assessment PracticesChild Welfare90(6), 129-147. Abstract retrieved from Link
  • Cook, A., Blaustein, M., Spinazzola, J., & van der Kolk, eds. (2003). Complex Trauma in Children and Adolescents: White Paper from the National Child Traumatic Stress Network, Complex Trauma Task Force. Los Angeles, CA and Durham, NC: National Child Traumatic Stress Network. Retrieved from Link
  • Creating Trauma-Informed Child Welfare Systems: A Guide for Administrators (2nd edition, 2013), The Chadwick Trauma-Informed Systems Project, San Diego, California, Chadwick Center for Children and Families, retrieved from Link (basic demographic information must be provided by the reader to access the full article)
  • Creating Trauma-Informed Systems of Child Welfare, 2011, Child Welfare Series, Center for Excellence in Children’s Mental Health, retrieved from Link
  • Cross, K., Complex Trauma in Early Childhood, American Academy of Experts in Traumatic Stress, retrieved from Link
  • Crystal, S., Olfson, M., Huang, C., Pincus, H., and Gerhard, T. (2009), Broadened use of atypical antipsychotics: Safety, effectiveness, and policy challenges, Health Affairs28(5):770, retrieved from Link
  • Developmental Status and Early Intervention Service Needs of Maltreated Children, Executive Summary, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, retrieved from Link 
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