Measuring Trauma in Child
Welfare Populations
Diligent Recruitment
Webinar Series
December 4, 2012
Ruth Hubbell McKey, Ph.D.
Elliott Graham, Ph.D.
James Bell Associates, Inc.
CWS and Trauma: Some Background
• Children in the child welfare system experience a variety
of traumatic events.
• For example, child abuse, neglect, exposure to family or
community violence, removal, and separation from
parents and siblings.
• Child welfare must coordinate with mental health
systems to ensure children receive the services they
need.
What is Child Traumatic Stress?
•
Child traumatic stress refers to the physical and
emotional responses of a child to events that
threaten the life or physical integrity of the child or
of someone critically important to the child (such as
a parent or sibling).
•
Traumatic events overwhelm a child’s capacity to
cope and elicit feelings of terror, powerlessness, and
out-of-control physiological arousal.
(Wilson, 2009)
Types of Traumatic Stress
• Acute trauma is a single traumatic event that is
limited in time.
• Chronic trauma refers to the experience of
multiple traumatic events.
• Complex trauma describes both exposure to
chronic trauma—usually caused by adults
entrusted with the child’s care—and the impact of
such exposure on the child.
Effects of Trauma Exposure
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Attachment: Social isolation, problems with empathy
Biology: Hypersensitivity to physical contact, unexplained
medical problems
Mood Regulation: Difficulty controlling and describing
feelings
Disassociation: Feelings of detachment &
depersonalization
Behavior Control: Poor impulse control, aggressiveness,
self-destructive behavior
Cognition: Problems with concentration, completing tasks,
planning, language development
Self Concept: Low self-esteem, shame, guilt
Childhood Trauma and Other Diagnoses
• Other common diagnoses for children in the child welfare
system include:
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Reactive Attachment Disorder
Attention Deficit Hyperactivity Disorder
Oppositional Defiant Disorder
Bipolar Disorder
Conduct Disorder
• Many children with these diagnoses have a complex trauma
history.
Trauma and the Influence of Culture
•
Social and cultural realities strongly influence children’s risk
for and experience of trauma.
•
Many children who enter the child welfare system are from
groups that experience:
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Discrimination
Negative stereotyping
Poverty
High rates of exposure to community violence
These children may have more severe trauma
symptomatology for longer periods of time.
Trauma and the Influence of Culture
•
People of different cultural, national, linguistic, spiritual, and ethnic
backgrounds may define “trauma” differently and use different
expressions to describe their experiences.
•
Child welfare workers’ own backgrounds can influence their perceptions
of child traumatic stress and how to intervene.
•
Some components of trauma response are common across cultural
backgrounds; others vary by culture.
•
Strong cultural identity and community/family connections can increase
resilience to trauma or can increase children’s risk for and experience of
trauma.
•
Example: Shame is a culturally universal response to child sexual abuse,
but the victim’s experience of shame and the way it is handled by others
(including family members) varies with culture.
Trauma and Child Developmental Stages
•
Child traumatic stress reactions vary by developmental
stage.
•
Children exposed to trauma expend significant energy
responding to, coping with, and coming to terms with the
event.
•
This may reduce a child’s capacity to master ageappropriate developmental stages.
•
The longer traumatic stress goes untreated, the farther a
child tends to stray from appropriate developmental
pathways.
Trauma and Young Children
•
Young children who experience trauma may:
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Become passive, quiet, easily alarmed
Become fearful, esp. regarding separations and new
situations
Experience confusion around assessing threats and
finding protection, esp. when a parent or caretaker is
the aggressor
Regress to earlier developmental behaviors (e.g.,
baby talk, bed-wetting, crying)
Experience strong startle reactions, night terrors, or
aggressive outbursts
Trauma and School-Aged Children
•
School-aged children who experience trauma may:
 Have unwanted and intrusive thoughts and images
 Become preoccupied with frightening moments from the
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traumatic experience
Replay the traumatic event in their minds to figure out what
could have prevented it or how it could have been different
Develop intense, specific new fears linked to the original event
Alternate between shy/withdrawn behavior and unusually
aggressive behavior
Become so fearful of recurrence that they avoid previously
enjoyable activities
Have thoughts of revenge
Experience sleep disturbances that interfere with concentration
and attention
Trauma and Adolescents
•
Trauma experienced by adolescents may lead to:
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Anxiety and depression
Intense anger
Low self-esteem and feelings of helplessness
Aggressive or disruptive behavior
Sleep disturbances masked by late-night studying,
television watching, or partying
Drug and alcohol use as a coping mechanism
Over- or under-estimation of danger
Expectations of maltreatment or abandonment
Difficulties with trust
Increased risk of re-victimization, esp. if the adolescent
has lived with chronic or complex trauma
Diligent Recruitment and Trauma:
Why It Matters
• Reunification: Children who went home and stayed home had a fourfold increase in internalizing behavior problems from baseline to
18-month follow-up. Although the percentage of children with behavior
problems at 36-month follow-up decreased, twice as many children still
met or exceeded clinical levels compared to baseline (Bellamy, 2008).
• Kinship Care: Kinship placements were not predictive of better
mental health outcomes regardless of the amount of time in kinship
care (Fechter-Leggett & O’Brien, 2010).
• Adoption: In assessments of children at 2, 4, and 8 years following
adoption, adopted foster youth were more behaviorally impaired
than their non-FC counterparts, although a number of non-FC youth
displayed behavior problems as well (Simmel, Barth, & Brooks, 2007).
Diligent Recruitment and Trauma:
Why It Matters
• Out-of-home placement is a significant traumatic
event for most children.
• Trauma symptoms and associated behaviors
often persist even after children go home, are
placed with kin, or are adopted.
• Resource families must learn to recognize and
address trauma symptoms and behaviors
expressed by children in their care.
• Especially relevant to resource family retention.
Trauma Screening and Assessment
CWS-involved children should be:
• Screened for trauma
• Assessed for trauma
• Provided a psychological evaluation
(sometimes this is the trauma assessment)
Measures for Trauma
Screening and Assessment
Measures used for this should be:
• Reliable — Consistent in their use across time
and settings
• Valid — Accurate in measuring the
psychological/functioning domain of interest
• Have standardized norms — be tested with a
sufficient population to provide guidance for
interpretation of the measure
However, the psychometrics for many tools have
not been developed.
Trauma Screenings
• A brief measure administered to all children by
CW staff at initial contact to determine exposure
to potentially traumatic events/experiences or to
identify possible traumatic stress
symptoms/reactions (e.g., behavioral,
educational, self-concept difficulties).
• Trauma screenings are not diagnostic.
• They do indicate if a child should be referred for
a trauma assessment.
Trauma Assessment
• Comprehensive process of evaluation conducted by a
trained mental health provider.
• Determines if symptoms of trauma are present.
• Determines the severity of the symptoms and impact
on child’s functioning.
• More comprehensive and detailed than screening.
• Examines trauma and developmental history; traumatic
stress symptoms; broader mental health symptoms;
caregiver/family needs; environmental issues;
resources and strengths.
• May include observations, administration of measures,
and clinical interviews with child, caregivers, others.
Psychological Evaluation
• Comprehensive diagnostic process of all
functional domains (cognitive,
developmental, social/emotional and
personality).
• Completed by licensed psychologist based on
referral.
• Measures used relate to reason for referral,
but may also include standard psychological
battery.
Trauma Screening Tools
Child and Adolescent Needs and Strengths (CANS) —
Kisel, Blaustein, et al., 2009
• Age range 0-18.
• Short version used as screener, longer version as
assessment.
• Gathers basic information on traumatic experiences
and whether adjustment to trauma affects child’s
functioning.
• Collected from multiple sources.
Trauma Screening Tools (cont.)
Child Welfare Trauma Referral Tool —
(CWT) Taylor, Steinberg, and Wilson, 2006
• Age range 0-18.
• Completed by caseworker.
• Questions about the child’s history and presenting
problems lead to identification of traumatic
experiences.
Trauma Screening Tools (cont.)
Trauma Symptom Checklist for Children (and Young Children)
(TSCC) — Briere, 1996
• Ages 8-16 for child version; Ages 3-12 for young children
version.
• Self-report for child version; Caregiver report for young
children version.
• 90-items; can also be used as an assessment.
• Evaluates acute and chronic post-traumatic symptomatology in
children who have experienced traumatic events.
• Based on theories of development and child trauma. Provides
information on other symptoms such as anxiety, depression,
anger, and abnormal sexual behavior.
Trauma Screening Tools (cont.)
UCLA Post Traumatic Stress Disorder Reaction Index
(UCLA-PTSD)
—
Pynoos, et al., 2004
• Age range 0-18.
• Caregiver, child, or adolescent report depending
on age.
• 48-item semi-structured interview to assess a
child’s exposure to 26 types of traumatic events.
• Assesses PTSD diagnostic criteria.
Trauma Screening Tools (cont.)
Strengths and Difficulties Questionnaire (SDQ) —
Goodman, 1997
• Brief behavioral screening tool including 5 areas:
(emotional symptoms, conduct problems,
hyperactivity/inattention, peer problems, prosocial
behavior) to yield a total difficulties score.
• Parent, teacher, and child versions.
Trauma Assessment Tools
• Trauma assessment may include
checklists, assessments, interviews, and
other measures.
• Most of these instruments will be used in
combination to complete a full trauma
assessment.
Trauma Assessment Tools
Child and Adolescent Needs and Strengths
(CANS)— Kisel, Blaustein, et al., 2009
• Long version can be used as an assessment
(short version used as a screener).
Trauma Assessment Tools (cont.)
Child Behavior Checklist (CBCL) —
Achenbach and Rescoria, 2001
• Versions for young and older children.
• Provides ratings for 20 competences and 120
problem items.
• Includes open-ended items covering physical
problems, concerns, and strengths.
• Yields scores on internalizing, externalizing, and
total problems.
• Very widely used.
Trauma Assessment Tools (cont.)
Ages and Stages Questionnaires (ASQ) 2nd Ed. —
Bricker et al., 1999
www.agesandstages.com
• Developmental and social-emotional assessment for
children from one month to 5 ½ years.
• Examines strengths, trouble spots, developmental
milestones.
• Based on parent report.
Trauma Assessment Tools (cont.)
Trauma Symptom Checklist for Children (TSCC) —
Briere, 1996
• Age range 8-16.
• Measures severity of post-traumatic stress and
related psychological symptomatology in children
who have experienced traumatic events (e.g.,
physical or sexual abuse, natural disasters, other
major loss).
• Based on child self-report.
National Child Traumatic Stress
Network (NCTSN): Core Data Set
• Developed to standardize data collected on CWS children
related to clinical evaluation, evidence-based interventions,
service use, and provider training.
• Consists of forms and assessment measures that collect
data on demographics, trauma exposure, client
functioning, treatment services, and provider training.
• Collected on over 10,000 children nationally. Includes:
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TSCC
UCLA PTSD
CBCL
Youth Services Survey
Other tools, surveys, interviews, and focus group guides
For more information on these and other
measures go to:
• The Measures Review database at the
NCTSN website (www.NCTSN.org)
-or• Website of Psychological Resources, Inc.
(www.parinc.com)
References
Barto, B., Barnett, E., & Ake, G. (2012). The application of trauma
screening/assessment in child welfare settings. Part II: direct level.
NCTSN Training Series. Retrieved from www.NCTSN.org.
Bellamy, J. (2008). Behavioral problems following reunification of children
in long-term foster care. Children and Youth Services Review, 30, 216-228.
Conradi, L., Wherry, J., & Kisiel, C. (2011). Linking child welfare and
mental health using trauma-informed screening and assessment practices.
Child Welfare , 90 (6), 129-147.
Chadwick Trauma-Informed Systems Project: www.ctisp.org.
Fechter-Leggett, M. O., & O’Brien, K. (2010). The effects of kinship care on
adult mental health outcomes of alumni of foster care. Children and Youth
Services Review, 32 (2), 206-213.
References (cont.)
National Child Traumatic Stress Network (2012). NCCTS leadership: The core data
set. Retrieved from www.NCTSN.org.
Pynoos R., Fairbank, J. A., & James-Brown, C. (2011). Effectively addressing the
impact of child traumatic stress in child welfare. Child Welfare, 90 (6), 7-11.
Putnam, F., Perry, M., Putnam, K., & Harris, W. (2008). Childhood antecedents of
clinical complexity. Presentation the Annual Meeting of the International Society
for Traumatic Stress Studies, Nov 15, 2008, Chicago, IL.
Simmel, C., Barth, R. P., & Brooks, D. (2007). Adopted youths psychosocial
functioning: A longitudinal perspective. Child and Family Social Work, 12 (4), 336348.
Wilson, C. (2009). Understanding how trauma impacts children in child welfare
and what to do about it. Presentation at the Department of Children and Family
Services Conference, Cleveland, OH. Retrieved from:
www.chadwickcenter.org/resources/resources.htm.
Questions and
Discussion
Ruth Hubbell McKey, Ph.D.
Elliott Graham, Ph.D.
James Bell Associates
3033 Wilson Blvd, Suite 650
Arlington, VA 22201
General Number: 703-528-3230
Direct Dial: 703-247-2653 (Ruth)
703-842-0958 (Elliott)