Linking child welfare and mental health using trauma-informed screening and assessment practices

An abundance of research suggests that children in the child welfare system (CWS) have experienced numerous traumatic events and are exhibiting traumatic stress symptoms. Therefore, it is critical that the CWS work closely with the mental health system to ensure that these children receive the appropriate trauma screening, trauma-focused assessment, and referral to the appropriate trauma-focused mental health services. This paper will begin by providing a concrete definition of trauma-focused screening and highlighting how that differs from a more comprehensive trauma-focused assessment process and a psychological evaluation. From there, the authors will highlight existing trauma-focused screening and assessment tools that are used widely within CWSs and the challenges related to integrating trauma-focused screening practices into CWSs. The authors will provide recommendations for ways in which child welfare jurisdictions can integrate trauma-focused screening practices into their daily practice.     

Trauma Focused Cognitive Behavioral Therapy with Children of Incarcerated Parents

This paper explores children’s trauma symptoms related to parental incarceration and lays the groundwork for the implementation of Trauma Focused Cognitive Behavioral Therapy (TF-CBT) within a clinical community-based setting treating children and adolescents affected by parental incarceration. Children and adolescents who experience parental incarceration are more likely to develop symptoms of post-traumatic stress disorder (PTSD): depression, anger, aggression, and isolating and self-harming behaviors. Although parental incarceration is a known source of trauma, there are no documented studies examining effective clinical treatments to reduce the effects of the trauma experienced by these children and adolescents. Except for children and adolescents affected by parental incarceration, TF-CBT, a promising model for treating and reducing the symptoms of PTSD, has been successfully applied to various populations affected by trauma. Children of incarcerated parents resemble populations treated with TF-CBT in earlier applications. In this paper, we present a case illustration that examines the application of TF-CBT with one child who experienced trauma symptoms related to parental incarceration, while discussing the results of that application and the potential for broader applicability of TF-CBT within community-based organizations that treat the population of children and families affected by parental incarceration.     

Complex trauma and mental health in children and adolescents placed in foster care: findings from the National Child Traumatic Stress Network

Many children in the child welfare system (CWS) have histories of recurrent interpersonal trauma perpetrated by caregivers early in life often referred to as complex trauma. Children in the CWS also experience a diverse range of reactions across multiple areas of functioning that are associated with such exposure. Nevertheless, few CWSs routinely screen for trauma exposure and associated symptoms beyond an initial assessment of the precipitating event. This study examines trauma histories, including complex trauma exposure (physical abuse, sexual abuse, emotional abuse, neglect, domestic violence), posttraumatic stress, and behavioral and emotional problems of 2,251 youth (age 0 to 21; M = 9.5, SD = 4.3) in foster care who were referred to a National Child Traumatic Stress Network site for treatment. High prevalence rates of complex trauma exposure were observed: 70.4% of the sample reported at least two of the traumas that constitute complex trauma; 11.7% of the sample reported all 5 types. Compared to youth with other types of trauma, those with complex trauma histories had significantly higher rates of internalizing problems, posttraumatic stress, and clinical diagnoses, and differed on some demographic variables. Implications for child welfare practice and future research are discussed.     

Trauma specific versus generic measurement of distress and the validity of self-reported symptoms in sexually abused children

This study examined two issues in the assessment of child sexual abuse victims: sensitivity to trauma-related symptoms and validity of self-reports. The Trauma Symptom Checklist for Children (TSCC) and Personality Inventory for Youth (PIY) were completed by 41 sexually abused children. Parents and children completed diagnostic interviews for PTSD. We predicted that TSCC validity scales would be moderately correlated with PIY scales measuring similar constructs, and that TSCC clinical scales would be more sensitive to PTSD status than the PIY clinical scales. Results supported both hypotheses. TSCC validity scales appeared to be less likely to identify clinical cases, however. Clinical and research implications are discussed.     

See no evil,hear no evil,speak no evil: assessing complex trauma in young children

Complex trauma generally refers to a child's exposure to multiple traumatic events often within the context of an interpersonal relationship. Childhood traumatic events are commonplace and can have significant implications for physical and mental health. However, traumatic events are often not assessed by clinicians involved in their care. This paper outlines an approach to assessing complex trauma in young children in clinical settings. This approach involves an initial interview, an assessment of traumatic events and trauma symptoms in the child, an assessment of the parent–child interaction, an understanding of the child's functioning in multiple settings, and an assessment of parental trauma where relevant. Complex trauma takes time to assess and is dependent on the parent's ability to recognise and acknowledge the effect trauma has had. The paper concludes with some of the challenges when assessing complex trauma in young children in clinical settings.     

A National Survey of Child Advocacy Center Directors Regarding Knowledge of Assessment,Treatment Referral,and Training Needs in Physical and Sexual Abuse

Mental health services are a core component of child advocacy centers in the United States. Child advocacy center directors were surveyed about (a) trauma and posttraumatic stress disorder; (b) referral criteria for treatment of abuse victims; (c) evidence-based treatments for abused children; (d) reliable, valid, and normed measures helpful in assessment; and (e) training needs. Directors accurately identified posttraumatic stress disorder symptoms, but additional symptoms were misidentified. Directors identified best practices for assessment and treatment, but they misidentified non-evidence-based practices. Primary reasons for referral for services included severity of abuse and emotional response of the child. However, referrals based on assessment findings were not a high priority. Directors expressed some training needs for staff consistent with issues identified in the study.     

Child-Parent Relationship Therapy with Extra-Familial Abused Children

Sexual abuse by a perpetrator outside of the family is the most prevalent form of child sexual abuse. It is associated with serious consequences for both the child and his family. Surprisingly, however, the issue of extra-familial sexual abuse has received very little research and clinical attention. The purpose of the current study was to explore the effectiveness of Child-Parent Relationship Therapy (CPRT), which uses nondirective play therapy tools, among parents of extra-familial abused children and their parents. In order to do so, data was collected from 51 parents who participated in CPRT, at three points in time: pretreatment stage, at the beginning of the first meeting; and in the post treatment stage. The data included the parents’ reports via three questionnaires: Parenting Stress Inventory (PSI), Compassion Fatigue Self-Test (CFST), Child Behavior Checklist (CBCL). Overall, the results indicated a decrease in internalizing and externalizing symptoms among the children, as well as in parenting stress and in parental secondary trauma symptoms. This study contributes to the literature on interventions with victims of extra-familial child abuse and their parents. Specifically, the results highlight the benefits and importance of involving both parents and children in therapeutic interventions for victims of extra-familial child sexual abuse, with particular emphasis on the benefits of Child-Parent Relationship Therapy.     

Precursors to Offending and the Trauma Outcome Process in Sexually Reactive Children

The authors delineate five precursors that lead to vulnerability to acting out sexually in children who have been victimized. Fielhor's preconditions for sexual perpetration are reviewed and applied to work with sexually reactive children ages 4- 12. The authors present he "Trauma Outcome Process" as an approach differentiating responses to trauma as self-victimizing. assaultive, andlor healthy coping. This article stresses that victims of sexual abuse make choices in their emotional and behavioral responses to trauma. This approach has implications for treatment.     

Longitudinal growth of post-traumatic stress and depressive symptoms following a child maltreatment allegation: An examination of violence exposure,family risk and placement type

Few longitudinal studies have analyzed how traumatic experiences (e.g. home removal, violence exposure) influence both depressive and Post-Traumatic Stress (PTS) symptoms in children involved with Child Protective Services (CPS). This study investigated the change trajectories of both depressive and PTS symptomatology as well as their associations over time, focusing on the effect of complex trauma. Data were obtained from the National Survey of Child and Adolescent Well-Being (1999–2007), a nationally representative study of children and adolescents who were referred to child protective services for alleged maltreatment. The Children's Depression Inventory (CDI) scale measured depressive symptoms and the Post Traumatic Stress Disorder section of a version of the Trauma Symptom Checklist for Children (TSCC) provided the measure of current trauma-related symptoms or distress. Analyses were conducted using a parallel process growth curve model. The participants' initial levels of depressive and PTS symptomatology were significantly and positively related; furthermore, any changes in these two outcomes were also correlated longitudinally. The initial assessment of PTS symptoms significantly contributed to the advancement of more severe depressive symptoms over time. No significant differences were found between youth who remained in the home and those removed from the home. However, violence exposure, sexual abuse, gender and age were significant predictors of level and rate of change in both PTS and depressive symptoms. PTS growth factors mediated the longitudinal relationship between witnessing severe violence and depressive symptoms. The findings suggest a complex developmental association between depressive and PTS symptomatology among CPS-involved youth that is rooted in early childhood experiences with complex trauma.     

Navigating post-trauma realities in family systems: Applying social constructivism and systems theory to youth and family trauma

Trauma affecting youth and families takes a variety of forms, from random one-time events such as accidents and natural disasters to chronic and highly personal trauma from child abuse or intimate partner violence. Though trauma has received increasing attention in theory and intervention research over the last several decades, the prevailing theories and treatments have limitations due to a linear perspective focused on the trauma problems of the individual. This is particularly concerning given the high dropout rates for trauma-focused treatments and the complexities of intergenerational trauma that cannot be adequately conceptualised at the level of the individual. To inform and improve family-based treatment of youth and family trauma, this paper proposes a theoretical framework informed by social constructivism and systems theory. Social constructivism upholds that reality is constructed through communication as an adaptive process for survival, with multiple potential realities possible. Systems theory promotes a non-linear view of causality within a system, such that the structure and properties of a system determine outcomes more than the inputs that go into the system. Together, the principles of these meta-theories contradict the orthodox focus on traumatic events causing trauma symptoms, and instead imply that family-based treatment should focus on helping families shift assumptions and dynamics that sustain the problem in the present. The joint application of a social constructivism–systems theory framework for trauma introduces several new principles to inform family-based treatment: (a) post-trauma realities; (b) mutual survival; (c) power–justice balance; and (d) adaptive reorganisation. The implications of these principles for youth and family trauma treatment will be discussed. Future intervention development and research should consider these principles in the ongoing effort to improve family therapy for youth and family trauma.     

Vicarious trauma: an exploratory study of the impact of providing sexual abuse treatment on clinicians' trust and intimacy

This study examined vicarious trauma effects in male and female clinicians who treat sexual abuse survivors (n = 111) and sexual offenders (n = 272). The national survey was conducted using a random sample of clinical members of two professional organizations. Analyses tested the relationships between demographic variables, maltreatment history, client population served, and cognitions about trust of and intimacy with others, using the Trauma Stress Institute Belief Scale (TSIBS-R-L, Pearlman 2003), the Childhood Trauma Questionnaire (CTQ, Bernstein & Fink, 1998), and author-generated questions. Respondents reported high rates of multiple forms of childhood maltreatment; however there was no relationship between history of child sexual abuse and vicarious trauma effects. Scores for self-reported disruption in cognitions about intimacy with others exceeded norms for mental health professionals. Sequential regression analyses were used to examine theoretically-derived variables. Implications for practice and research are detailed.     

ASSESSING THE NEEDS OF TRAUMATIZED CHILDREN TO IMPROVE OUTCOMES

This paper is about the development of an outcomes‐based treatment approach in work with traumatized children and of an assessment model to measure progress. In particular, it shows how a spider diagram is used to give a powerful, visual representation of a child's progress. The work described has been carried out by SACCS — an independent UK organization providing treatment based in residential and family settings for children who are severely traumatized by abuse and neglect. This trauma has had a massive impact on their development socially, physically, emotionally, academically and spiritually. The children have complex needs which are extremely difficult to work with. However, the potential for recovery from their injuries remains. I will use a single case study of a child to illustrate the process of assessment and measurement of recovery. The treatment approach used is broadly psychodynamic. The concept of an outcomes‐based approach and the measurement tool described also has widespread relevance in social care.     

When children’s testimonies are used as evidence: how children’s accounts may impact child custodial decisions

Abstract

In child custody cases, children oftentimes provide allegations of experienced trauma against one of their parents. Such allegations can happen before any investigative interviews (e.g., by the police or child protective services) have taken place. A central theme here concerns how to appraise such allegations and make certain that children’s accounts are taken seriously. In the current special issue, the focus is on new work on the functioning of children’s memory and its relation to trauma or work on children’s suggestibility and memory when they are traumatized. Specifically, key experts in the field of children’s memory provided contributions on: (1) the impact of interviewer support and rapport building on children’s testimonies, (2) the role of parental alienation in children’s testimonial accuracy, and (3) different types of false memories in children’s memory reports.     

Trauma adapted family connections: reducing developmental and complex trauma symptomatology to prevent child abuse and neglect

Families living in urban poverty, enduring chronic and complex traumatic stress, and having difficulty meeting their children's basic needs have significant child maltreatment risk factors. There is a paucity of family focused, trauma-informed evidence-based interventions aimed to alleviate trauma symptomatology, strengthen family functioning, and prevent child abuse and neglect. Trauma Adapted Family Connections (TA-FC) is a manualized trauma-focused practice rooted in the principles of Family Connections (FC), an evidence supported preventive intervention developed to address the glaring gap in services for this specific, growing, and underserved population. This paper describes the science based development of TA-FC, its phases and essential components, which are based on theories of attachment, neglect, trauma, and family interaction within a comprehensive community-based family focused intervention framework.     

Profiles of adult survivors of severe sexual,physical and emotional institutional abuse in Ireland

Adult survivors of institutional abuse were interviewed with a comprehensive assessment protocol which included the Childhood Trauma Questionnaire, the Institutional Child Abuse Processes and Coping Inventory, the Structured Clinical Interviews for Disorders of the Diagnostic and Statistical Manual of Mental Disorders IV axis I disorders and personality disorders, the Trauma Symptoms Inventory, a Life Problems Checklist, the Experiences in Close Relationships Inventory and the Kansas Marital Satisfaction Scale. Profiles were identified for subgroups that described severe sexual (N = 60), physical (N = 102), or emotional (N = 85) abuse as their worst forms of maltreatment. Survivors of severe sexual abuse had the most abnormal profile, which was characterised by higher rates of all forms of child maltreatment and higher rates of post‐traumatic stress disorder, alcohol and substance abuse, antisocial personality disorder, trauma symptoms and life problems. Survivors of severe emotional abuse were better adjusted than the other two groups. The profile of survivors of severe physical abuse occupied an intermediate position between the other two groups. A thorough assessment of abuse history and current functioning should be conducted when providing services to adult survivors of institutional abuse, since this may have important implications for the intensity of services required. Survivors of severe sexual abuse may require more intensive services. Copyright © 2009 John Wiley & Sons, Ltd.     

THE RELEVANCE OF THE CONCEPT OF DISSOCIATION IN CHILD PROTECTION

This paper explores one aspect of unresolved trauma, namely dissociation. Its relevance to child protection is discussed with reference to two aspects: emotional neglect and choice of partner. There is an exploration of the implications for both assessment and treatment. The central place of shame in relation to dissociation is also explored. It is argued that dissociation is an important concept in child protection assessments and that social work assessments should be alert to this.     

Family Assessment and Intervention Using an Interactive Art Exercise

The authors have developed a family-centered interactive art exercise from a synthesis of clinical tools used by attachment theory and family art therapists. The exercise aims to facilitate assessment and treatment of families with younger children (two to eight years) at a tertiary referral child and family psychiatric facility, by observing how a family collectively as well as individually sets about planning and completing an art task. Art exercises allow for both verbal and non-verbal communication. The exercises are deliberately kept simple in order to span a range of developmental abilities, and allow the therapist/s to observe from behind a one-way screen, so as to be less intrusive in the family dynamics. Although developed for assessment with a specific population, the exercise is likely to be useful in other clinical situations and has been used as a treatment tool by the authors.     

Emotional death: the charity advert and photographs of childhood trauma

This essay will use current and historical advertisements by the British charity Barnardo’s to analyse the representation of abused children. In particular, it will focus on the 1999–2003 campaigns to explore the connection between the experience of trauma, death and the photographic image in the context of a first world, Western preoccupation with the spectre of the missing, lost or abused child. It will consider the complex attempt to photographically capture the missing image, to invoke a subjective loss and to conjure up the accompanying wound of trauma. The Barnardo’s adverts, like many charity adverts of abuse, attempt to show a traumatic past, that by its very nature as trauma, defeats easy representation. Trauma as an experience produces a crisis of representation. The traumatic event, with its radical disruption of psychic defences, results in an absence or gap in memory, knowledge and recall. The devastating event so overwhelms the senses that it produces a perpetual sense of “belated uncertainty” about “a truth to which there is no simple access” (Caruth , p. 6). These photographs attempt to capture the dislocation of time and distortion of identity for the traumatised child. Whilst structurally they can be read for invoking a sense of aura or credibility as testimony, they do so in a digital age when the status of the “truth” of the photograph as evidence is called into doubt (Robins ). This dislocation of image from referent can be read for its parallels with the dislocating structures of trauma. As such they raise questions of the ethics of “spectral evidence” in a commercialised charity sector.     

Trauma-informed forensic child maltreatment investigations

Trauma-informed child welfare systems (CWSs) are the focus of several recent national and state initiatives. Since 2005 social work publications have focused on systemic and practice changes within CW which seek to identify and reduce trauma to children and families experiencing child maltreatment or other distressing events, as well as to the agency personnel working with these clients. Within the body of trauma-informed literature, little attention has been devoted specifically to the initial investigative response and its role in controlling for system induced trauma to the child, family, and caseworker. Training child protection services (CPS) workers on the impact of trauma in child maltreatment forensic investigations and the worker's role in anticipating and mitigating the effects of trauma during the investigative process is rarely addressed in the trauma-informed literature. This article reports on a training strategy to infuse trauma information into an existing forensic child maltreatment investigation curriculum with the goal of enhancing CPS caseworker's knowledge, skills, and values concerning the importance of viewing investigations and their associated tasks through a trauma lens.     

Statewide dissemination of trauma-focused cognitive-behavioral therapy (TF-CBT)

Despite evidence linking childhood trauma to subsequent social, emotional, psychological, and cognitive problems, many children who have experienced trauma do not receive mental health treatment that has been proven to be effective. Large-scale dissemination of evidence-based practices (EBPs) is one possible solution to enhance the current negative state of mental health treatment for these children. This article describes a dissemination effort of an EBP (i.e., Trauma-Focused Cognitive-Behavioral Therapy [TF-CBT]) for childhood symptoms of post-traumatic stress disorder throughout Arkansas. The effort targeted mental health professionals within child advocacy centers and community mental health centers across the state. The article describes the process of dissemination and implementation. Lessons learned and recommendations for future dissemination efforts are highlighted.