Trauma-Informed System

Trauma-Informed System As you learned in your pre-work, Child Welfare is dedicated to creating a more trauma-informed approach in the way we do our work. This definition speaks to any system, organization, or team that is involved with providing some type of service that intersects with the lives of vulnerable children and families. It is the lens through which we see those we are attempting to serve. The Child Behavioral Health Screener (CBHS) is but a tool to assist us in crafting the conversations we hope are being had in homes already ~ it provides a consistent framework to ask important questions that can provide tremendous insight into both how a child is faring in their lives and how each responding caregiver sees/experiences and responds to that particular child. A Trauma Informed System: Realizes the widespread impact of trauma and understands potential paths for recovery; Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and Seeks to actively resist re-traumatization. How does Trauma-Informed Child Welfare Help Children? Earlier and more accurate identification of children s developmental and mental health needs Matches child s needs with appropriate evidence-based services Reduces placement disruptions Reduces maltreatment in care and during re-entry Decreases length of time to permanency Reduces use of psychotropic medications Adverse Childhood Experiences The ACE study highlights the importance of Child Abuse Prevention. The Ace study looked at three categories of adverse experiences in childhood; Abuse, Neglect experienced in childhood, and Family Dysfunction including mental illness, domestic violence, and growing up with an incarcerated parent. The study found experiences in childhood have a tremendous and lifelong impact on an adult s health and overall quality of life. 1

Emotional abuse Physical abuse Sexual abuse Emotional neglect Physical neglect Mother treated violently Household substance abuse Household mental illness Parental separation/divorce Incarcerated household member The study showed a dramatic link between ACE experiences and alcohol/drug abuse, chronic illness, psychological issue, which are all problems are CW system is burdened by today. The higher the number of ACEs a person has the higher the risk of alcohol/drug abuse, chronic illness, and psychological issues. Left unaddressed, 4 or more of them can lead to an average of 21 years shorter lifespan. ACEs Have a Strong Influence on: adolescent health reproductive health smoking alcohol abuse illicit drug abuse sexual behavior mental health risk of re-victimization stability of relationships, homelessness performance in the workforce ACEs increase the risk of: Heart disease Chronic Lung disease Liver disease Suicide Depression HIV and STDs and other risks for the leading causes of death 2

A family s involvement with DHS may be an opportunity to truly address the impact of some of these factors, as well as provide needed services in the home, when available. Long-term damage can be prevented if there is early, prompt, and appropriate intervention, but this requires making early identification and intervention a higher priority. The CBHS is our first glance at a child via their current behaviors, progress, and/or regression in certain areas. ACEs give us a window into what may have contributed to them becoming involved with CW, and the screener certainly has the ability to highlight possible elevations that can impact the neurodevelopment of children, both prior to their CW involvement and during their tenure within it. Being able to better and more quickly identify those children who may be speaking with their behavior that they are having social, emotional, or cognitive challenges, and/or demonstrating some risky behaviors, and getting them referred to quality behavioral health providers is one valuable way CW is becoming not just trauma-informed, but truly trauma-responsive. Child Behavioral Health Screenings The role of screening in child welfare settings is used to identify the prevalence of particular needs or symptoms and identify children who may require further assessment and intervention. In completing this work CW staff are assessing the family's history, family functioning, and child needs, including the areas of educational, medical, and mental health needs. The more the CW staff understands the family's history and needs, the better CW staff can target the right services and interventions to meet those needs. The idea is for earlier identification of behavioral health needs for children in care and quicker connection with services for better overall outcomes. Screening is not diagnostic. It is used to determine if a child needs to be referred for a more comprehensive assessment. Children identified through screening as potentially having behavioral, mental health and trauma related symptoms should then be referred for a more in-depth clinical assessment that determines a child s need for a particular intervention. Quality mental health services are limited; we need to make sure the children and youth who need the services have access to them. 3

Qualified Professionals Board Certified Psychiatrist (MD) with specialized trauma-informed training in childhood psychiatric disorders Types of Child Screening & Assessment Psychiatric Assessment/Evaluation Designed to determine the presence of a psychiatric diagnosis and determine the need for psychiatric treatment and/or psychotropic medication treatment Licensed Psychologist (PhD in clinical, counseling, or school psychology) with specialized training in trauma-informed child assessment Psychological Assessment/Evaluation Designed to determine the presence of a psychiatric diagnosis and determine the need for psychological treatment. Comprehensive, includes the use of psychological tests, and results in an integrated psychological report Licensed Mental Health Clinician (LPC, LCSW, LBP, PhD) with specialized training in traumainformed child assessment Clinical Assessment Designed to assess current symptoms and psychosocial functioning. May look at overall functioning or assess a specific area such as trauma exposure and its effects. Direct Care Worker or Health Care Professional with specialized training in trauma-informed child screening Screening Universally administered to determine a child s service needs related to their current functioning. May be used to assess for trauma exposure and the need for a mental health referral to determine treatment needs. This illustration shows how all children in CW will be screened via the CBHS **(NOTE: A Screen is just a brief, focused inquiry to determine whether an individual has experienced specific events or reactions due to adversity and/or abuse, neglect AND to determine if developmental markers are being met)** It is done by direct-care workers such as child welfare staff. It usually includes questions regarding exposure to possibly traumatic events and related symptoms; Assists workers in understanding the child s and family s history and potential triggers; and directs trauma-informed case planning. Screening tools identify broad and encompassing problem areas (e.g., externalizing, internalizing, etc.) rather than specific conditions or diagnoses (e.g., anxiety, depression, etc.). By utilizing a screener, CWS can promote the prevention, early detection, and treatment of behavioral and mental health difficulties following the experience of an event/or events that are traumatic for that child. Moving up the pyramid, fewer children, but those who have a Positive screen, will trigger referral for comprehensive clinical mental health assessment. Fewer still, but some, may continue on as needed for possible psychological testing or even a psychiatric evaluation. 4

Children of all ages must have access to mental and behavioral health screens and assessments, both on a routine basis and when they show signs of possible emotional, behavioral, or developmental difficulties. If the mental and behavioral health needs are identified and the treatment planning process is driven by what the underlying needs are, services and supports can be seen primarily as strategies for meeting the needs. As a result, there is a natural emphasis on using services and supports flexibly and tailoring them to meet the unique needs of the family. There is also an emphasis on prioritizing only those strategies, services, and supports that aim to meet these needs, reducing complexity of plans and the burden on families that can arise from plans that include too many services or conflicting strategies. In addressing the social and emotional elements of functioning for children who experienced maltreatment, well-being and permanency outcomes for children in care will improve. The integration of screening will help in identification and utilization of the right array of services. Child Behavioral Health Screener A brief measure designed to screen for the presence of behavioral and trauma-related symptoms that may be negatively impacting child functioning. Additional questions track counseling progress and psychotropic medication management. 11 versions tailored to different developmental levels. Population to Screen Children, birth through 17 years, who remain in their own home or placed in foster care for 30 days or longer, in kinship, traditional, TFC, Level B & C group homes, or are placed in trial reunification. We are not asking to screen children in high levels of care or shelters as those levels of care call for different interventions. The screeners are caregiver reports; the worker asks the questions to the primary caregiver. Ages 1 month to 3 Years/11 Months Version: Developmental milestones Pediatric symptom checklist in baby and preschool versions: Inflexibility Irritability Difficulty with routines Current services and treatments Psychotropic medication The 0-4 CBHS measures for developmental milestones and social/emotional functioning. The Pediatric Symptom Checklist, Baby (0-17months) or Preschool (18-47months) version measures for inflexibility, irritability, and difficulty with routines. There are questions that track current services and psychotropic medication usage. If there are concerns around the child s development the screener gives guidance for the workers to make a referral to Sooner Start; if 5

previously made notify the Sooner Start Coordinator of the results. For the 35-47 month screener it will guide the worker to contact the PFR for Education for Developmental Assessment referral sources. When the Pediatric Symptom Checklist scales are elevated guidance is to call the Department of Health Warmline to connect workers with a provider that specializes in Infant Mental Health. Ages 4 to 17 Years Version: Symptom checklist: o Attention o Internalizing o Externalizing o Trauma Reactions Assessment of current functioning o Are symptoms distressing and do they negatively impact the youth and family? o Does the youth have a problem with substances or sexual behavior? o Does the youth have any suicidal talk or behavior? Current services and treatments Psychotropic medication The 4-17 years CBHS has a symptom checklist that has subscales which measures for attention, internalizing behaviors, externalizing behaviors, and trauma reactions. There is also an assessment of current functioning, which addresses how the symptoms impact the youth on a daily basis. There are three red flag questions that address suicidal talk and behavior, substance use, and sexual behavior. There are the same questions as the 0-4 screener to track current services and psychotropic medication usage. If any of the scales are elevated the workers are guided to make a referral for a trauma-informed mental health assessment. The worker continues to monitor changes in the child s symptoms or progress in services by completing the screener on a monthly basis. By completing the screeners on a monthly basis it tracks progress overtime which measures for improvement in skills and competencies that contribute to well-being, as well as potential difficulties. The information gathered through the screening process is beneficial to inform conversations and decisions about the appropriateness of services. The repeated screening/functional assessment data will increase the case workers capacity to better understand the children s mental and behavioral health needs and provide for a systematic means to understanding which services provide positive outcomes. This frequency will also solidify the quality of the implementation process and institutionalize the instruments use as sustained practices. 6