Trauma in Youth in Residential Care: Comparing Self-reports and Worker Perceptions

1. Assessing traumatic events in a child welfare youth population: A multiple source informant comparisonDelphine Collin-Vézina, Kim Coleman & Lise Milne

2. Objective and Rationale • Goal: To present the findings of a mixed methods research study on the levels of trauma and subsequent needs of youth who reside in residential care. • Why focus on trauma? • Why focus on youth in residential care?

3. Why focus on trauma? • Official maltreatment reports correspond toonly a small manifestation of a larger problem (tip of the iceberg), i.e. most traumas get unreported. • Thus, gathering information from additional sources regarding past traumatic experiences is warranted. Analogy of the iceberg: Only one-ninth of the volume of an iceberg is above water. The shape of the underwater portion can be difficult to judge by looking at the portion above the surface.

4. Why focus on youth in residential care? • Residential care is considered to be the most restrictive setting (e.g. secured units for youth who are deemed to be at risk to themselves or to others). • Most studies conducted among these youth describe the host of behavioural and emotional problems that they have… …but fail to connect these problems to actual trauma by documenting them through trauma-specific research or measures.

5. Current debate • Current controversy: ethics of asking and not asking research participants about abuse • By failing to ask about a history of child maltreatment, an important predictor of later-life problems may be overlooked: • strong evidence of the association between early traumatic experiences and some of the major public health and mental health problems issues of our day. Becker-Blease & Freyd, 2006

6. Other potential benefits • The study on trauma and subsequent needs of youth who reside in residential care has potential benefits: • To provide a more comprehensive representation of the youth’s past and current issues. • To review existing programming so as to better address the whole array of needs these youth present with. • To give youth a voice in child welfare research.

7. Method • A convenience sample of 53 youth aged 14 to 17 recruited from six child protection residential care units agreed to voluntarily participate in the study. • After parental consent was obtained, youth were invited to participate in the completion of a questionnaire. • Child care workers were asked to fill out a questionnaire on behalf of each of these youth.

8. Method

9. Sample N =53

10. Research Questions • What is the prevalence and severity of trauma symptoms of adolescent youth who reside in residential care? • How do the workers’ perceptions compare to youth self-reports on identifying and measuring trauma indicators? • Why have youth in residential placement entered the child welfare system and how does the reason for involvement (i.e. alinéa) correlate to the trauma reported by both youths and workers? • How do projective drawing measurements compare to standardized self-report instruments on identifying and measuring trauma indicators?

11. Research Question #1 What is the prevalence and severity of trauma symptoms of adolescent youth who reside in residential care? 60% 68% 38% 98% 58%

12. Research Question #1 What is the prevalence and severity of trauma symptoms of adolescent youth who reside in residential care? • No youth from the sample reported no history of maltreatment; • 18.9% of the sample reported only one form of maltreatment, • 11.3% reported two, • 18.9% three, • 30.2% four (N=16), • 20.8% all five forms of maltreatment (N=11). More than half of the sample (51%) reported four or all five different forms of abusive or neglectful experiences that the CTQ captures.

13. Research Question #1 What is the prevalence and severity of trauma symptoms of adolescent youth who reside in residential care? • Many of these youth experience trauma-related symptoms including depression, posttraumatic stress, dissociation, anger, and sexual concerns. • The findings point to two groups in particular who stand out as especially vulnerable: • Females with a history of sexual abuse trauma who are at higher risk for clinical levels of sexual concerns, posttraumatic stress and dissociation symptoms; • Youth who report 4 or all 5 forms of trauma who are at higher risk for clinical levels of depression, anger, posttraumatic stress, and dissociation symptoms and who have lower levels of resiliency features.

14. http://www.springerlink.com/content/j517044141005444/fulltext.pdfhttp://www.springerlink.com/content/j517044141005444/fulltext.pdf Published article

15. Research Question #2 • How do the workers’ perceptions compare to youth self-reports on identifying and measuring trauma indicators? Sexual Abuse Physical Abuse Physical Neglect Emotional Abuse & Neglect

16. Research Question #2 • How do the workers’ perceptions compare to youth self-reports on identifying and measuring trauma indicators? • Child Welfare Trauma Referral Tool • This measure is designed to help child welfare workers make more trauma-informed decisions about the need for referral to trauma-specific and general mental health services. • It is to be completed by the child welfare worker through record review and key informants. • Section A allows the child welfare worker to document history of exposure to a variety of types of trauma and indicate the age range over which the child experienced each trauma.

17. Research Question #2 • How do the workers’ perceptions compare to youth self-reports on identifying and measuring trauma indicators?

18. Research Question #2 • How do the workers’ perceptions compare to youth self-reports on identifying and measuring trauma indicators? *includes emotional neglect 15.1% (n=8) 13.2% (n=7) 28.3% (n=15) 41.5% (n=22) 54.7% (n=29) 9.4% (n=12) 1.9% (n=1) 22.6% (n=12) 69.8% 35.8% 37.7% 43.4% Youth – YES Worker - SUSPECTED 15.1% (n=8) 20.8% (n=11) 28.3% (n=15) 17.0% (n=9) Total Agreement 84.9% 56.6% 66.0% 60.4%

19. Research Question #2 • How do the workers’ perceptions compare to youth self-reports on identifying and measuring trauma indicators? • By including suspected maltreatment category there is the risk of false positives (ie worker suspects, child does not indicate maltreatment)

20. Research Question #3 • Why have youth in residential placement entered the child welfare system and how does the reason for involvement (i.e. alinéa) correlate to the trauma reported by both youths and workers? Sexual Abuse Physical Abuse Physical Neglect Emotional Abuse & Neglect Legal reason for service (Pij)

21. Research Question #3 • Why have youth in residential placement entered the child welfare system and how does the reason for involvement (i.e. alinéa) correlate to the trauma reported by both youths and workers? *psychological maltreatment Sexual abuse n=3 Youth – Yes / Worker – Yes n=3 3/3 Youth – No / Worker – Yes n=2 Physical abuse n=2 0/2 Emotional abuse* n=1 Youth – Yes / Worker – Yes n=1 1/1 Youth – Yes / Worker – Yes n=5 5/14 Neglect n=14 Youth – Yes / Worker – Suspected n=5 Youth – Yes / Worker – No n=4

22. Research Question #4 • How do projective drawing measures compare to • standardized self-report instruments on identifying & measuring • trauma indicators?

23. Drawings as a Source of Information: A Brief History:

24. Draw a Person in the Rain The DAPR is a variation of Machover’s Draw-A-Person assessment (1948). Seeks to asses: * A person’s vulnerability * Environmental stressors * Supports * Coping strategies . . . Can it be used to assess the impact of TRAUMA?

25. 3 Methods of Analysis: Distress Index, Level of Pathology & Content Indicators • Protective Factors: • Hat • Coat • Shoes • Umbrella • Tree • Roof/Awning • Smile • Distress Factors: • Small Rain • Large Rain • Diagonal Rain • Rain Focused over Figure • Clouds • Puddles Distress Index Non-Clinical Range Borderline Clinical Range Clinical Range

26. Research Question #4 • How do projective drawing measures compare to • standardized self-report instruments on identifying & measuring trauma indicators? Therefore it supports the wealth of research that questions the interpretation of drawings as an assessment technique Our study shows that drawings do not compare to standardized self-report measures on identifying & measuring trauma indicators

27. Research Question #4 • How do projective drawing measures compare • to standardized self-report instruments on • identifying & measuring trauma indicators? • However, there is a renewed interest & growing research evidence to support other benefits of children drawings: • As catalysts to discussion (Driessnack, 2005) • * Especially when it comes to topics or events • that are difficult to discuss • (Gross & Hayne, 1998; LaGreca, 1990; Pipe, Salmon, & Priestley, 2002; • Stafstrom, Rostasy, & Minster, 2002; Weinle, 2002; Wesson & Salmon, 2001). • Their expressive capabilities (Burkitt, et al. 2003a, b, 2004; Jolley et al. 2004). • In aiding traumatic memory recall when drawing is • incorporated into trauma assessment interviews(Burgess & • Hartman, 1993), often eliciting a more accurate recall of events • than interviews alone (Butler, Gross, & Hayne, 1995).

28. Results revealed high rates of abusive and neglectful experiences in the lives of these youth; most have experienced multiple forms of trauma. Youth are the best sources of information for their own trauma experiences. Worker perceptions are usually accurate but may result in false negatives/some false positives. We fall short of having the proper information if we rely solely on the legal reason for child welfare service. Projective measures do not seem to be appropriate tools for identifying and measuring trauma indicators. Concluding Thoughts

29. Concluding Thoughts • Future research including a larger sample of youth would enable cluster analyses that could more precisely identify profiles of youth. • This knowledge has the potential to inform social services, referrals, and therapeutic programs implemented in residential care settings. • Mandatory requirement for parental consent is an obstacle to conducting studies in this area • Our sample may not include youth who have experienced serious trauma (many filters) • Every youth cannot be given a voice • Next steps? Implementing systematic screening tools…

30. For more information, please contact Delphine, Kim or Lise Milne Delphine.collin-vezina@mcgill.ca Kim.coleman@mail.mcgill.ca Lise.milne@mail.mcgill.ca