Lisa Conradi, Psy.D. Rady Children’s Hospital – San Diego

1. Increasing Collaboration between Child Welfare and Mental Health: Use of Trauma-informed Screening and Assessment Practices within Child Welfare Settings Lisa Conradi, Psy.D. Rady Children’s Hospital – San Diego Chadwick Center for Children and Families

2. Objectives of Today’s Presentation

3. Audience Poll • Do you currently conduct a mental health or trauma-focused screening in your agency? • If so, what do you use? Who does the screening? What kinds of questions does it contain? How is the information used? • Do you or your partners currently assess for trauma and behavioral health needs within your practice or agency? • If so, what kinds of tools do you use? Who does the assessment? How is the information used? • What have been your successes? Your challenges?

4. Screening and Assessment Screening? Assessment? Evaluation? These terms are often used interchangeably, but what are they? When it is appropriate to use one vs. the other?

5. Screening Screening refers to a brief, focused inquiry to determine whether an individual has experienced specific traumatic events or reactions to trauma and if they need trauma-focused mental health treatment. Done by front-line workers, such as Child Welfare and, in some cases, mental health. Usually includes questions regarding a child’s exposure to trauma and his/her symptoms

6. Assessment Assessment is a more in-depth exploration of the nature and severity of the traumatic events, the impact of those events, current trauma-related symptoms and functional impairment. Usually done by a mental health provider to drive treatment planning. A good assessment usually occurs over at least 2-3 sessions of therapy and includes a clinical interview, use of objective measures, behavioral observations of the child, and collateral contacts with family, caseworkers, etc. Domains covered include: Basic demographics Family history Trauma history (comprehensive, including events experienced or witnessed) Developmental history Overview of child problems/symptoms

8. Prior to Embedding a Screening or Assessment Process • Provide broad training on the following topics: • Mental and behavioral health in children • Child traumatic stress. This includes training on different trauma types (sexual abuse, physical abuse, exposure to domestic violence, emotional abuse, etc.) and various traumatic stress reactions that children may exhibit, including internalizing and externalizing behavior problems.

9. Prior to Embedding a Screening or Assessment Process, cont’d • Establish a relationship with your mental health partners and is actively work with them to build their capacity to provide trauma-focused mental health treatment when appropriate. • Have a mechanism in place to address secondary traumatic stress within child welfare workers and supervisors. Integrating a system for preventing and addressing secondary traumatic stress is critical.

10. Where Does Screening Fit into the Process?

11. Why Screen? • Screening provides information on broad symptoms that the child may be experiencing that warrant a more comprehensive assessment. • In many cases, workers are already gathering this information, but they don’t have a process to make sense of the information that they are gathering. • Screening assists caseworkers in identifying the types of events or situations that may potentially trigger symptoms for the child. This information can be conveyed to the foster parent and can ultimately help the foster parent manage the difficult behaviors and minimize placement changes. • Screening plays a critical role in case planning and referral to the appropriate mental health services, if appropriate.

12. Systemic Decision-Making Process for Selecting and Implementing Screening Tools

13. Client-level Decision-Making Process for Selecting and Implementing Screening Tools

14. Types of Screening Tools

15. Child-Completed Tool • If a child has the developmental capacity to read and complete a screening tool (usually ages 8 and above, but will vary significantly across children) • Questions/items are given in writing or verbally administered in an interview format.

16. Child-Completed Tool:Strengths and Challenges • A benefit to this strategy includes providing the child with an opportunity to verbalize their responses aloud. • CW worker should take great care in asking highly personal and sensitive questions and be aware that a child may be sharing their experiences for the first time or be hesitant to share them at all. • It may be difficult for both the child to share their experiences and for the caseworker to hear. • Training and support on asking these questions in a sensitive manner is critical.

17. Caregiver-Completed Tool • For infants, toddlers, and young children (ages 0-–8) or children with developmental delays, it may be more appropriate to have a caregiver complete a trauma screening tool either by providing written responses to the questions/items or through an interview by the CW worker.

18. Caregiver-Completed ToolStrengths and Challenges • This strategy is particularly helpful for detecting exposure to trauma for young children who cannot verbalize information themselves. • Birth parents may be cautious in sharing detailed information about all of the child’s traumatic experiences given how this may impact decisions about placement, visitation, and reunification. • Foster parents may not know the child’s trauma history and may over- or underreport trauma symptoms based on their experiences fostering other children in their care.

19. Provider Completed Tool • An information integration tool can be completed by the caseworker or clinician as he or she reviews and integrates all available information on a child, including court reports, interviews with caregivers and teachers, other questionnaires, and behavioral observations.

20. Provider Completed Tools Strengths and Challenges • This integration strategy is particularly helpful in allowing the caseworker to make sense of a wealth of information that is available for children in all age groups and can be used to screen infants and toddlers. • However, if they have not asked the child or caregiver specific questions, they may not have the complete picture of the child’s unique experiences.

21. Examples of Tools that Screen for Mental and Behavioral Health

22. Child Behavior Checklist (CBCL) • Developed by Achenbach (2001) • Contains 113-items • Versions for both the parent/caretaker to complete and a teacher version • 2 versions: 1.5-5 years; 6-18 years • Provides information on child behavioral and emotional problems, and competencies • Established reliability and validity • Available in Spanish • 10-15 minutes to administer

23. Pediatric Symptom Checklist • Psychosocial screen designed to facilitate the recognition of cognitive, emotional, and behavioral problems so that appropriate interventions can be initiated as early as possible. • Designed for children 4-18 years. • Consists of 17 items that are rated as “Never,” “Sometimes, ” or “Often” present. A value of 0 is assigned to “Never”, 1 to “Sometimes,” and 2 to “Often”. • The total score is calculated by adding together the score for each of the 17 items. • A PSC-17 score of 15 or higher suggests the presence of significant behavioral or emotional problems. • Correlates highly with the Child Behavior Checklist. • Can be downloaded for free at http://www.massgeneral.org/psychiatry/services/psc_home.aspx

24. Strengths and Difficulties Questionnaire (SDQ) • A brief behavioral screening questionnaire for 3-16 year olds. • Is readily accessible and has strong reliability and validity • It exists in several versions to meet the needs of researchers, clinicians and educators. • It contains 25 items covering 5 scales: • Emotional symptoms • Conduct problems • Hyperactivity/inattention • Peer relationship problems • Pro-social behavior • Can be downloaded for free at www.sdqinfo.com

25. Child and Adolescent Needs and Strengths (CANS) - Trauma • A shorter version of the CANS can be incorporated as a screener tool that can gather basic information on whether any trauma experiences have occurred and whether problems with adjustment to this trauma impact a child’s current functioning. • If this initial information suggests that the child is experiencing problems with adjustment to trauma, this often indicates the need for a more detailed trauma assessment on a range of needs and strengths of the child and caregiving system, either by using a comprehensive version of the CANS or other relevant tools.

26. Brief Assessment Checklist • Developed by Tarren-Sweeney (2007) • 20-item caregiver-report psychiatric rating scale • Designed to screen for and monitor clinically-meaningful mental health difficulties experienced by children and adolescents in various types of care; • Also designed to be used as brief casework monitoring tools by foster care and adoption agencies, and for treatment monitoring in CAMHS. • Available in two versions: • The Brief Assessment Checklist for Children (BAC-C for 4-11 years) • The Brief Assessment Checklist for Adolescents (BAC-A for 12-17 years).

27. Examples of Trauma Screening Tools

28. Trauma Symptom Checklist for Children (TSCC) • Developed by Briere (1996) • 54-items • Boys and girls (ages 8-12 and 13-16 years; normative adjustments for 17 year olds) • Child completed trauma measure • Two validity scales (underresponse and overresponse) • Six clinical scales (anxiety, depression, pts, dissociation, anger, sexual concerns) • Completed by mental health professionals with training in psychometrics • Approx. 10 minutes to complete

29. Child PTSD Symptom Scale (CPSS) • Developed by Foa, Johnson, Feeny, and Treadwell (2001) • Designed for children ages 8-18 • This self-report measure assesses the frequency of all DSM-IV-defined PTSD symptoms and was also designed to assess PTSD diagnosis. • The first 17 items measure PTSD symptomatology and yield a total Symptom Severity score. • Seven additional items assess daily functioning and functional impairment. • Available for free

30. UCLA PTSD Reaction Index • The UCLA PTSD Index for DSM-IV is a 48-item semi-structured interview that assesses a child’s exposure to 26 types of traumatic events and assesses PTSD diagnostic criteria from the DSM-IV. • It includes 19 items to assess the 17 symptoms of PTSD as well as two associated symptoms (guilt and fear of event’s recurring). • This tool may be used as a screening tool on its own, or part of a larger trauma-informed assessment or psychological evaluation.

31. Traumatic Events Screening Inventory (TESI) • The TESI-PRF-R is a 24-item parent-administered interview that assesses a child’s experience of a variety of potential traumatic events including current and previous injuries, hospitalizations, domestic violence, community violence, disasters, accidents, physical abuse, and sexual abuse. • Additional questions assess exposure to traumatic events and other additional information about the specifics of the event(s).

32. Child Welfare Trauma Referral Tool • Questions about the child’s history and presenting problems guide the caseworker in identifying whether the reactions are directly related to the child’s traumatic experiences, or existed before the traumatic event. • Based on the answers, the caseworker determines whether to make a general mental health referral, a referral to a specialized program such as a hospital or substance abuse program, a trauma-specific mental health referral (i.e., trauma assessment), or no mental health referral.

33. Strategies to Integrate Screening into Practice • Research the available measures and identify a couple that meet your needs. Ask staff to pilot test various measures to find the one that is most helpful and easy to administer, based on your system. • Consider embedding trauma screening practices into the already existing system in a more formalized manner. • Integration of questions into Structured Decision-Making • Weaving into existing practices and initiatives • Important to consider how critical reliability and validity is in this process. • Have multiple strategies available, based on the age of the child and education level of the workforce.

34. Trauma-Informed Assessment:Rationale and Importance

35. Why is Trauma-Informed Assessment Important ?

36. How Client/Family Engagement in Assessment Process is of Benefit

37. What to Assess: Key Components and Perspectives Child Developmental history History of trauma/adverse experiences Needs/symptom presentation – including risk behaviors and functional impairment Strength and resources/supports Perception of trauma and coping mechanisms Caregiver / Family Relationships / allegiances Caregiver needs/problem presentation Knowledge of child/ability to support and supervise Strengths and resources/supports Perception of trauma and coping mechanisms Environment / System Levels of system involvement (child welfare, legal) Cultural perception or understanding of the trauma Deficits or contributions to problems Areas of Support

38. Factors to Consider when Identifying Assessment Strategies

39. Assessment Based Treatment for Traumatized Children: A Trauma Assessment Pathway (TAP) The TAP Model is a treatment model that incorporates assessment, triage, and essential components of trauma treatment into clinical pathways. It helps treatment center staff incorporate standardized assessments into the intake and ongoing treatment process. It is directed by the uniqueness of the child and his or her family. It provides guidelines for clinicians to make decisions regarding trauma treatment strategies based upon the child’s unique presentation.

40. Three Components of TAP

41. Assessment Pathway Process

42. Integrating Assessment Data into Treatment Planning

43. Consider All Assessment Feedback

44. Engage Client and Family through Review of Assessment Results

45. Symptom Change Over Time

47. Treatment goals are written at this stage and will reflect:

48. Use of Trauma-Informed Assessment Information in Practice: Lessons Learned

49. Summary of Existing Challenges: Use of Assessment Information in Practice Access to trauma-focused MH services

50. Questions?