Moving Toward Trauma-Informed Child Welfare

Examples from the field

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In early June, a group of about 100 people representing a cross-section of child welfare, mental health, courts, foster parents, birth families, and alumni of care from nine child welfare jurisdictions around the country came together in Baltimore. They gathered to discuss the progress they've made in moving toward more trauma-informed practices to improve placement stability in foster care and what they could do to sustain their efforts. Their stories represented a growing shift toward more trauma-informed practice in child welfare agencies across the country.

In the past few years, increasing numbers of public and private child welfare agencies have been taking steps to become more trauma-informed. While there is not yet a common agreement of what a fully trauma-informed child welfare system would look like, the National Advisory Committee of the National Child Traumatic Stress Network's (NCTSN) Chadwick Trauma-Informed Systems Project (CTISP) at the Chadwick Center for Children and Families has tried to describe it. They define a trauma-informed child welfare system as

"one in which all parties involved recognize and respond to the varying impact of traumatic stress on children, caregivers, and those who have contact with the system. Programs and organizations within the system infuse this knowledge, awareness, and skills into their organizational cultures, policies, and practices. They act in collaboration, using the best available science, to facilitate and support resiliency and recovery."

Brain and resiliency research, along with the research emerging from federal initiatives such as the Substance Abuse and Mental Health Services Administration-funded NCTSN, have played key roles in informing not only the mental health field but also the child welfare field regarding the different types of trauma that children and their families experience. The research has shown the significant impact traumatic stress can have on children and their families, as well as the workforce involved with them. SAMHSA's recognition of children involved with the child welfare system as a special population--along with its funding of sites that have helped advance a more trauma-informed child welfare system--has helped inform how to effectively address the impact of child traumatic stress and minimize further trauma for children and families, leading to improved outcomes for those served by child welfare.

"The tools, trainings, and evidence-based programs and practices emerging from the work of the NCTSN that target the various child welfare system stakeholders such as judges, courts, CASAs, resource parents, birth parents, and mental health professionals have provided excellent resources so that everyone is speaking the same language," explains Chris Siegfried, network liaison for the National Center for Child Traumatic Stress (NCCTS, which is part of the NCTSN) at the University of California, Los Angeles.

"The NCTSN has been using and adapting the Break-through Series Collaborative (BSC) approach, which was developed and pioneered by the Institute for Healthcare Improvement, more recently to help advance a more trauma-informed child welfare system," Siegfried explains. In July 2010 the NCTSN sponsored the Trauma-Informed Child Welfare Practice (TICWP) BSC, which focused on using trauma-informed child welfare practices to improve foster care placement stability. She indicated that nine sites, many of which are CWLA members, were chosen to participate in the TICWP BSC.

The team from Colorado, above, attended a meeting about trauma-informed child welfare last June. Colorado is one of the sites participating in the Trauma-Informed Child Welfare Practice Breakthrough Series Collaborative.

Lisa Conradi is the program manager for the TICWP BSC, as well as the CTISP project manager. "The beauty of the BSC is that it was created to allow those within the system to be agents of change for that system," she says. "The model is set up to allow participants to start small by testing an idea or strategy to address an issue. They then study the outcome and modify it based on the data. Once the idea has proven effective, then the next step is to spread it to other parts of the organization."

Each of the nine TICWP BSC teams is compromised of a public (county or state level) child welfare agency and a mental health organization providing evidence-based, trauma-focused treatment in the community. Each team represents the vast array of individuals necessary to make the child welfare system more trauma-informed--ranging from administrators, managers, and supervisors to frontline workers and therapists from both the child welfare and mental health systems, as well as birth parents, foster parents, and even alumni of care. The teams are from California (Los Angeles and San Diego Counties), Colorado, Florida, North Carolina, New Hampshire, Massachusetts, Oklahoma, and Texas.

Based on the Plan-Do-Study-Act (PDSA) cycles of continuous quality improvement, small changes can be tested, adjusted based on the data, replicated, and then spread across the broader agency and used in training, ongoing practice, and policy. "This BSC is focused on using knowledge of child trauma to shape all levels of the organization--from decisions and actions to policies, procedures, and staffing," Conradi explains. "This would also include supports for children, their families, and their caregivers, which will result in more stable placements for children while they are in care with fewer disruptions."

So far, the nine teams report that the BSC process has prompted an increased use of child trauma knowledge in both organizational decision-making and worker actions. "Transforming child welfare agencies to become trauma-informed is a big task. But the BSC model is allowing the sites to start small--to test out an action or practice that is trauma-informed and discover how this can help lead to improvements. It is transforming the way these child welfare agencies are doing business," says Charles Wilson, the executive director of the Chadwick Center for Children and Families, the project director of CTISP, and a co-chair of the TICWP BSC. The team from Oklahoma agrees with Wilson. In their impact statement at the meeting in Baltimore, the Oklahoma team wrote: "Once you develop a trauma lens, it is not something you can take off and ignore. It has an impact on your perspective of yourself, the child, the family, the system you work in, and the world around you. When you begin to see the real reason a person or child has certain behaviors and reactions, it makes a huge difference in how effective you can be on a case."

At the beginning of the TICWP BSC, each site chose a target population. For one team, it was the cases of a specific worker, while for another it was a specific unit. Efforts were focused on practice areas identified as being essential for improving foster care placement stability through trauma-informed practices. The key areas were: (1) knowledge building and developing practices, (2) trauma-informed mental health assessments, (3) case planning and management, (4) externally delivered trauma-informed services, and (5) child welfare systems, cross-system partnerships, and system collaboration. Each team developed strategies using the PDSAs for the various elements within each of these practice areas.

To help monitor their progress, teams used an electronic data dashboard with a color coding system. The dashboard provided an easy visual to demonstrate which strategies had been tested and were ready to spread across the unit or organization; which strategies were in the process of being tested; which strategies were in the planning stage; and which strategies still needed attention but had not yet been planned. "The sites had an opportunity to share their successes and lessons learned through calls as well as learning sessions. As one site had success, others sites drew from that and either adopted [the successful strategy] or considered a similar strategy that was modified for their area," Conradi explains.

At the most recent learning session in Baltimore, the teams indicated that the TICWP BSC has helped them put strategies into place that facilitated positive changes. During the past year, each site has made significant strides and has been able to realize tangible impact on stability of placements for the children served. On the most basic level, the teams reported that general understanding and awareness of trauma significantly increased among the child welfare staff at their agencies. The Colorado team said that as team members brought trauma information and training back to their agency with them, they noticed the term 'trauma' being used much more frequently. Conradi and Siegfried both indicated that the teams reported developing a foundational understanding of child traumatic stress as well as a significant increase in the degree of comfort for child welfare staff in discussing trauma. As with the Oklahoma site, the Colorado team indicated that "workers note that they are getting better at identifying how trauma drives children's behavior as opposed to looking at behavior out of context."

"Early on, sites learned how significantly different the conversation and proposed solutions were [by] having birth families and youth as part of their team," Conradi says. The Massachusetts team reported having "learned the importance of having a parent's perspective, positive or negative, be a part of our conversation and learning." The Massachusetts and San Diego sites have worked to change the relationship between birth parents and resource parents by finding ways for them to work together in more of a co-parenting relationship focused on the needs of the children. Conradi reports that all sites have created strategies to have open and ongoing communication between child welfare agency staff, birth parents, caregivers, alumni of care (when appropriate and available), and other child-serving systems. Additionally, many of the child welfare agencies involved now ensure that children speak with their birth parents immediately after placement.

Nine teams from around the country comprise the Trauma-Informed Child Welfare Practice Breakthrough Series Collaborative. At the start of the project in 2010, the teams created posters that represented the journeys they were about to begin.

Conradi, Siegfried, and Wilson all emphasize that the changes can't just be made by child welfare agency social workers; the approach needs to be much more holistic to build bridges among resource parents, birth parents, and the community. Toward this end, many of the teams have begun providing trauma materials for resource parents, incorporating trauma information in trainings for resource parents, giving caregivers information regarding the child's trauma issues and needs, and facilitating meetings between resource parents and birth parents. Sites are reporting that children are now being screened for trauma more often and referred for appropriate trauma treatment more frequently. Conradi reports that work has also taken place to have screening and assessments become more trauma-informed. Sites such as Los Angeles, North Carolina, and New Hampshire now have child welfare services driven by trauma-informed screenings, while Texas has started collaborating with centers that do assessments to modify children's psycho-social reports to be more trauma-focused. In New Hampshire, the caregiver selection is based on matching their ability to meet the specific trauma-related needs of the child.

Involvement in the TICWP BSC has also led teams to increase community outreach about trauma and placement stability in foster homes. Sites indicated in their June impact statements that there are more discussions in nearby schools and courts, as well as between social workers and pediatricians, about children's trauma history. Other sites reported stronger relationships between child welfare and mental health staff, including more active discussions about child traumatic stress and the corresponding needs of the children and families both groups are serving. The teams from Texas and Colorado found that there was not enough community capacity for trauma-specific treatments; in response, they instituted strategies to train more mental health providers on evidence-based trauma treatment.

While the changes and improvements so far may seem small, the spread of the successful strategies has shown promising results. For example, the Florida team has implemented a number of PDSAs in their target area that have now spread to an additional four counties. They have quantifiable data showing that the effort to become more trauma-informed has made the goals of permanency and placement stability much more realistic. Florida has "impacted stability in less than a year's time--from 82.5% of children having two or fewer placements to 87.5% for the five [participating] counties," according to the team's recent impact statement. Although the primary focus of this TICWP BSC has been to improve placement stability, it has also affected how the Florida team approaches their entire system of care.

In Oklahoma, stability of placements for the one worker who has tested initial strategies has increased. And interestingly, placement disruptions have decreased for the other workers in the unit as a result of the spread of the successful strategies from the PDSA cycles.

Once agencies make the move to become more trauma-informed, the only way is forward. All nine sites have committed to using the PDSA methodology going forward. A number of the state teams have either applied or are in the process of applying for grants to continue their trauma-informed work, and some even plan to expand to other areas of child welfare such as in-home services. Plans to continue meeting on a regular basis also demonstrate the commitment these teams have to becoming increasingly trauma-informed. The North Carolina team, for example, has been trying to have the state incorporate trauma-informed knowledge into foster parent training so all foster parents have the competencies to appropriately care for the trauma needs of the children placed with them. And in Florida, all service contracts between Kids Central and the Department of Children and Families will now also include language and expectations related to trauma.

Aside from the TICWP BSC, other work being done by the NCTSN shows significant progress. Building on the work of an existing NCTSN site, the Michigan Trauma-Informed Child Welfare System Change Initiative, now in its third year and currently operating in nine counties, has partnered with key local leadership within the Department of Human Services, community mental health, family court, and intermediate school districts to create a trauma-informed child welfare system. "We recognized that all key child-serving systems needed to be partners and involved, including the courts," says James Henry, project director. He reports that the project has focused on providing a series of trainings and ongoing consultations, trauma-informed screenings, trauma-informed comprehensive assessments, and evidence-based trauma treatment. "During the initiative several new trauma- informed instruments have been created including a validated Trauma-Informed Organizational Survey, Trauma-Informed Court Report, and Trauma-Informed Therapist Report. Local professional change has occurred, as evidenced by statistically significant changes in trauma-informed practices and policy development across the var-ious child-serving systems involved," Henry explains.

The CTISP initiative at the Chadwick Center for Children and Families is also making progress. The goals of the project are ambitious: to provide leadership in identifying effective treatments developing specialized service delivery models to children in the public child welfare system who have been victims of abuse and/or domestic violence; to support the evolution of public child welfare agencies into trauma-informed organizations and agents of change in their communities; and to transform the wider child welfare system into a multidimensional, trauma-informed, evidence-based system.

To achieve these goals, CTISP is creating and testing work products at three test sites: Oklahoma, New Hampshire, and San Diego. The work products include a policy guide for trauma-informed child welfare, a desk guide on trauma-informed services for child welfare supervisors, trauma-informed casework practice guidelines, and a trauma-informed policy toolkit. These will build on the already existing NCTSN tools like the Child Welfare Trauma Training Toolkit. While the toolkit provided good and important information, CTISP's work goes a step further; Wilson, the project director of CTISP, says the work will "provide the hands-on tools for how to embed [trauma] in policy and practice at both the supervisory and worker level."

"As part of the initial activities with the three test sites, a community trauma readiness assessment was conducted," says Alison Hendricks, CTISP's operations manager. "This assessment is an important first step for understanding what the level of readiness for implementing a trauma-informed child welfare system is of each site." The assessment involved the child welfare agency itself and the broader child welfare community, including judges, CASAs, foster care providers, and mental health professionals. Hendricks points out that because the public child welfare system is not alone in serving children and families, it is important to take a community-wide perspective to ensure the entire system is trauma-informed.

Beyond the work of the NCTSN, Wilson notes that the federal Department of Health and Human Services' Administration for Children, Youth, and Families recently announced a funding opportunity to support the implementation of trauma-informed child welfare practice--more evidence of the exciting progress towards making the child welfare field fully trauma-informed. "As a former child welfare administrator, I have come to recognize the essential importance of the whole agency being trauma-informed in order to have improved outcomes for the children and families served by child welfare," Wilson says, "and this funding opportunity is helping to do just that."

Julie Collins is the Director of Standards for Practice Excellence at CWLA.

CWLA intern Sylvia Tsakos contributed to this article.

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