for children, families, and society has resulted in effects, the brief explores trauma-informed practice and Behavioral Health Services in Child.

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1Trauma refers to a deeply stressful experience or its short and long-term impacts. Because exposure to trauma can cause a host of problems with lifelong consequences, early screening and intervention is essential. Child maltreatment can cause traumatic stress in some children, while others are more resilient and show few, if any, lasting effects. Widespread recognition of trauma’s harmful impacts and the related consequences for children, families, and society has resulted in Federal, State, and local initiatives over the last decade to promote trauma-informed care. This issue brief outlines the essential components of a trauma-informed child welfare system and features examples from State and local programs that are incorporating trauma-informed practice. After providing a brief overview of trauma and its effects, the brief explores trauma-informed practice and the importance of strengthening families and communities to help them develop resilience and heal. The brief concludes by highlighting the importance of cross-systems collaboration in creating a trauma-informed child welfare system that improves child and family well-being. WHAT’S INSIDE The Importance of a Trauma- Informed Child Welfare System Building resilience: The role of protective factorsTrauma and its effects What is trauma-informed practice? Transitioning to a trauma-informed child welfare system Children’s Bureau/ACYF/ACF/HHS | 800.394.3366 | | Email: Cross-system collaboration ISSUE BRIEFS | MAY 2020 Additional resources ConclusionReferences

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2Some of the information in this issue brief is based on interviews with practitioners and thought leaders who have been at the forefront of implementing and evaluating trauma-informed child welfare practice, including U.S. Department of Health and Human Services (HHS) grantees funded through the Children’s Bureau and the Substance Abuse and Mental Health Services Administration (SAMHSA). TRAUMA AND ITS EFFECTSAccording to SAMHSA, “individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being” (HHS, SAMHSA, 2014, p. 7). Trauma that follows a single event and that is limited in time (such as a car accident, shooting, or earthquake) is called acute trauma . Complex trauma occurs when children are exposed to multiple traumatic events over time that are severe, pervasive, and interpersonal in nature (such as repeated abuse and neglect) and that cause long-term harmful consequences (National Child Traumatic Stress Network [NCTSN], 2014). Complex trauma may interfere with a child’s ability to form secure attachments to caregivers and many other aspects of healthy physical and mental development. Children’s responses to trauma are affected by many factors, including their age at the time of the event, the severity of the traumatic event, their caregivers’ reactions, and a prior history of trauma and other behavioral health conditions (NCTSN, n.d.-a). Traumatic freeze” response that affects children’s bodies and brains and overwhelms their natural ability to cope. Chronic exposure to trauma can create toxic stress , which interferes with normal child development and can cause long-term harm to children’s physical, social, emotional, or spiritual well-being. This can impair a child’s emotional responses; ability to think, learn, and concentrate; impulse control; self-image; attachments to caregivers; and relationships with others. Across the life span, for example, complex traumatic experiences have been linked to issues such as addiction, depression and anxiety, and risk-taking behavior (NCTSN, n.d.-c). These in turn can lead to a greater likelihood of chronic ill health, including obesity, diabetes, heart disease, cancer, and stroke (Harvard Women’s Health Watch, 2019). A recognition of the potentially lifelong consequences of trauma from adverse childhood experiences (ACEs) is at the core of Federal and State child maltreatment prevention policies and initiatives. Child Historical trauma affects populations who have experienced cumulative and collective trauma over multiple generations (e.g., American Indians, African Americans, immigrant groups, families experiencing intergenerational poverty) (Brave Heart, 1998). Children within these families may exhibit signs and symptoms of traumaŠ such as depression, grief, guilt, and/or anxietyŠeven if they have not personally experienced traumatic events.

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3Welfare Information Gateway’s Adverse Childhood Experiences webpage discusses impacts from traumatic stress and offers a wide variety of prevention and information resources. Information Gateway’s factsheet, Long-Term Consequences of Child Abuse and Neglect, explores these impacts further. For detailed information and resources, see SAMHSA’s manual, Concept of Trauma and Guidance for a Trauma-Informed Approach , and the HHS Administration for Children Families (ACF) toolkit titled Resource Guide to Trauma-Informed Human Services .WHAT IS TRAUMA-INFORMED PRACTICE? Trauma-informed practice involves an ongoing awareness of how traumatic experiences may affect children, families, and the human services professionals who serve them (NCTSN, 2016). Trauma-informed child welfare staff recognize how clients may perceive practices and services. They are aware of how certain actions and physical spaces have the potential to retraumatize or trigger behaviors in the families they serve (HHS, ACF, n.d.). Trauma-informed practice likewise acknowledges the reality of secondary traumatic stress (STS) and incorporates efforts to address and mitigate it so staff can be grounded and effective in their interactions with families or clients and families. informed system as one in which programs and agencies “infuse and sustain trauma awareness, knowledge, and skills into their organizational cultures, practices, and policies” and use the best available science to “maximize physical and psychological safety, facilitate the recovery of the child and family, and support their ability to thrive.” It is an ongoing commitment that involves the day-to-day work of the entire system. Child welfare systems that are trauma informed are better able to address children’s safety, permanency, and well-being needs. Service improvements include more children receiving the trauma screenings, assessments, and evidence-based treatments (EBTs) they need. These improvements, in turn, may produce better outcomes for children and families, including the following (HHS, 2013): Fewer children requiring crisis services, such as emergency department visits or residential treatment Decreased prescriptions for psychotropic medications Fewer foster home placements, including reentries Overall improved child functioning and well-being SAMHSA notes that a trauma-informed practice achieves the following (HHS, SAMHSA, 2014): Realizes the impact of trauma Recognizes the signs and symptoms of trauma in clients, families, staff, and others Responds by fully integrating knowledge about trauma into policies, procedures, and practice Resists the retraumatization of children and the adults who care for them

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4SAMHSA also notes that trauma-informed care recognizes the importance of safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and cultural, historical, and gender issues (HHS, SAMHSA, 2014). TRANSITIONING TO A TRAUMA-INFORMED CHILD WELFARE SYSTEMMoving to a trauma-informed approach requires a major commitment from child- serving systems. The Children’s Bureau awarded three clusters of grants in 2011, 2012, and 2013 to help child welfare agencies become more trauma-informed at the individual and systems levels to improve safety, permanency, and well-being for children and families. These grants include Integrating Trauma-Informed and Trauma- Focused Practice in Child Protective Service Delivery (HHS-2011-ACF-ACYF-CO-0169), Initiative to Improve Access to Needs-Driven, Evidence-Based/Evidence-Informed Mental and Behavioral Health Services in Child Welfare (HHS-2012-ACF-ACYF-CO-0279), and Promoting Well-Being and Adoption After Trauma (HHS-2013-ACF-ACYF-CO-0637). The grants explored key elements in building a trauma-informed child welfare system, including routine screening and assessment, workforce development, acknowledgement and treatment of STS, measurement-driven case planning and referral to evidence- supported treatment, changes to data systems, and sustainability. This section explores some of the basic components of a trauma-informed system and related grantee work. SCREENING AND ASSESSMENTScreening and assessment are fundamental to identifying children and families with trauma histories and, if necessary, securing effective treatment as soon as possible. The goals of trauma screening and assessment include the following: To learn about a child’s trauma history, identify current symptoms and functional delays and identify children who need further assessment and possible treatment To conduct a more detailed clinical evaluation for children whose trauma screen indicates a trauma history combined with psychological symptoms and/or functional delays, which will form the basis for treatment planning To gather data about a child’s strengths and needs via a functional assessment, measure improvement in skills and competencies and inform ongoing case planning To measure outcomes to ensure that services are achieving desired effects at the child level, and, if not, to inform changes to the treatment plan To identify changes needed at the system level to improve the effectiveness of the service array Several considerations are involved in selecting the appropriate screening and assessment instruments including the following: Length. Initial screenings should be as brief as possible. If the initial trauma screening is positive, a mental health clinician should follow up with a thorough assessment.

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5Screening for trauma exposure versus screening for symptoms. Tools that facilitate connections between the two will help identify more appropriate referrals. Administration and data-sharing. Agencies and partners should assess the ease with which data can be shared. Is the screening administered by paper and pencil or by computer entry that links to an existing data system? Is the tool self-scoring? Is the information taken from the parent, the child, or case records? Costs. Items to consider include the initial purchase of the tool, required training, and expenses associated with data collection and/or analysis. Psychometric properties. How accurately does the tool measure what it purports to measure? How many false positives or false negatives are likely? State Examples of Screening and Assessment Work In Connecticut, statewide trauma screening was implemented as a major part of its Collaborative on Effective Practices for Trauma (CONCEPT), a Federal grant in the Integrating Trauma-Informed and Trauma- Focused Practice in Child Protective Service Delivery cluster designed to improve outcomes for trauma-exposed children. The grant resulted in the statewide use of a brief screening tool, the Child Trauma Screen , developed by Connecticut’s Department of Children and Families (DCF) in collaboration with the Child Health and Development Institute (CHDI) and Yale University. The screening tool is used during the multidisciplinary evaluations that take place when children come into DCF care. In North Carolina, the Judicial College at the University of North Carolina’s School of Government is training judges to become more trauma informed. One unintended consequence of widespread training has emerged, however. As judges learned about one highly evidence-based treatment for child trauma, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), some began court-ordering children and youth in the treatment. Now, the North Carolina Child Treatment Program (NC CTP) and other stakeholders are working to ensure that children and youth receive a trauma-informed clinical assessment and the most appropriate treatment, since no single treatment will work for every child. NC CTP trains clinicians in several EBTs, including TF-CBT, parent- child interaction therapy, child-parent psychotherapy, structured psychotherapy for adolescents responding to chronic stress, and CBT for children and youth with problematic sexual behavior (M. Blythe, personal communication, October 14, 2019). For additional resources on screening children for trauma and related assessment tools, visit the following webpages: Screening and Assessment of Child Trauma (Information Gateway) Screening and Assessment (NCTSN) Screening Tools (SAMHSA)

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6WORKFORCE DEVELOPMENTThe development of a trauma-informed implementing an effective trauma-informed system. It is important to integrate a trauma perspective in the organization’s day-to-day activities so that all levels of agency staffŠ receptionists, caseworkers, supervisors, managers, administrators, and other program staff Šconsider this as foundational to their work. This includes training for foster and adoptive parents. Moving to a trauma-informed approach requires the workforce to make paradigm shifts in the areas listed below: Perspective. Becoming a trauma-informed system involves shifting the conversation from asking “What’s wrong with you?” to “What happened to you?” Traumatic stress is often misunderstood and misdiagnosed as a behavioral problem by foster parents, child welfare workers, and other professionals. Applying a trauma- informed lens involves close consideration of an individual’s trauma experience as an underlying explanation for behavioral or emotional issues. Goals. The focus of child welfare services is often on substantiating a case of abuse or neglect and ensuring a child’s physical safety. With trauma-informed care, the goal includes helping children heal from the impact of the trauma and improving their social and emotional well-being while preventing additional trauma. Importance of collaboration. When child welfare agencies successfully work with other service systems through improved communication, collaboration on joint goals, data sharing, and strategic use of funding streams, they are more likely to enhance well-being and maximize access to services. Focus on early intervention. A trauma- the understanding that focusing more and early intervention services may prevent or mitigate some of the long-term effects. Approach to families. It is important to be clear with families about the boundary between their involuntary participation in the child welfare system (i.e., when there is a substantiation of maltreatment) and what may be their voluntary participation in services to promote healing from trauma. Awareness of intergenerational trauma. It also is important to understand that, like their children, caregivers’ challenging behaviors may be most productively viewed as maladaptive responses to their own trauma. Role of child welfare professionals. With the shift in attention toward well-being and healing, the child welfare professional’s role changes. Staff will spend more time screening for trauma, facilitating effective mental health treatment, and following up to ensure appropriate progress is being made toward those treatment goals, including monitoring the use of psychotropic medication.

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8 Creation of groups to address staff burnout and STS Engagement of evaluators to assess the organization’s trauma-informed practices and processes and ensure sustainability For more on TST, visit the NCTSN website . WORKFORCE TRAININGIt is essential that child welfare professionals recognize trauma and provide early and appropriate interventions for children and families who have experienced child abuse, neglect, or other acts of violence. Trauma training should be introduced from the beginning of each staff member’s employment. In addition to the basics about what trauma is, its impact on the brain, and how it affects children (including the role of triggers and reminders), training topics should include the following: How to screen children for trauma Children’s need for physical and psychological safety Resiliency case planning (i.e., using services to build a child’s resilience and sense of competency) When, how, and where to refer children for evidence-based trauma treatment How to work with parents and caregivers who have been traumatized The impact of STS Effective training for trauma-informed practice will require more than a single workshop or class session. Ongoing training and staff mentoring are essential. Trauma training may be more effective if child welfare staff are cross-trained with professionals from partner agencies and systems, such as mental health and education, so that all child- serving systems can work together in the best interests of children and their families. After the initial training, follow-up training and technical assistance can be provided in the following formats: monitoring, and accountability Coaching and mentoring In-house trauma consultants or “trauma trained in trauma therapy) Learning collaboratives Periodic booster trainings (face to face or via webinars) Tips and reminders in newsletters or other symptoms, behaviors, and impact See the NCWWI website for more information. SECONDARY TRAUMATIC STRESS A trauma-informed child welfare agency recognizes the need to invest in the health, well-being, and resilience of its workforce. Because child welfare professionals and resource parents often experience STS, agencies should consider making STS training and coaching available. Left untreated, STS (sometimes referred to as vicarious trauma or compassion fatigue ) can lead to lower

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9productivity, increased absenteeism, and high rates of turnover (HHS, ACF, n.d.). Agency leaders committed to trauma-informed care can offer the following to combat STS: Continuing education on the pervasiveness of STS and how to manage it Wellness activities, such as mindfulness training or other forms of self-care, to mitigate STS Therapeutic supports, including restorative spaces to help staff decompress, access to counseling, or the availability of therapy dogs There are many resources for STS, including the following: The July 2016 issue of Children’s Bureau Express features articles on STS by Children’s Bureau trauma grantees. The resources section of the NCTSN website offers several publications on STS. “Addressing Trauma Through a Culture of Resiliency ,” a NCWWI video, looks at strategies to help children, families, and workers cope with trauma. The Secondary Traumatic Stress section on the Information Gateway website offers resources about what STS is, its impact, how to identify symptoms, and how it can be prevented and mitigated. NCTSN offers several trauma-related training resources: Child Welfare Trauma Training Toolkit “Working With Parents Involved in the Child Welfare System” Core Curriculum on Childhood Trauma: An Introduction and Overview “The 12 Core Concepts for Understanding Traumatic Stress in Children and Families” For more training resources, visit the NCTSN website .STS Trainings Tailored for Workers and SupervisorsIn North Carolina, county child welfare staff have access to several online training programs for STS, including a program another class designed for supervisors and managers. The supervisor and manager class gives agency leadership an opportunity to understand how STS is affecting their team so they can develop agency-level strategies to build staff resilience (J. McMahon, personal communication, November 1, 2019).

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10RESOURCE PARENT TRAINING The lack of a trauma-informed perspective from resource parents can put a foster care placement at risk, as parents may struggle to understand and respond to negative and trauma-based behaviors and emotions. Training for new foster or adoptive parents should include information about child traumatic stress. This training also should be offered to kinship caregivers as well as to parents who are reuniting with their children. It should include the basics of trauma and its triggers, how to recognize and respond appropriately to trauma-related behaviors, how foster and kinship caregivers can work effectively with parents, and the importance of self-care. Some examples of trauma-informed resource parent training are included below: “Caring for Children Who Have Experienced Trauma: A Workshop for Resource Parents ,” also referred to as the Resource Parent Curriculum, is a 16-hour training curriculum developed by NCTSN to help resource parents understand the effects of trauma on the children in their care. Safety and Engagement It is important for child welfare professionals to understand trauma-informed care; however, adding training requirements to a professional’s already busy schedule may be met with resistance. While principles can act as a safeguard by helping them recognize the signs of escalating behaviors and the importance of co-regulating themselves and their families to a safer place. For example, mind to understand how the presentation of that information may trigger past feelings of loss, personal communication, November 12, 2019). While there may be challenges in getting agency Increased personal safety Improved ability to self-regulate and engage with families

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11Child Development and the Effects of TraumaSeries is a free training for resource parentssponsored by the Family and Children’sResource Program at the University of North Carolina at Chapel Hill and developed in partnership with North Carolina’s Division of Social Services.”RPC [Resource Parent Curriculum] + TIPS [Trauma Informed Parenting Skills]for Tuning In” is a free 10-week trainingprogram developed by the Vermont Child Welfare Training Partnership to teach foster, kinship, and adoptive caregivers positive parenting skills to help address behaviors associated with complex trauma.The training focuses on caregiver self- regulation and positive attention ratherthan a reactive parenting approach to help children heal from trauma.TST for Foster Care is a four-moduletraining curriculum containing Power Point slides, facilitator guides, an implementation guide, and a resource guide for foster parents. This curriculum helps foster caregivers build resilience and promote regulation in children affected by trauma byreinforcing their sense of safety and theirability to trust adults. Education and support are an ongoing process. After the initial training, a trauma- informed perspective can be infused in work with resource parents in additional ways, including the following: Connect foster parents or kinship caregivers with parents soon after placementŠor, if this is not possible, collect information from the parents or othersŠ to better inform caregivers regarding the child’s trauma history, triggers, and behaviors. Conduct child-focused team meetings that engage parents and kinship caregivers or foster parents in collective planning and problem-solving. Agencies can include a trauma consultant on these teams to provide early intervention to children who display troubling behavioral symptoms in placement. Information Gateway’s factsheet for families titled Parenting Children and Youth Who Have Experienced Abuse or Neglect may also be a valuable resource for families. Trauma Trainings to Improve Placement StabilityTennessee’s TRANS/form (Trauma/ Transformation), a Children’s Bureau grant from the Promoting Well-Being and Adoption After Trauma cluster , yielded several interventions and tools to improve placement stability. It developed a storytelling tool to help children process their trauma as they navigate through State custody and care. The Tennessee Department of Children’s Services added this life-narrative model to its training module for new hires, which also includes multiple courses that address trauma-informed care. The State has also training suite for foster parents .

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