in Child Welfare - The Trauma Center

Center for Advanced Studiesin Child WelfareSchool of Social WorkCW360 oa comprehensive look at a prevalent child welfare issueSafety Permanency Well-BeingTrauma-Informed Child Welfare PracticeWinter 2013

2 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013From the EditorsWe, at the Center for Advanced Studies inChild Welfare (CASCW), have had a verybusy and exciting year in 2012 and areproud to present the first issue of CW360°for 2013! CW360°, typically released as anannual publication, was developed to providecommunities, child welfare professionals,and other human service professionals withcomprehensive information on the latestresearch, policies, and practices in a key areaaffecting child well-being today. We are onceagain fortunate to co-produce a special editionof CW360° with one of our partners at theUniversity of Minnesota: Ambit Network.As anyone working in the field of childwelfare in the last few years can attest, therehas been increased attention placed on therole of trauma in our work. In this issue, weshift our focus from the secondary traumaexperienced by the child welfare workforce(the topic of our spring 2012 issue) to theexamination of trauma-informed practicewith children and families involved inthe child welfare system. Recognizing anoverwhelming body of research on the criticalimpact of trauma on almost every aspectof our lives, the field of child welfare is atthe dawn of major shift in how it views itswork. It is no longer a question of whether toincorporate trauma-informed organizationaland practice strategies into child welfarepractice, but how. As a leader in helpingcommunities navigate research and practicein child trauma, Ambit Network has beenan instrumental partner in bringing togetherthe rich collection of practical knowledge andresources you will find throughout this issue.As in previous editions, CW360° isdivided into three sections: overview, practice,and perspectives. In the overview section,articles focus on key issues from researchon complex trauma to the development oftrauma-informed child welfare organizations.The practice section includes articles onevidence-based and promising practicesthat use a trauma-informed perspective foraddressing the experiences of children andfamilies in the child welfare systems. Finally,the perspectives section presents articlesfrom a variety of child welfare stakeholdershighlighting innovative examples ofintegrating a trauma-informed perspectiveinto practice and policy and offering practicalsuggestions and strategies for system andpractice improvements.Traci LaLiberte, PhDDirector, Center for Advanced Studies in Child WelfareExecutive Editor, CW360 oTracy Crudo, MSWDirector of Outreach, Center for Advanced Studies in Child WelfareManaging Editor, CW360°From the EditorsThis special issue of CW360°, focused onchildhood traumatic stress, is a product ofthe long-standing partnership between AmbitNetwork and the Center for Advanced Studiesin Child Welfare (CASCW). We are gratefulto CASCW for this opportunity and we wishto express our deep appreciation to the manyauthors who contributed their expertise tothis publication.Ambit Network, a National ChildTraumatic Stress Network (NCTSN)Community Treatment and Services CenterAbigail Gewirtz, PhD, LPDirector, Ambit Network &Associate Professor, University of MinnesotaGuest Editor, CW360 ofunded through the Substance Abuse andMental Health Services Administration(SAMHSA), is a university-communitypartnership committed to raising thestandard of care and improving access toquality services for traumatized children,their families, and communities throughoutMinnesota and eastern North Dakota.Traumatic events can be devastating tochildren and families. Children and familiescan respond to traumatic events in a rangeof ways. Some children are resilient andChris Bray, PhD, LPAssociate Director, Ambit NetworkGuest Editor, CW360 ohave strong supports in their lives, whichcan mitigate the damage traumatic eventsoften engender. Children and families inthe child welfare system often experiencetrauma that is complex and ongoing and maylack the resources to resolve their traumaticexperiences. It is our hope that this issue ofCW360° will provide all of you who workalongside troubled children and families witha resource that guides you in your work asyou recognize and understand the effects oftraumatic stress.

CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 3Table of ContentsOverviewWhat is Traumatic Stress?, Lucy Berliner, MSW .................................................................... 4The Impact of Trauma from Early Childhood through Adolescence:A Developmental Perspective, Keri LM Pinna, PhD and Abigail Gewirtz, PhD, LP ......................................... 6The Heart of the Matter: Complex Trauma in Child Welfare, Joseph Spinazzola, Ph.D.,Mandy Habib, Psy.D., Angel Knoverek, Ph.D., LCPC, Joshua Arvidson, MSS, LCSW, Jan Nisenbaum, MSW,Robert Wentworth, MSW, Hilary Hodgdon, Ph.D., Andrew Pond, LICSW, and Cassandra Kisiel, Ph.D.. ......................... 8The Impact of Traumatic Stress on Parents Involved, in the Child Welfare System,Erika Tullberg, MPH, MPA ....................................................................................... 10The Emergence of Trauma-Informed Child Welfare Systems, Charles E. Wilson, MSSW ................................. 12By What Yardstick Should We Measure Success in Child Welfare Policy?,Janice L. Cooper, PhD, MPA and Yumiko Aratani, PhD................................................................ 14Integrating Safety, Permanency, and Well-Being for Children and Families in Child Welfare,An excerpt from the 2012 year end message from Commissioner Bryan Samuels,Administration on Children, Youth and Families ..................................................................... 16PracticeOperationalizing Trauma-Informed Child Welfare Practice usingthe Child Welfare Trauma Training Toolkit, Alison Hendricks, LCSW .................................................. 18Giving a Trauma Lens to Resource Parents, Liz Sharda, LMSW ...................................................... 19Addressing Early Childhood Trauma in the Context of the Child Welfare System,Betsy McAlister Groves, MSW, LICSW ............................................................................. 20Trauma Screening within the Child Welfare System, Lisa Conradi, PsyD and Cassandra Kisiel, PhD. ....................... 21Trauma-Focused Cognitive Behavioral Therapy (CBT) for Youth in Child Welfare,Judith A. Cohen, MD and Anthony Mannarino, PhD .................................................................. 22Trauma-Informed PMTO: An Adaptation of the Oregon Model of Parent Management Training,Laura A. Rains, MSW, LCSW, and Marion S. Forgatch, Ph.D.. .......................................................... 24Cultural Adaptations of Trauma Treatments in Indian Country,Wynette Whitegoat, AB, and Richard van den Pohl, PhD .............................................................. 25Homeless Youth Emerging from the Child Welfare System, Arlene Schneir, MPH ....................................... 26Trauma-Informed Care Using the 3-5-7 Model,Darla L. Henry, PhD, MSW, and Amelia Franck Meyer, MS, MSW, APSW, LISW ........................................... 27Table of ContentsPerspectivesRepacking the Invisible Suitcase, Chaney Stokes As told to Johanna Zabawa, Research Assistant .......................... 28A Birth Parent’s Perspective: What Happened?, Pamela Toohey. ..................................................... 29Native Families Impacted by Historical Trauma and the Role of the Child Welfare Worker,Marilyn J. Bruguier Zimmerman, MSW and Patrick Shannon, BSW ..................................................... 30Treating Child Traumatic Stress: Bearing Witness to Healing, Sara Younge PsyD, LP ................................... 31Training New Child Welfare Workers, Rebecca Wilcox, MSW, LGSW and Kristi Petersen, MSW. ............................ 32Lessons Learned from Implementing the Resource Parenting Curriculumwith Foster and Adoptive Parents, George S. Ake III, PhD. ........................................................... 33Using a Trauma-Informed Lens To Create A Perspective Shift in Child Welfare Practice:One Organization’s Journey, Ann Leinfelder Grove, MSM ............................................................ 34Breaking Down Barriers Across Systems: Implementing a Trauma Perspective, Beth Barto, LMHC ...................... 36ReferencesIntegrated Bibliography ........................................................................................ 38

4 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013What is Traumatic Stress?Lucy Berliner, MSWWhat is a Trauma?Traumas are events involving threat or danger.They do not have to be actually violent.The perception that something terriblecould happen can make the event traumatic.Traumas may be directly experienced,witnessed or happen to a close loved one.They include child abuse, rape, violent crime,witnessing DV or community violence,serious accidents or natural disasters, and theviolent or sudden death of a loved one. Notall bad experiences are traumas. Neglect, notbeing loved, foster care, parental incarcerationand mental illness are adversities that can havenegative effects.The Prevalence of Traumatic EventsExposure to trauma is very common.According to Finkelhor (Finkelhor et al,2009) each year about 60 % of childrenexperience at least one trauma. A subset,about 22%, has four or more different typesof traumas. Traumas can range from the lessserious, being hit by a sibling occasionally,to the extremely serious such as being rapedor witnessing a parent murdered. Traumaexposure is almost universal among childrenin the child welfare system (CWS). Forexample, even though neglect comprises themajority of all CWS cases, many neglectedchildren have witnessed DV or communityviolence.What is Post-Traumatic StressDisorder (PTSD) and How Does itDiffer from PTS?A minority of children will experiencepersisting or worsening traumatic stress thatbecomes Post-Traumatic Stress Disorder.PTSD and altered brain structures and stressresponse systems. It is not clear whetherthese biological differences create increasedsusceptibility to PTSD or are the biologicalexplanation of PTS (Neigh, Gillespie, &Nemeroff, 2009). Overall, research showsthat the accumulated burden of multipleFinding out that a child has been exposed to trauma creates theopportunity for all involved in child serving settings to actively contributeto the child’s recovery from the impact.OverviewWhat is Posttraumatic Stress(PTS) and How Does it Differ fromTrauma?Being exposed to a trauma is almost alwaysupsetting. Trauma-specific reactions are calledposttraumatic stress (PTS). PTS is unwantedand upsetting memories or dreams of thetrauma and intense emotional and physicalreactions when thinking about or beingreminded of the traumas. Avoidance copingstrategies decrease the negative emotionalstates when thinking about the traumas. PTSalso includes heightened physical arousalresponses such as jumpiness, irritability,difficulty concentrating, and trouble sleeping.Traumatic stress is a normal reaction to a verybad experience; most children exposed totraumas have at least some symptoms. PTSis not the only consequence of exposure to atrauma observed in children. Symptoms ofgeneral anxiety, depression, and behavioraldisruption are also seen following traumas.Some children do not show distress followingtraumas, and for most the PTS will subsideover time without treatment.Occasionally, children develop PTSD after aperiod of appearing to be fine. To make thediagnosis, a qualified professional conductsa systematic assessment to find out if thesymptoms required by the Diagnostic andStatistical Manual (DSM) are present.The diagnosis requires a certain number ofsymptoms of intrusive memories, avoidanceor numbing reactions, and hyperarousalsymptoms and that symptoms have persistedfor at least a month and interfere withfunctioning. Just being exposed to a traumaor being upset about the trauma does notmean PTSD.Predictors of PTSD in ChildrenCertain factors place children at greater riskfor developing PTSD. The main predictorsare more serious traumas, perception of lifethreat, prior traumas or psychiatric problems,and being female. A negative reactionfrom others also is associated with PTSD.Recent biological research demonstrates anassociation between child abuse and neglect,and different bad experiences (traumas andadversities) is more important than thespecific type of trauma in predicting PTSD.Immediate Responses to TraumaWe now have strategies to help children whohave experienced trauma and have PTS.Psychological First Aid (PFA) (NationalChild Traumatic Stress Network, www.nctsn.org) is an approach for acute situationswhere the trauma has just occurred. Itwas originally designed for disasters, thepsychological field response accompanyingother rescue efforts. The main ingredientsare focusing on here and now concerns,providing psychoeducational informationand normalization, support, reinforcement ofcoping skills, and, when needed, facilitatingaccess to ongoing services. With children,engaging caregivers is key. PFA usuallyinvolves one or two sessions. This type ofapproach can be used in emergency rooms,during child welfare investigations, in ChildAdvocacy Centers, and DV shelters. A

CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 5slightly more intensive approach is the Childand Family Traumatic Stress Intervention(Berkowitz, Stover, & Marans, 2011). Thisfour session intervention is delivered withina month of the traumatic event and cansignificantly lower PTS and PTSD.Screening for PTS and PTSDRoutine screening is the best way to identifychildren who have high levels of PTS orPTSD and would benefit by trauma-specifictherapy. It is most important in childserving settings where children have highrates of exposure and are most likely to besignificantly affected by their experiences,such as child welfare, mental health andjuvenile justice. Experience shows thatchildren are not distressed at being askedabout traumas and are more likely to reportwhen asked. There are checklists for screeningfor a trauma history (see the article byConradi in this publication for more detailedinformation on screening). Screening is thefirst step to insure that children are assessedfor mental health needs and to facilitateaccess to evidence-based therapy such asTrauma-Focused CBT (Cohen, Mannarin,& Deblinger, 2006). Professionals operatingwithin the best practice multidisciplinarymodel or a Child Advocacy Center are wellequipped to seamlessly facilitate access totrauma-specific assessment and therapy.Providing SupportSimply asking about abuse and trauma is notsufficient since the children already knowwhat they have experienced. The key is tolearn about children’s reactions and respondin a supportive way. Professionals and otherssuch as foster parents can provide nonclinicalinterventions that are immediatelyhelpful, such as normalizing PTS reactions,offering support and giving comfort. Evenchildren who do not have significant PTSmay have been affected by their experiencesand appreciate acknowledgement that thetrauma was bad, frightening or wrong. CPSinvestigators or forensic interviewers may berequired to take care in the degree to whichthey validate children’s reports of abuse, butthey can still express appreciation and offersupport.PTS is a common reaction to exposureto trauma. Finding out that a child has beenexposed to trauma creates the opportunityfor all involved in child serving settings toactively contribute to the child’s recoveryfrom the impact. Simple steps such asacknowledgement, normalizing reactions,and providing support can reduce stress andpotentially avert the development of longertermconsequences. It is also the platform forfacilitating access to assessment and evidencebasedtrauma-specific treatment whennecessary. The key to making a differenceis not avoiding the trauma but rathercommunicating directly about the trauma andmaking sure there is access to needed care.Lucy Berliner, MSW is Director ofHarborview Center for Sexual Assaultand Traumatic Stress, University ofWashington at Harborview MedicalCenter. She can be reached at lucyb@u.washington.edu.OverviewEmail us at info@childwelfare.gov orcall toll-free at 800.394.3366Stay connected to child welfare information and resourcesFrom child abuse and neglect to out-of-home careand adoption, Child Welfare Information Gatewayis your connection to laws and policies, research,training, programs, statistics, and much more!Go to www.childwelfare.gov:- Sign up for FREE subscriptions- Order publications online- Chat live with our Information SpecialistsUse your smartphone toaccess the Gateway website.

6 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013The Impact of Trauma from Early Childhoodthrough Adolescence: A Developmental PerspectiveKeri LM Pinna, PhD and Abigail Gewirtz, PhD, LPThe impact of potentially traumaticexperiences on a child’s adjustment variessignificantly depending on the developmentalstage at which the child experiences trauma.This is true regardless of the nature ofpotentially traumatic event (i.e. whetherit be abuse, neglect, exposure to violence,or some other traumatic event). Children’sperceptions of threat during and following apotentially traumatic event (Kahana, Feeny,Youngstrom, & Drotar, 2006) and the natureof caregiver responses following the trauma(Scheeringa & Zeanah, 2001) are among thestrongest predictors of children’s adjustmentfollowing trauma. Children’s perceptionsof their experiences vary as a function ofdevelopment as do the outcomes associatedwith caregiver responsiveness. Manners inwhich trauma-related symptoms manifestfollowing a potentially traumatic experiencealso vary by developmental level. Thus, weexplore developmental variations in children’sperceptions of threat, outcomes associatedwith caregiver response to the child followingtrauma, and manifestations of trauma-relatedsymptoms across developmental stages frominfancy through adolescence.imagines could have happened if, for example,the police were not called when mommyand daddy were fighting near the kitchenknives. An adolescent is more likely to beable to gather and evaluate informationabout a potentially traumatic event todetermine the actual threat involved butmay also overestimate his/her sense of safety(Wickman, Greenberg, & Boren, 2010). Theadolescent child of an abused mother mayunderestimate the risk involved in steppingin to protect his mother from her abusivepartner. The adolescent’s sense of invincibilitymay lead him to becoming the victim of thepartner’s abuse in the process, or even anunwitting perpetrator.Caregiver Response & AttachmentWhen a child is traumatized in the presenceof supportive caregivers, his responsesmay mimic those of the parent (van derKolk, 2003). Children whose caregiversare unresponsive and/or inconsistent intheir responses to the child’s distress maydevelop insecure attachments and associatedemotion regulation deficits. Disorganizedattachment (one form of insecure attachment)develops when a parent responds to a childinconsistently, with frustration, violence,intrusiveness, or when a parent is severelyneglectful. Children with disorganizedattachment learn that they are unable torely on their caregivers becoming eitherOverviewPerceptions of ThreatUnderstanding how a potentially traumatizedchild experienced a traumatic event isthe first step in determining how best tomeet the child’s needs in the immediateand longer-term aftermath. For an infant,facial expressions, tones of voice, suddenloud noises, and experience of caregiverresponsivity to the infant’s cues (e.g. crying)serve as the basis for interpreting safetyversus danger (e.g. Moore, 2009). Whilean infant may not be capable of thinking“This is terrifying!,” angry voices and facialexpressions, and the sound of breaking glassin the next room are processed as threateningin the infant brain. Further, the absence ofcomfort in response to terrified cries leads aninfant to learn that her caregivers cannot betrusted to provide comfort in times of need.With each stage of development,perception builds on prior stages. Forexample, a toddler or school aged childalso perceives facial expressions, tones ofvoice, sudden loud noises, and parentalnon-responsiveness to the need for comfort.As cognitive development becomes moreadvanced, the capacity for imagining thepossibility of negative outcomes increases(Grist & Field, 2012). Thus, perceptionof threat begins to include what a child

8 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013The Heart of the Matter: Complex Trauma in Child WelfareJoseph Spinazzola, Ph.D., Mandy Habib, Psy.D., Angel Knoverek, Ph.D., LCPC, Joshua Arvidson, MSS, LCSW, JanNisenbaum, MSW, Robert Wentworth, MSW, Hilary Hodgdon, Ph.D., Andrew Pond, LICSW, and Cassandra Kisiel, Ph.D.OverviewComplex trauma involves chronic or repeated,typically early-onset exposure to two or moreof the following forms of trauma exposure:sexual, physical or emotional abuse, domesticviolence, or neglect, as well as severe caregiverimpairment and school/community violence(Kisiel et al., 2009). A national sample of over2,200 children in child welfare found thatover 70% met exposure criteria for complextrauma (Greeson et al, 2011). A substantialsubset of children—typically those withthe fewest social and economic resources,and those living amidst poverty, crime orcultural minority status (Cohen, 2007)—haveexperienced all of these forms of exposure.Complex trauma impacts multiple coredomains of functioning: children’s physiologyand brain development; their ability toidentify, tolerate, control and appropriatelyexpress emotions, impulses and bodilysensations; to concentrate, learn and engage ingoal-directed behavior; to form a positive andcohesive sense of self, meaningful values andhopeful future outlook; to cultivate secure andhealthy attachment bonds, sustain intimaterelationships, safely negotiate conflict andcommunicate their needs; and to interpretsocial cues accurately, set healthy personalboundaries and differentiate safe fromthreatening situations and interactions withpeers and adults (Cook et al, 2005; Kisielet al, 2009; Spinazzola et al, 2005). By thetime they reach adolescence, many complexlytraumatized youth are already caught in avortex of intense somatic, behavioral andemotional dysregulation in which dailylife is fraught with an ever-expanding hostof traumatic reminders and subtle falsealarms that activate extremes of hyper- andhypo-arousal. Like “live wires,” complexlytraumatized youth can become chargedwith heightened vigilance and physiologicalreactivity at levels that are emotionallyoverwhelming and debilitating to the immunesystem. Like “walking dead,” they canretreat or slip into extended periods of severewithdrawal, emotional constriction, avoidanceand numbing of consciousness induced viacoping strategies that include dissociation,binge eating or substance dependence.The legacy of unresolved complex traumais staggering, and has been causally linkedwith increasingly dire outcomes across thelifespan that collectively place an enormouseconomic burden on society, conservativelyestimated at over $200,000 per impactedchild and over 100 billion per year (Fang et al,2012). Long-term outcomes include scholasticfailure, dropout and unemployment; earlypregnancy, sexually transmitted disease,rape and domestic violence; chronic mentaland physical illness, health risk behaviors,The legacy of unresolved complex trauma is staggering, and has beencausally linked with increasingly dire outcomes across the lifespanthat collectively place an enormous economic burden on society,conservatively estimated at over $200,000 per impacted child and over100 billion per yeardisability and premature mortality (Edwardset al, 2004; Felitti et al, 1998, Ford et al,2010).Psychological maltreatment: Thesleeping giant of complex traumaPsychological maltreatment has beenrecognized by the American PediatricAssociation as the most prevalent form ofchild maltreatment and thus far the mostoverlooked despite substantial evidence ofits deleterious impact at levels comparableto more readily recognizable forms ofmaltreatment such as physical and sexualabuse (Hibbard et al, 2012). Psychologicalmaltreatment is comprised of various overtand subtle forms of chronic emotional abuseand neglect, including prolonged verbalabuse, terrorizing, shunning, and socialisolation. A recent study on a large sampleof over 5,000 children and adolescents fromthe Core Dataset of the NCTSN revealedpsychological maltreatment to have equal orsignificantly greater association than physicalor sexual maltreatment to 27 out of 30frequency and severity symptom, diagnosticand risk indicators assessed (Spinazzola etal, 2011). Psychologically maltreated youthwere the most likely to exhibit significantinternalizing, attachment and substanceabuse problems and the most likely todevelop anxiety and depressive disorders. Alsonotable was that exposure to psychologicalmaltreatment resulted in equal levels of PTSDsymptom severity compared to physical orsexual abuse. The child welfare system canserve as a critical gatekeeper of suspectedThe term complex trauma wasintroduced by a special taskforceof the National Child TraumaticStress Network (NCTSN) to helpmultidisciplinary service providersbetter understand and respondto the multifaceted relationshipbetween children’s exposure tomultiple traumatic events and thewide-ranging, long-term impactof this exposure (Complex TraumaTaskforce, Cook et al, 2003, 2005,2007). The complex trauma constructdiffers in important ways fromother conceptual frameworksof child maltreatment. Whereas“polyvictimization” addresses thecircumstances of children’s exposureto multiple, often inter-relatedtraumatic forms of trauma (Finkelhoret al., 2007, 2009), complex traumaspeaks to the cascading interplaybetween trauma exposure, impactand (mal)adaptation. Moreover,unlike “Complex PosttraumaticStress Disorder,” introduced in anattempt to characterize a broaderand more pronounced symptom-setexhibited in a subset of traumatizedadults (Herman, 1992), the complextrauma construct was formulated inrealization that the PTSD diagnosisneither typically nor sufficientlycaptures the cardinal featuresof disturbance observed in youthexposed to prolonged and severemaltreatment, violence, and neglect(Ackerman et al., 1998; Spinazzola etal., 2005).and reported psychological maltreatmentin children and families with its power andauthority to open the door to thoroughinvestigation of its presence and impact inreported youth.

CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 9What lies beneath: The need forcomprehensive assessmentChildren impacted by complex trauma are notonly at high risk for revictimization but aremore vulnerable than other youth to exposureto other forms of acute, non-interpersonaltrauma. For example, chronically neglectedchildren are at significantly increased riskof exposure to accidents and burns in thehome. The aberrant socialization thatfrequently accompanies familial incest oremotional abuse can increase children’ssusceptibility to school bullying and lead tojuvenile delinquency, substance abuse andhigh-risk sexual behaviors. In turn, chronicphysical abuse often underlies and fuelsconduct problems and social aggression.Comprehensive evaluation that includesa thorough caregiving and trauma historyand integrates developmental, psychiatric,behavioral, scholastic and interpersonalstrengths and difficulties is essential. The childwelfare system can play a pivotal role notonly through early screening and assessment,triage, and trauma-informed referral butin working with providers to connect allthe dots. “Unpacking” these exposure, riskand protective trajectories for youth inthe child welfare system is the critical firststep toward rerouting pathways to healthyoutcomes, fostering resilience, and disruptingintergenerational cycles of complex trauma(Layne et al, 2008).Placement instability: The sine quanon of complex trauma?Children in child welfare with complextrauma have been found to have significantlyhigher rates of placement disruption (Kisielet al., 2009). A child’s risk for poor outcomescan increase exponentially in child welfareas a result of cycles of impaired caregivingfollowed by periods of separation fromprimary caregivers, potential incidents ofplacement instability, revictimization in thenew home, failed reunification attempts,or ultimate loss of primary caregivers.For children whose sense of self, intimateattachments, material possessions, access tofriends and siblings—in effect, their entireworld—hangs in the balance of the successor failure of these placements, each juncturecan be experienced as another complextrauma exposure irrespective of the effortsand intentions of child welfare personnel andfoster, kinship, or biological parents. Thechild welfare system can play a pivotal rolein mitigating this risk by: a) recognizing thecritical importance of placement stabilityin altering risk trajectories for complexlytraumatized children, b) prioritizing carefuldeliberation around the timing and nature ofplacement decisions, c) establishing structuresto support emotional regulation of childrenfacing unavoidable placement transitions, andd) delineating proactive strategies to preventor rapidly respond to child decompensationassociated with abrupt placement disruption.Helping the most vulnerable:Complex trauma andresidential carePlacement in a residential treatment facilitycan be a common outcome for those childrenmost severely and chronically impacted bycomplex trauma. In turn, complex traumais heavily over-represented in youth inresidential care. Analysis of the NCTSN CoreDataset revealed that when compared withtraumatized youth receiving outpatient orcommunity-based services, those receivingresidential services had the highest rates oftrauma exposure and associated impairment(Briggs et al, 2012). While the majorityof outpatient youth no longer exhibitedsymptoms by the end of treatment, asubstantial percentage of complexlytraumatized youth in residential carecontinued to manifest impairment indicatingthe need for more extensive services. Thehighly structured, predictable and consistentenvironment and caregiving offered withintrauma-informed residential settings mayprovide these children with a sufficient senseof safety and emotional containment to beginto shift from a survival-based preoccupationwith threat detection and avoidance to amore present and future-oriented focus onskill acquisition and identity development. Aresidential placement can afford child serviceproviders a unique window of opportunityto guide complexly traumatized children inthe development of internal capacities forself-control and affect management, in therehearsal of effective problem-solving andcommunication skills, and in the delineationof interpersonal boundaries and cultivationof safe and healthy relationships. The childwelfare system can provide leadership oninitiatives that ensure maximal treatmentgains for complexly traumatized children bymaking purposeful, collaborative, treatmentgoaldriven decisions about the timing,duration and type of residential placementsto which complexly traumatized childrenare assigned, extended, transitioned anddischarged.Complex trauma requirescomplex solutionsTraditional treatment of PTSD in childrenhas focused on processing and resolving vividand painful memories, beliefs, and emotionsassociated with one or more specific traumaticexperiences. Intervention models designedto treat complex trauma of necessity attendto the broader array of deficits and domainsof maladaptive functioning. Of the overtwo dozen evidence-based and empiricallysupported interventions created or advancedby members of the NCTSN over the pastdecade (NCTSN, 2012), several have beenspecifically developed to treat complextrauma by addressing six core componentsidentified in complex trauma intervention:safety; self-regulation; attachment; identitydevelopment; trauma experience integration;and strength-based cultivation of self-worth,positive affect, personal competencies andmastery experiences (Cook et al, 2005).Treatment models are predicated upon ashared recognition that training is insufficientto achieve successful intervention withcomplexly traumatized children; responsibletreatment of complex trauma entails ongoingtraining, supervision, fidelity assessmentand careful adaptation responsive to uniquecultural, setting and developmental needs ofContinued on page 37Overview

10 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013OverviewThe Impact of Traumatic Stress on Parents Involvedin the Child Welfare SystemErika Tullberg, MPH, MPAThomas is a new caseworker supervising avisit between his client, Denise, age 25, andher three children, Christopher, Jr., age 5,Tanya, age 3, and Damon, age 2. This visithas already been rescheduled twice – it wassupposed to happen after the agency’s weeklydomestic violence group, which Denise ismandated to attend as part of her service plan,but she keeps missing the meetings. Thomaswants to talk to Denise about how she needsto come to these groups if she wants her kidsback, but he has seen her temper and doesn’twant to do anything to make today’s visit gobadly so decides to let it go.Damon has not said anything sincearriving at the agency; he is still strappedinto his stroller and since coming intothe visitation room has been whining andreaching up to Denise, but she keeps tellinghim to “behave” while she tries to get hissiblings to settle down. After a few minutesof running around Christopher trips on hisshoelaces and starts bleeding from his head –Tanya shrieks when she sees the blood, andDenise yells at Christopher saying that he’sruined the visit and is always out of control,just like his father. Thomas goes to comfortTanya, who has started to shake and cryuncontrollably, but Denise steps in front ofhim saying that she can handle her kids andthat they don’t need his help.The child welfare system has becomeincreasingly attuned both to the traumathat children and youth in the systemhave experienced and to the importance ofaddressing such trauma as part of ensuringtheir safety, permanence and well-being(Kisiel, Fehrenbach, Small, & Lyons, 2009).Research on the impact of trauma on fostercare placement stability in the short term,and long-term health outcomes over thelifespan, has helped to spur increased trainingon trauma for staff, resource parents, andother system stakeholders and availability ofevidence-based interventions for children andyouth (Landsverk, Garland, Reutz, & Davis,2011).However, we know that for children in thechild welfare system, the trauma they haveexperienced has often happened at home:abuse or neglect from a caretaker, exposureto domestic violence, or separation from aparent due to homelessness, incarceration orother family stressors. For parents who grewup under similar circumstances, or who haveexperienced traumatic events in adulthood, itmay be difficult to provide their own childrenwith support and structure if their owntrauma remains unaddressed. Research hasdemonstrated, in fact, that a parent’s traumahistory may increase his or her children’srisk of maltreatment (Banyard, Williams, &Siegel, 2003; Cohen, Hien, & Batchelder,2008), and that the parent’s trauma-relatedsymptoms and ability to respond in aprotective manner to his or her children isa predictor of a child developing traumasymptoms following exposure to a traumaticevent (Chemtob, Nomura, & Abramovitz,2008). If parents do not feel safe, they will beless able to keep their children safe.Anecdotal evidence and growing researchsuggests that trauma is very common amongparents receiving child welfare services. InNew York City, the ACS-NYU ChildrenTrauma Institute’s Safe Mothers, SafeChildren program is addressing traumaexperienced by mothers receiving child welfarepreventive services. During project planninginterviews conducted in 2008, East Harlempreventive service program directors reportedconcerns about trauma experienced by theirclients, citing related problems with theirability to have patience with, empathy for,and express affection towards their children.During subsequent screenings with mothersreceiving services from a subset of theseagencies, 92 percent reported at least oneprior traumatic experience with the averagebeing 2.6 categories of traumatic events. Fiftyfourpercent of mothers met probable criteriafor post-traumatic stress disorder, 62 percentmet probable criteria for depression, and 49percent met probable criteria for both PTSDand depression (Chemtob, Griffing, Tullberg,Roberts, & Ellis, 2011).Research has shown that parents withhistories of trauma can be harder to engagein services and have difficulty trusting serviceproviders (Kemp, Marcenko, Hoagwood,& Vesneski, 2009; Dawson & Berry,2002). Despite this and the prevalence oftrauma among parents in the child welfaresystem, our experience is that it is relativelyFor parents who grew up under similar circumstances, or who haveexperienced traumatic events in adulthood, it may be difficult to providetheir own children with support and structure if their own traumaremains unaddressed.uncommon for parents to receive traumaspecificscreening, much less trauma-informedmental health services – and many childwelfare staff are not trained to recognizetrauma symptoms and how trauma canimpact parenting and child safety. As a result,child welfare staff may be more likely toregard parents like Denise as non-compliant,disengaged, detached from their children,angry and defensive.How else could Thomas understandDenise, the decisions she’s making, and howshe responds to her children? How can he usethat knowledge to help her? With the benefitof a “trauma lens,” the above scenario couldbe reframed as follows:• Ask questions. Caseworkers are oftenworried that asking clients detailedquestions about their past traumaticexperiences may cause their clients to

CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 11become anxious or distraught, but afterbeing trained to conduct trauma screeningsby Safe Mothers, Safe Children projectclinicians, caseworkers said they learnedhelpful information while reporting lowlevels of distress for themselves and theirclients (Dawson & Berry, 2002). Askingmay also help ease the shame associatedwith clients’ past experiences and result intheir feeling more supported and less alone.• Anticipate trauma triggers. The domesticviolence between Denise and her children’sfather was likely a traumatic experiencefor both her and her children, and thefact that she is not attending domesticviolence groups may be due to avoidance,a common trauma symptom. Denisemay be more likely to attend visits withher children if they were scheduled at adifferent time than these groups. Likewise,if Thomas approached Denise’s nonattendancewith this understanding andempathy, helping to explore the impact ofher past experiences on her current actions,rather than by using a punitive approach,he could be more successful in engagingher in services.• Understand the impact of trauma onparent-child relationships. Trauma cancause parents to have a negative worldview and, in particular, develop negativeattributions regarding their children’sbehavior. Their child’s actions, or eventheir appearance, may trigger themresulting in them reacting in an overlyharsh or punitive way. Helping parents tounderstand that their reactions may be aresult of their trauma, and are not the faultof their children, can help them respondmore positively to their children.• Understand the impact of traumaon children’s development andmental health. Children who have alsoexperienced trauma, such as exposureto domestic violence, may have theirown trauma symptoms—such as Tanya’sextreme reaction to her brother’s fall andher mother’s harsh response—whichcan in turn be triggering for the parent.Children’s development can also beimpacted by trauma, and concerns suchas Damon’s potential speech delay maynot be recognized by the parent becausehe or she is overwhelmed and/or does nothave information about expected childdevelopment. When working with a parentor family that has experienced trauma,child welfare staff should be attuned to howit may have impacted each of the children.• Recognize and manage traumareactions. Thomas’s past experiences withDenise’s anger and defensiveness have ledhim to avoid addressing an important partof Denise’s service plan and Christopher,Tanya and Damon’s safety. He may also befrustrated by what he perceives to be herlack of concern for her children and lackof urgency around her service plan goals.Using a “trauma lens” could help Thomasbetter understand Denise’s behavior towardsher children and how he (as a man and asa person in a position of authority) couldbe triggering for her, and provide strategiesfor working together with her rather thanfeeling like they are at cross-purposes. Thiscould help Thomas depersonalize Denise’sreactions towards him, regulate his ownemotions, and feel less frustrated puttinghim in a better position to approach heropenly and with compassion.Trauma can impact parents in many waysincluding their ability to keep their childrensafe. As described above, using a “traumalens” can help child welfare staff moreeffectively partner with families, workingtogether to ensure both their physical andpsychological safety.Erika Tullberg, MPH, MPA, isAdministrative Director of the ACS-NYUChildren’s Trauma Institute at NYULangone Medical Center. She can bereached at erika.tullberg@nyumc.orgOverviewSchool of Social WorkPreparing professionalsto be leaderswww.cehd.umn.edu/sswfor a just and caring society

12 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013The Emergence of Trauma-Informed Child Welfare SystemsCharles E. Wilson, MSSWOverviewOver the last 30 years, society’s understandingof the effects of traumatic stress has increasedsignificantly and more recently we have begunto recognize the interaction between traumaticstress and the service systems we put in placeto support vulnerable populations. Nowhereis this connection between trauma and thesystem more striking than in the nation’s childwelfare systems. Almost all children servedby the child welfare system report chronicand complex trauma histories, complicatedby system-imposed stresses such as removaland multiple foster care placements. Childrenwith such experiences often require supportof a skillful and well trained mental healthprofessional, but treatment alone is notenough. Over the last six years, it has becomeclear to many working in the National ChildTraumatic Stress Network 1 (NCTSN) thatmeaningful treatment of children in thechild welfare system must be matched withsystem supports. Essentially, the entire childwelfare system needs to be transformed into a“trauma-informed system.”What is a trauma-informed system?The term first appeared in substance abuseliterature to recognize that many seriouslyaddicted individuals had experienced majortraumas, and those traumatic events hadshaped their lives in sometimes disastrousways (see Conradi & Wilson, 2010 for a fullreview of this topic). By 2004, NCTSN wasapplying similar concepts to child traumavictims and that work led to a variety ofproducts and services developed withinthe Network. One definition of a traumainformedsystem has been advanced by theChadwick Trauma-Informed Systems Project(CTISP), with support of a national advisorycommittee. CTISP defines a trauma-informedchild welfare system as a system “in which allparties involved recognize and respond to thevarying impact of traumatic stress on children,caregivers and those who have contact with thesystem. Programs and organizations within thesystem infuse this knowledge, awareness andskills into their organizational cultures, policies,and practices. They act in collaboration, usingthe best available science, to facilitate andsupport resiliency and recovery” (ChadwickTrauma-Informed Systems Project, 2011).There are key phrases in this definitionthat are worth pointing out. First, thedefinition applies to the wider child welfaresystem not just the public child welfareagency. Second, the definition focuses notonly on child trauma victims but also theircaregivers and the workforce who seek tosupport them. All three of these groupsare affected by traumatic events, includingprimary traumatic experiences that threatentheir own or their loved one’s lives or physicalintegrity as well as vicarious trauma fromwhat they see, hear, and experience whenworking intimately with traumatized children.The definition stresses the “varying impactof trauma,” indicating that each child andadult is unique and reacts to trauma in hisor her own way. Some children and adultshave great resilience and may not requireclinical intervention while others exposedto similar levels of trauma are devastatedand require skillful intervention. Thedefinition emphasizes that it is not enoughto be knowledgeable about trauma but alsoasserts that the system must act to makeuse of that knowledge by integrating it intoeveryday interactions with families and theirorganizational cultures.To undertake this effort, the child welfaresystem needs a framework, and the NCTSNoffers one in its “Essential Elements of atrauma-informed child welfare system.”The NCTSN Child Welfare Committeeis currently in the process of refining theessential elements, first introduced in 2006.What emerges are the following sevenessential elements (Child Welfare Committee,personal communication, March 7, 2012).1. Maximize Physical andPsychological Safety for theChild and FamilyWhile child welfare has always had a focuson physical safety, a trauma-informedsystem must go further and recognizethat psychological safety is importantto the child’s long-term recovery andsocial and emotional well-being and hasdirect implications for physical safetyand permanence. Psychological safety isa sense of safety or the ability to feel safewithin one’s self and safe from externalharm and is critical for functioning aswell as physical and emotional growth.A lack of psychological safety can impactchildren’s interactions with all otherindividuals, including those trying tohelp them, and can lead to a variety ofmaladaptive strategies for coping withthe anxiety associated with feeling unsafe.These “survival strategies” often includea range of symptoms and behaviorsfrom substance abuse to self-mutilation.Children and/or adults may continue tofeel psychologically unsafe long after thephysical threat has been removed or theyhave been relocated to a physically safeenvironment, such as a relative or fosterhome.The system should offer universal screening for traumatic historyand traumatic stress responses, which will assist the workers inunderstanding the history of a child or family.Even after the child or adults gainssome degree of security, people, places,and events may unexpectedly remind themof past traumas and draw their attentionback to intense and disturbing memoriesoverwhelming their ability to cope again.At times, a seemingly innocuous eventor sensory stimuli such as smells, sights,sounds, touches, or objects may triggersubconscious reminders of the traumathat produce a strong physiologicalresponse wherein the biochemical systemsof the body react as if the trauma werehappening again. A trauma-informedchild welfare system understands thatthese pressures may help to explain achild or parent’s behavior and can use thisknowledge to help them better managetriggers and to feel safe.2. Identify Trauma-Related Needsof Children and FamiliesThe child welfare workforce should beeducated on trauma and how it affects anindividual at any stage of developmentand intersects with his/her culture. Thesystem should offer universal screeningfor traumatic history and traumatic stressresponses, which will assist the workersin understanding the history of a child orfamily. The screening will help identifypotential triggers and will create a guide1Established by Congress in 2000, the National Child Traumatic Stress Network (NCTSN) is a unique collaboration of academic and communitybasedservice centers whose mission is to raise the standard of care and increase access to services for traumatized children and theirfamilies across the United States.

CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 13for direct trauma-informed case planning.Those who screen positive for traumashould receive a thorough assessment bya trained mental health provider. Thisprofessional will identify the reactions ofa child or parent and determine how theirbehaviors are connected to a traumaticexperience. This assessment will guidesubsequent intervention efforts.3. Enhancing Child Well-Beingand ResiliencyA child’s recovery from trauma oftenrequires the right evidence-based orevidence-informed mental healthtreatment delivered by a skilled therapistwho helps the child reduce overwhelmingemotion related to the trauma, cope withtrauma triggers, and make new meaning ofhis/her trauma history.But to truly address the child’strauma the child needs the support ofcaring adults in his or her life. Manytrauma-exposed children have significantsymptoms that interfere with theirability to master developmental tasks,build and maintain relationships withcaregivers and peers, succeed in school,and lead a productive and fulfilling life.Case planning must focus on givingchildren the tools to manage the lingeringeffects of trauma exposure and to buildtheir relational capacity so they can takeadvantage of opportunities as they growand mature. By helping them developthese skills in a clinical setting and buildsupportive relationships, we enhance theirnatural resilience.who have experienced maltreatment,parents who have acted in abusive orneglectful ways, and systems that donot always meet the needs of families,feelings of helplessness, anger, and fearare common. A trauma-informed systemmust acknowledge the impact of primaryand secondary trauma on the workforceand develop organizational strategies toenhance their resilience.6. Partnering with Youth andFamiliesYouth and family members who haveexperienced traumatic events often feellike powerless “pawns” in the system,reinforcing feelings of powerlessness felt atthe time of the trauma. Providing youthand families with choices and a voice intheir care plays a pivotal role in helpingthem to reclaim the power that was takenaway from them during the trauma andtap into their own resilience.7. Partnering with SystemAgenciesNo one agency can function alone, andin trauma-informed systems child welfaremust reach out and coordinate withother systems so they too can view andwork with the child and family through atrauma lens. This partnering includes:• Teaming with law enforcement tominimize the number of front-endinterviews children must experience• Cross training with other primarypartners to enhance their understandingof their roles in the interventionprocess, recognize how steps withintheir processes can exacerbate existingtraumas, trigger traumatic reactions anddevelop processes to reduce the risk ofduplicative interactions with the child,family, and collaterals.• Working with mental health agenciesto ensure therapists are trained inspecialized trauma assessment andevidence-based trauma treatments• Coordinating with schools, the courts,and attorneys.Such coordination is necessary to preventone part of the system undoing the goodtrauma- informed work of another part ofthe system.In the end, a trauma-informed systemproduces far greater synergy as oneelement of the system supports the workof the others with all working to buildon the natural resiliency of the child andfamily.Charles E. Wilson, MSSW is the SeniorDirector at Chadwick Center forChildren and Families, and the Sam andRose Endowed Chair in Child Protectionat Rady Children’s Hospital, San DiegoCA. He can be reached at cwilson@rchsd.orgOverview4. Enhancing Family Well-Beingand ResiliencyMost birth families that interact with childwelfare systems have also experiencedtrauma. Providing trauma-informededucation and services to birth parents andresource parents enhances their protectivecapacities, thereby increasing the resiliency,safety, permanency, and well-being of thechild.5. Enhancing Family Well-Beingand Resiliency of Those Workingin the SystemWorking within the child welfare systemcan be a dangerous business, and theworkforce may be confronted with threatsor violence in their daily work. Adding tothese stressors, many workers experiencesecondary traumatic stress reactions, whichare physical and emotional stress responsesto working with a highly traumatizedpopulation. When working with children

14 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013By What Yardstick Should We Measure Success in Child Welfare Policy?Janice L. Cooper, PhD, MPA and Yumiko Aratani, PhDOverviewThe last decade has seen a tremendouschange and progress in child welfare. This isparticularly true of child welfare policy. Thefocus on permanency, led to increases in thepercentage of foster care children adoptedfrom 17% to 21% between 2000 and 2010(U.S. Department of Health and HumanServices Administration for Children andFamilies, 2011). There was a 26% decreasein the child welfare rolls from 552,000to 408,000 during the same period (U.S.Department of Health and Human ServicesAdministration for Children and Families,2011). The rates of children being victimized(a child with maltreatment dispositionsubstantiated, indicated, or having alternativeresponse by the child welfare agencies) havedeclined from 12.2 to 10 per 1000 (U.S.Department of Health and Human Services,2002, 2012). Conditions of foster care alsoimproved, such as reduced average lengths ofstay from 32 months to 26 months, marginalincreases in kinship care (from 24% to 25%)and in non-relative foster care (from 47%to 48%), and reductions in the use of grouphomes and/or institutions from 18% to 15%(U.S. Department of Health and HumanServices Administration for Children andFamilies, 2011). During the same period,there were increases in child welfare fundingsuch as the Child Abuse Prevention andTreatment Act, State grants, and adoptionincentive payments (American HumaneAssociation, 2012). Also significant was anarrowing in disparities marked by reductionsin the proportion of African-Americanchildren in foster care from 39% to 29%(American Humane Association, 2012). Onthe other hand, the period also saw setbacks.More young children (ages 0-5), enteredfoster care, increasing from 29% to 36%(American Humane Association, 2012).This article focuses on the impact ofpolicy on the child welfare system (CWS)using another measure: the extent to whichinfusing a trauma-informed care frameworkhas taken hold. While not every child inthe CWS will experience trauma, previousresearch shows different estimates of theprevalence of post-traumatic stress disorder(PTSD) among children in the CWS, rangingfrom 19% to 55% (Annie Casey Foundation,2011; Grasso, et al., 2009; Greeson, et al.,2011; Jackson, O’Brien, & Pecora, 2011;Kolko, et al., 2010). Nearly 12% of childrenin child welfare who remained at home alsoexperienced PTSD (Kolko, et al., 2010).Risk factors for PTSD include multipleexposures to maltreatment. Over 70%of children in foster care had two or moretrauma experiences (Greeson, et al., 2011).Children with multiple trauma exposures tendto experience other mental health problemsincluding depression and externalizingconditions (Kolko, et al., 2010; Richardson,2001). Trauma experiences have a long-termdetrimental effect on health and mental healthand susceptibility to re-traumatization(Dube,2001; Felitti, et al., 1998; Widom, Czaja, &Dutton, 2008).Trauma-informed care and atrauma-informed frameworkTrauma-informed refers to the process ofengagement with a parent, child or familycharacterized by intentional efforts to ensurethat no action is taken that further causesharm. It creates an environment that enablesthe victimized child or person to feel safe andpromotes the ability of the victim to cope andto increase resiliency. A trauma-informedframework refers to embedding up-to-daterobust knowledge on trauma in policy andpractice such as how to prevent trauma,address its consequences, and ensure thesystem does not contribute to re-traumatizing.Operationally, this would suggest policiessuch as funding and supporting effectivesystems for prevention and intervention,beginning with evidence-based (EB) andculturally-normed screening and assessmentof trauma, ensuring the widespread adoptionof EB treatment and engagement strategies,support for training within and across childservingsystems, and requiring accountabilitythroughout systems.The way forwardA 2007 National Center for Children inPoverty report presented the adverse impactof the child serving systems in America andtheir failure systematically to adopt a traumainformedperspective in policy (Cooper,Masi, Dababnah, Aratani, & Knitzer, 2007).It addressed the need to include the useof EB screening and treatment for traumaand related mental health conditions in thechild welfare system. It called for increasedWe offer the following recommendations to support improved practice andbetter outcomes.• Mandate EB trauma screening at all entry points into child welfare and atdischarge• Require that child and adolescent trauma histories are integral to theirconfidential records available at all entry points to the care delivery systemand that individualized care planning address the child and family needs in atrauma-informed manner• Ensure that trauma-informed care is integrated into the pre-service trainingand continuing education for all child welfare professionals and paraprofessionals• Set up systems to better identify and match staff suitable for working in theCWS, reward and support them appropriately and recognize the need for thehuman resource development plan to be trauma-informed.• Increase funding and tie it not only to reduction in child welfare rolls butimproved outcomes such as child and family health and mental health.• Develop guidelines for regulations and/or certification pertaining to traumaexpertise.• Fund initiatives that support staff who work with children and youth whoexperienced trauma and reduce secondary trauma associated with traumarelatedwork.• Partner with tribal and other colleges that target specific populations todevelop workforce capacity in evidence-based practices for both tribal andnontribal communities.

16 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013Integrating Safety, Permanency, and Well-Beingfor Children and Families in Child WelfareAn excerpt from the 2012 year end message from Commissioner Bryan Samuels, Administration on Children,Youth and FamiliesOverviewIn fiscal year (FY) 2012, the Administrationon Children, Youth and Families (ACYF)disbursed $46.6 million to States, Tribes,Territories, and local entities and grantedtitle IV-E child welfare waivers to nine Stateswith the goal of more fully integrating thethree aims of child welfare in the U.S.: safety,permanency, and well-being. These projectshave a specific focus on addressing traumaand improving the well-being of children,youth, and families. Across Federal agencies,preventing trauma and mitigating its impacton healthy development is a growing priority.In much of its work, ACYF has partneredwith the Centers for Medicare and MedicaidServices (CMS) and the Substance Abuseand Mental Health Services Administration(SAMHSA) to align and strengthen efforts;CMS and SAMHSA are engaged in several ofthe projects listed here.The focus on preventing and treatingearly exposure to trauma, including childmaltreatment, is grounded firmly in emergingscience about its devastating impact onlifelong well-being, as detailed in many of thearticles in this publication.As we learn more about how traumaaffects children’s well-being, researchers andpractitioners are developing increasinglyeffective methods for mitigating its harm.There is a rapidly growing array of evidencebasedand evidence-informed interventionsthat, when delivered with fidelity, canhelp restore developmentally appropriatefunctioning and improve outcomes forchildren and youth who have experiencedmaltreatment. ACYF’s projects promotingwell-being revolve around better identifyingchildren and youth whose development hasbeen disrupted by trauma, increasing accessto effective interventions, and strengtheninglinkages between systems that serve vulnerablechildren and families.Historically, Federal policies haveimpelled child welfare systems to focusdisproportionately on ensuring safety andpermanency for the children they serve, withless emphasis on the promotion well-being.However, as policies shift to more fullyintegrate safety, permanency, and well-beingin child welfare, systems are increasinglyreorganizing themselves to better servechildren and families.The April 2012 informationmemorandum, Promoting Social andEmotional Well-Being for Children andYouth Receiving Child Welfare Services(http://www.acf.hhs.gov/sites/default/files/cb/im1204.pdf) lays out essential elementsof the approach, summarized here. Childwelfare systems and their partners shoulduse screening and assessment tools that arevalid, reliable, and normed to the generalpopulation to identify the needs and strengthsof children and families. They should ensurethat appropriate evidence-based interventionsare used to address problems, reduce risks,and build strengths. The use of ongoingprogress monitoring indicates whetherinterventions are working and provides datathat can be used to fine-tune the array ofservices available to the population.For children who have experiencedtrauma, healing and recovery take place insafe, nurturing contexts. The image aboveshows how an approach that promoteswell-being for children known to childwelfare ensures that young people receive therelational and environmental support theyneed to heal and recover, as well as intensiveintervention, when necessary. The foundationof the approach is a knowledgeable workforce,assuring the use of an effective, traumainformedresponse that promotes well-beingfor children and families.Alignment of ACYF Opportunitiesto Promote Social and EmotionalWell-BeingNew title IV-E child welfare waiverdemonstrations and ACYF’s FY 2012discretionary grant programs were designedto (1) increase the capacity of the workforceto meet the needs of children and families;(2) support caregivers so they can providechildren with environments and relationshipsthat offer security and developmental support;(3) offer targeted supports that help childrenbuild coping skills and social skills; and (4)enhance access to screening, assessment, andeffective intervention. A list of evidencebasedand evidence-informed interventionsdelivered by ACYF grantees can be found inthe full year end message from CommissionerSamuels at http://z.umn.edu/acyf. Whilethe projects have differing areas of focus andvaried methods, the goal of each is to facilitatehealing and recovery and promote socialand emotional well-being for children andfamilies.By aligning funding opportunities aroundthis vision achieved through shared methods,ACYF is helping to build nationwidecapacity to identify and address trauma. Agrowing network of systems and providersare delivering evidence-based interventionsto children and their families. In many of theprojects described below, child welfare systemsare partnering with mental health, substanceabuse treatment, Medicaid, and other systemsto streamline services and increase theireffectiveness. Wherever you are, the odds aregood that ACYF is supporting cross-system,evidence-based and evidence-informedstrategies for treating trauma near you.Child WelfareDemonstration ProjectsNine States received waivers to conductTitle IV-E Child Welfare DemonstrationProjects beginning in 2012. Through anagreement with ACYF, these States have beengranted flexibility to use Federal funds totest innovative child welfare strategies. Theprojects aim to increase safety, permanency,and well-being for children and familiesinvolved with child welfare. Nearly all of thedemonstration projects will be implementingapproaches designed to address trauma andimprove the social and emotional well-beingof the young people receiving services. Thesecomprehensive projects incorporate screeningand assessment, expand the array of availableevidence-based interventions, and greatlyenhance the capacity of the workforce to meetthe needs of the population.For example, Pennsylvania’s demonstrationproject will test a new case practice modelfocused on family engagement, enhancedassessment, and the introduction orexpansion of evidence-based programs.The project will target children 0-18 inor at risk of entering foster care with thegoals of improving permanency, increasingpositive well-being outcomes for childrenand families, and preventing maltreatmentand re-entry of children into foster care.Pennsylvania’s waiver team has alreadyidentified several standardized well-being,developmental and behavioral assessmenttools for consideration, as well as potentialevidence-based interventions. A robustevaluation will not only track changes inkey child welfare outcomes for children andfamilies participating in the demonstrationbut also assess the effectiveness of specificinterventions with the population.

CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 17Discretionary FundingGrantees in the Initiative to Improve Accessto Needs-Drive, Evidence-Based/Evidence-Informed Mental and Behavioral HealthServices in Child Welfare will focus explicitlyon increasing screening and assessment anddelivering evidence-based interventions.Using data from screening and assessmenttools, each of the grantees will tailor theirservice array to better fit their population.While working to scale up evidence-basedinterventions, they will also identify andde-scale services that are not achieving thedesired improvements in well-being forchildren and youth. One grantee, WesternMichigan University and its partners, will usethe Trauma Symptom Checklist to identifychildren with trauma-related needs. Using aLearning Collaborative model, the granteewill build the workforce’s capacity to deliverevidence-based and evidence-informedtrauma treatments, including Trauma-FocusedCognitive Behavioral Therapy (TF-CBT).Ongoing functional assessments will be usedto track children’s progress.The Family Connection DiscretionaryGrants Program yielded three fundingopportunities in FY 2012, each of whichsupports a distinct approach for ensuringthat children have nurturing relationshipsin stable, developmentally appropriateenvironments. For instance, the CombinedFamily-Finding/Family Group Decision-Making Programs will use family-findingand/or family group decision-makingmethodologies to keep children safely withtheir parents, when possible, or locate kincaregivers. Because many families who cometo the attention of child welfare systems havecomplex, multiple needs, ComprehensiveResidential Family Treatment Programs willprovide a range of services within a residentialsetting to strategically stabilize, preserve, andreunite families. The Child Welfare/TANFCollaboration in Kinship NavigationPrograms, meanwhile, will specifically targetkinship caregivers, providing supports andservices that help them provide nurturing,stable environments for the children in theircare.Other discretionary grant programstarget children and families facing particularrisks. The Regional Partnership Grants toIncrease the Well-Being of, and to Improvethe Permanency Outcomes for, ChildrenAffected by Substance Abuse will servefamilies with children who are in or at riskof entering foster care as a result of a parent’sor caregiver’s substance abuse. Granteesmust strengthen existing collaborationsacross systems to deliver evidence-basedand evidence-informed interventions totreat parental substance abuse and addressthe complex array of needs faced by theseSocial and EmotionalWell-Beingfor Children, Youth,and FamiliesIntensiveInterventionTargeted Socialand EmotionalSupportsStress Reducing andDevelopmentallyAppropriate Environmentsfamilies. This includes building caregivers’parenting skills and responding to children’sexposure to trauma. For example, Childand Family Tennessee aims to address thecomplex needs of its target population bycollaborating with an array of partnersto provide early intervention and familyassessment, housing services, family-centeredtreatment and integrated healthcare services.Child and Family Tennessee will evaluate theeffectiveness of the evidence-base and traumainformed approaches utilized, including theMatrix Model.Partnerships to Demonstrate theEffectiveness of Supportive Housing forFamilies in the Child Welfare System alsotarget a specific at-risk population: childrenand families who come to the attentionof the child welfare system due to severehousing and service needs. Grantees willprovide community-linked services throughthe implementation of supportive housingservices designed to respond to the complexneeds of families with child protective servicesinvolvement in a multidisciplinary andongoing way. These grants will demonstratethat strong collaborations between childwelfare and housing authorities can makethe delivery of services to high-need familiesmore efficient and effective. For example,the San Francisco Human Services Agency’sRapid Support and Housing for FamiliesProject will serve a minimum of 160 familieswho are homeless and at risk of foster careplacement over the course of the five-yeargrant period. Elements of the project includeidentification, assessment, and rapid referralof families; use of multi-disciplinary teams tohelp families maintain housing and improvewell-being; use of mobile housing vouchers;Healing and RecoverySafe, Supportive, and ResponsiveRelationshipsKnowledgeable and Effective WorkforceAssessment drives individualized treatment planwith evidence-based interventionsSystematic approaches to teaching coping skillsand social skillsNurturing environments provide securityand promote positive outcomesSupportive, responsive relationshipspromote healing and recoveryand reinforce growing socialand emotional skillsSystems and policies promote andsustain screening, assessment, theuse of evidence-based interventions,progress monitoring, and continuousquality improvementAdapted from the Technical Assistance Center on Social Emotional Intervention for Children and the Center on the Social and Emotional Foundations for Early Learningexpanded trauma-informed services; and afocus on increasing family income throughSupplemental Security Income advocacy andwage subsidies.Looking AheadThe projects funded by the ACYF in FY 2012are ambitious. As they progress, they willcontribute much to our understanding abouthow child welfare systems can meaningfullyimprove the well-being of the children, youth,and families they serve. Much of the workdescribed here includes robust evaluation,both of individual grantees’ work and acrossproject sites. Findings and lessons learnedwill be disseminated widely and integratedthroughout ACYF’s ongoing activities.Around the country, we are collectivelybuilding a truly responsive system thatfacilitates the healing and recovery of ournation’s most vulnerable children, provingthat this urgent, important work, thoughcomplex, is possible.This is an excerpt from the year endmessage from Commissioner Samuels,titled Integrating Safety, Permanency,and Well-Being for Children andFamilies in Child Welfare and availablein full at http://z.umn.edu/acyf.Overview

20 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013PracticeAddressing Early Childhood Traumain the Context of the Child Welfare SystemBetsy McAlister Groves, MSW, LICSWThree-year-old Kayla’s mother was arrested athome by police for suspected drug possessionand distribution. Kayla was with her motherat the time; her father’s whereabouts wereunknown. The police reported an unclean,chaotic household with scant food available,and they notified child protection services. Thechild was placed in a temporary foster homefor 4 days and then moved to a kinship careplacement.The story of Kayla is all too common inthe Child Protection System. Children 0-3constitute 31.9% of all maltreatment victimsreported to authorities and nearly 80% of allchild fatalities age 0-4 (U.S. Department ofHealth and Human Services, 2011). Thesechildren are both the most vulnerable to abuseand neglect and the least able to communicatetheir experiences, fears and needs.How does Kayla understand whathappened? How might this event affect herbehavior and her relationships with hermother and the adult caregivers she will nowbe living with? What supports do Kayla andthe caregivers in her life need to manage thestress of these events? These questions are atthe center of decision-making for all childrenin the child protection system. This articlefocuses on the unique needs of very youngchildren.Previously, it was thought that a young agesomehow protected children from traumaticstress—they were too young to understand,and therefore, they could not be seriouslyaffected. However, research has shown thatbabies and young children take in muchmore of their world than previously thought,and their brains are highly responsive to thecaregiving environment. This knowledgeof the sensitivity of very young children totheir environment and the malleability ofthe developing brain in the newborn andearly childhood developmental periods hasincreased the importance of understandingand responding to the impact of earlychildhood stressors.At age three, Kayla lacks the cognitiveabilities to understand what has happened.She cannot reliably anticipate danger orkeep herself safe. Young children use theirrelationships with attachment figures toregulate their emotional responses in timesof fear or stress, to help them cope with theirnegative feelings, and to help them learnadaptive ways to calm and regulate themselves(Lieberman, 2004). In Kayla’s case, she hasexperienced the sudden, unanticipated loss ofher mother. It is likely that the specifics of thearrest were highly stressful with screams, loudvoices, perhaps a search of the house. Likeall young children, she looks to her motherfor comfort and cues as to how to react tothis stress. In this case, her mother was notavailable. This disruption of the attachmentrelationship is at the core of risk for children.Kayla’s sudden separation from her caregiveraffects her expectations for protectivecaregivers and for a safe and predictable world(Groves, 2002).Young children respond to trauma-relatedfeelings of fear and vulnerability in a varietyof ways. Often, the child is fearful andaggressive. They may be withdrawn, slow towarm up to others, and are anxious abouttheir environments. Many have irregularsleeping and eating patterns. These behaviorsA trauma-informed child protection system is knowledgeable about thepotential short- and long-term impacts of disruptions in attachmentrelationships on young children and encourages child protection workersto understand young children’s behavior in the context of traumaticstress and disrupted attachment.may interfere with the child’s adjustment tofoster care and often are misunderstood by theadults who are providing care.The child protection system will conductan investigation and make recommendationsto ensure Kayla’s safety and well-being.However, in the initial period of crisis andhighest stress for Kayla, the child protectionworker’s skills in making a trauma-sensitiveintervention are essential. In Kayla’s case, thechild protection worker was able to talk withthe mother after the arrest. She explainedwhere Kayla was going; she obtainedessential information about Kayla’s health;she asked about Kayla’s favorite toys andobjects of comfort. She talked to Kayla ina soothing tone telling her in language thatwas appropriate for a 3-year-old about whatwas happening. She reassured Kayla that hermother would be okay. She gave the resource(foster) parent appropriate information sothat she could understand Kayla’s experiences.She maintained regular contact throughoutthe transition from the resource parent to thekinship care setting. By helping the caregiversunderstand the context of Kayla’s experiencesand behaviors, she helped them respond moresensitively to her stress and her needs forcomfort.A trauma-informed child protectionsystem is knowledgeable about the potentialshort- and long-term impacts of disruptionsin attachment relationships on young childrenand encourages child protection workers tounderstand young children’s behavior in thecontext of traumatic stress and disruptedattachment. The workers are able to translatethe meaning of this behavior to the adultcaregivers in the child’s life while also offeringspecific developmentally appropriate supportand resources. The trauma-informed systemunderstands that important relationshipsare key to a young child’s feelings ofsafety; its efforts focus on supporting thoserelationships. These efforts are essential tothe recovery and well-being of society’s mostvulnerable children.Betsy McAlister Groves, MSW, LICSW isFounding Director of the Child Witnessto Violence Project at Boston MedicalCenter. She can be reached atbetsy.groves@bmc.org.

CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 21Trauma Screening within the Child Welfare SystemLisa Conradi, PsyD and Cassandra Kisiel, PhDChildren involved in the child welfaresystem (CWS) are particularly vulnerableto traumatic exposure and traumatic stresssymptoms whether it is by virtue of the eventsthat brought them into the system or throughthe process of removal from their caregivers.A national study of adult “foster care alumni”found higher rates of posttraumatic stressdisorder (PTSD; 21%) compared with thegeneral population (4.5%) (Pecora et al.,2006). If left untreated, the effects of childtrauma can be far-reaching and pervasive.Recently, the importance of screening fortrauma among children in the child welfaresystem has received increased attention.In December 2011, the Child and FamilyServices Improvement and Innovation Actof 2011 PL 112-34 amended Title IV-B, inpart, to require states to screen for “emotionaltrauma associated with a child’s maltreatmentand removal from the home.” While specificguidelines are not yet established on how stateswill implement this mandate, it suggests thatpolicy makers recognize screening for traumaas playing a critical role in assisting childwelfare systems (CWS) towards meeting theirgoals of safety, permanency and well-being.A trauma screening tool is designed tobe universal, administered to every childwithin the CWS, and typically evaluatesthe presence of two critical elements: (1)exposure to potentially traumatic events/experiences and (2) endorsement of traumaticstress symptoms/reactions. Using a traumascreening tool is critical to understandingthe unique experiences of children and theirneeds; however, there are a number of barriersthat impede child welfare workers fromconducting trauma screens on every child whocomes into care. These barriers include lack oftraining on administration of screening, lackof time to administer screening tools, lackof training to effectively use the informationgathered for case planning, and difficultymanaging the effects of secondary/vicarioustrauma that may emerge when asking a childabout his/her traumatic experiences.While there are barriers to administeringuniversal trauma screening tools, there are anumber of benefits. CW workers may alreadyIn December 2011, the Child and Family Services Improvement andInnovation Act of 2011 PL 112-34 amended Title IV-B, in part, to requirestates to screen for “emotional trauma associated with a child’smaltreatment and removal from the home.”be asking about the child’s traumatic exposureand symptoms although they may notexplicitly identify their questions as such. Forinstance, many practices within child welfare,including Structured Decision Making(Wiebush, Freitag, & Baird, 2001) and Signsof Safety (Turnell, 2011) include questionsrelated to a child’s trauma history, fears, andtriggers. Therefore, integrating some questionsabout specific trauma experiences andsymptoms can readily be woven into existingpractices and tools. Further, caseworkerswho have conducted trauma screenings canidentify the types of events or situations thatmay potentially trigger symptoms for thechild. This information can be conveyed tothe foster parent along with psychoeducationand skill-building on managing difficultbehaviors and trauma triggers, ultimatelyhelping the foster parent manage difficultbehaviors and minimize placement changes.Finally, a trauma screening plays a criticalrole in determining whether or not a childshould be referred for general mental healthtreatment and/or trauma-focused treatment,if needed.Before implementing any screening tool orprocess, it is useful to integrate some generalrecommendations into existing child welfarepractice:1. Broad training on child traumatic stressshould be made available to the entirechild welfare workforce. This includestraining on different trauma types (e.g.,sexual abuse, physical abuse, neglect,exposure to domestic violence) and varioustraumatic stress reactions that childrenmay exhibit, including internalizingand externalizing problems. There are anumber of resources that exist to assistchild welfare systems in training onthese topics, including the Child WelfareTrauma Referral Tool (Taylor, Steinberg &Wilson, 2006).2. The child welfare system should fosterrelationships with its mental healthpartners and actively work with them tobuild their capacity to provide traumafocusedmental health treatment whenappropriate. If a screening processdetermines that a child would benefitfrom a trauma-focused mental healthassessment, it is critical to link him or herto a provider who is trained in providingsuch an assessment.There are several existing trauma screeningtools designed to help child welfare workersget a better sense of the child’s traumahistory, make sense of the child’s behaviorproblems, and inform the case planningprocess. For a fuller review of somecommonly used screening tools and methodsof administration, refer to Conradi, Wherryand Kisiel (2011). Given the extraordinarynumber of children who enter the CWS witha history of trauma, it is critical to embed aprocess in which children are screened fortrauma exposure and reactions, and thenreferred for trauma-focused assessment andtreatment as needed.Lisa Conradi, PsyD is Project Managerof the National Child Traumatic StressNetwork (NCTSN) at the ChadwickCenter for Children and Families,Rady Children’s Hospital and HealthCenter, San Diego, California. She canbe reached at lconradi@rchsd.org.Cassandra Kisiel, PhD is ResearchAssociate Professor at the NorthwesternUniversity Feinberg School of Medicine,Department of Psychiatry & BehavioralSciences. She can be reached atc-kisiel@northwestern.edu.Practice

22 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013Trauma-Focused Cognitive Behavioral Therapy (CBT)for Youth in Child WelfareJudith A. Cohen, MD and Anthony Mannarino, PhDPracticeChildren show the negative effects of traumaexperiences in different ways. Let’s take a lookat a couple of case examples that illustrate thispoint. Six year old Maria was sexually abusedby her mother’s boyfriend while her mother,who was addicted to drugs, was unableto protect Maria. Mother was sometimespresent when her boyfriend, Jack, abusedMaria. Maria cries and clings to her fostermother when she sees a man who looks likeJack. (This is an example of responding to atrauma reminder—a person, place, situation,smell, feeling, or something else that remindsthe child of the original trauma experience.)Maria also has nightmares and is afraid togo to sleep alone at night (when Jack oftenabused her). She will only sleep if she isallowed to sleep in her foster mother’s bed.When asked about the abuse, Maria says shedoesn’t want to talk about it because it’s “tooscary.” Foster parents, teachers and mentalhealth professionals readily connect Maria’sproblems with her previous sexual abuse.Robert, 13 years old, also does not want todiscuss his past, which includes a long historyof physical and verbal abuse and neglect,witnessing domestic violence, and bullying atschool. Unlike Maria, Robert denies havingnightmares and being afraid and does notappear to the adults in his life to be negativelyaffected by his past trauma. He has beenremoved from four foster homes due to hisangry, aggressive behavior and refusing tocomply with rules. Typically Robert tells hiscaseworker that the foster parents “disrespect”him; the parents say that Robert is the onebeing disrespectful. In his current fosterhome, as Robert has become more defiant,his foster parents have become increasinglystrict, and are now giving him commandsin loud voices. His foster father has evenphysically restrained him to “teach him who’sthe boss.”. Like Maria, Robert is experiencingtrauma reminders (in his case, loud voices andphysical punishment from parent figures) andtrauma responses (problems regulating hisfeelings, thoughts and behaviors in responseTrauma-focused Cognitive Behavioral Therapy is the most tested EBT fortraumatized youth.to trauma reminders), but the adults in his lifedo not understand this; they see him as a kidwith bad behaviors who needs discipline.Maria, Robert, and thousands of otheryouth in the child welfare system needeffective treatment for their trauma problems.They currently have little chance of receivingsuch treatment because few therapists treatingthese youth learn evidence-based traumafocusedtreatments (EBTs).Figure 1: TF-CBT PRACTICE ComponentsP: PsychoeducationP: Parenting SkillsPRAC:R: Relaxation SkillsCoping Skills PhaseA: Affective Modulation SkillsC: Cognitive Coping SkillsT:Trauma Narrative andProcessing PhaseICE:Treatment Consolidationand Closure Phase(TG: Traumatic Grief Components as needed)T: Trauma Narrative and ProcessingI: In vivo Mastery of Trauma RemindersC: Conjoint Youth-Caregiver SessionsE: Enhancing SafetyEvidence-Based TraumaTreatmentsEvidence-based trauma treatments (EBTs)are trauma treatments that have been testedin scientific studies. The most rigorous kindof study to test a treatment’s effectiveness is arandomized controlled trial (RCT). In a RCTthe treatment being tested (Treatment A) iscompared to another treatment (Treatment B)to see which works best to help traumatizedchildren recover. In RCT studies, children arerandomly assigned (“randomized”) to receiveTreatment A or Treatment B. This is doneto eliminate the possibility of bias. In RCTstudies, both treatments are monitored (e.g.,by listening to audiotaped treatment sessionsor using a fidelity measure) to assure thatchildren are receiving the assigned treatment.Children’s outcomes are evaluated by peoplewho do not know which treatment thechildren have received (“blinded” evaluators).This is an additional step to prevent bias inthe outcome of the study.In order to be considered an EBT,Treatment A must produce significantlybetter outcomes than Treatment B in atleast one RCT study. For trauma-focusedtreatments, these outcomes may includePosttraumatic Stress Disorder (PTSD),externalizing or sexualized behavior problems,anxiety, depressive symptoms, shame, orthe child’s negative beliefs about himself.Other important outcomes may relate to thecaregiver, such as change in positive parentingpractices, caregiver support of the child,or resolving caregiver emotional distress.Outcomes specific to children in childwelfare may include prevention of placementdisruption or running away from the child’scurrent placement.Trauma-Focused CognitiveBehavioral Therapy (TF-CBT)Trauma-focused Cognitive BehavioralTherapy (TF-CBT, Cohen, Mannarino &Deblinger, 2006; www.musc.edu/tfcbt) isthe most tested EBT for traumatized youth.TF-CBT is comprised of several treatmentcomponents, summarized by the acronymPRACTICE. These components are dividedinto three modules or phases as shown inFigure 1: Coping Skills,; Trauma Narrativeand Processing, and Treatment Consolidationand Closure. Typically TF-CBT treatment is12-16 sessions, but for very complex trauma,this treatment may be 25-30 sessions. TF-CBT has been used for many youth in childwelfare and applications for these youth have

CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 23been described (Dorsey & Deblinger, inpress).During each subsequent TF-CBTcomponent youth use coping skills totolerate gradually increasing exposure to theirtrauma reminders, a process called “gradualexposure”. Caregivers (e.g., biological orfoster parents) participate in parallel parentingsessions throughout TF-CBT treatment.However, youth with frequent changes inplacement, youth without caregiver contact,or youth who refuse to allow the caregiverto participate in treatment can also receiveTF-CBT. For these youth, TF-CBT engagesthe youth in the youth-focused componentsof TF-CBT while simultaneously attemptingto create a supportive network from otheravailable adults (www.cdc.gov). If feasible,another supportive adult may eventuallyparticipate in the youth’s TF-CBT treatment.The early coping skills phase consists ofbuilding skills for the youth to use whenconfronted with trauma reminders and touse generally when experiencing regulationdifficulties. These skills are also importantfor the caregiver. Psychoeducation helps thecaregiver to view the youth’s problems asbeing related to his past trauma experiencesrather than simply as “bad” behavior.Parenting skills provide the caregiver withtools to more effectively respond to theyouth’s trauma-related regulation problems.For children like Maria, a step- by-step invivo (in real life) plan will help her masterher fear of sleeping in her own bed. Since thismay take several weeks, the in vivo masterywill begin early in TF-CBT. For youth likeRobert with serious behavioral problems, itmay take 10-12 sessions to achieve reasonablestability and self-regulation (Cohen, Berliner& Mannarino, 2010; Cohen, Mannarino,Kliethermes & Murray, in press).The next phase of TF-CBT is trauma narrativeand processing. During this phasethe youth develops and processes a detaileddescription of his trauma experiences. A youthwho has lived through chronic, multipletraumas may create a narrative focusing on histrauma theme (Cohen, et al, 2012). Creatingand processing the narrative typically takesabout 1/3 of the TF-CBT treatment.After the youth has created and come to a betterunderstanding of these experiences duringsessions with the therapist and the therapisthas shared this narrative with the caregiver inindividual sessions, the youth shares it withthe caregiver in conjoint youth-caregiversessions. With appropriate preparation thesesessions are highly rewarding and validatingsessions for youth and caregivers. Finally,re-establishing a sense of safety for youth inchild welfare is critical. For many youth inchild welfare this is the most critical componentand TF-CBT may begin and end withestablishing trust and safety.TF-CBT Effectivenessfor Youth in Child WelfareA dozen RCT studies have shown the effectivenessof TF-CBT in improving multipleoutcomes (e.g., PTSD, depression, anxiety,behavior problems, youth cognitions, parentingoutcomes) after traumas commonly experiencedby youth in child welfare (e.g., sexualabuse, domestic violence, multiple traumas).Two studies specifically focused on youth inchild welfare. The first study examined youthin care in Illinois, comparing TF-CBT toyouth receiving Systems of Care treatmentas usual (SOC). TF-CBT was significantlysuperior to SOC in improving PTSD symptoms,emotional and behavioral problems asmeasured by the Child and Adolescent Needsand Strengths (CANS) and in preventingplacement disruption and running awayfrom current placement (Weiner, Schneider& Lyons, 2009). The other examined theeffectiveness of TF-CBT with or withoutan additional module for engaging fosterparents. This study found that the engagementstrategy significantly improved fosterparents engagement in their youths’ TF-CBTtreatment but otherwise did not change youthoutcomes, with both groups experiencing significantimprovement after receiving TF-CBT(Dorsey, 2011).For more information about TF-CBT, therapistscan refer to the free TF-CBT trainingresources available at www.musc.edu/tfcbt,www.musc.edu/ctg and www.musc.edu/tfcbtconsult.Information about upcoming TF-CBT training is available at www.musc.edu/tfcbt under “Resources.” The location of over200 TF-CBT trained clinicians in Minnesotais available at www.ambitnetwork.org.Judith Cohen, MD is Medical Directorof the Center for Traumatic Stress inChildren & Adolescents at AlleghenyGeneral Hospital in Pittsburgh PA andProfessor of Psychiatry at the DrexelUniversity College of Medicine. She canbe reached at Jcohen1@wpahs.org.Anthony Mannarino, PhD is Chairman,Department of Psychiatry, and Directorof the Center for Traumatic Stress inChildren and Adolescents at AlleghenyGeneral Hospital, Pittsburgh, PA. Heis also Professor of Psychiatry at theDrexel University College of Medicine.He can be reached at amannari@wpahs.org.Practice

24 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013PracticeTrauma-Informed PMTO: An Adaptation of theOregon Model of Parent Management TrainingLaura A. Rains, MSW, LCSW, and Marion S. Forgatch, Ph.D.Consistent effective parenting is a cornerstonefor children’s healthy adjustment undernormal circumstances; it is even moreessential for families facing adversities.Providing effective treatment to families inthe child welfare (CW) system who haveexperienced traumatic stress can promoterecovery from adversity and a return tohealthy balance. The Oregon model ofParent Management Training (PMTO)is an evidence-based program (EBP) thatincreases effective parenting, which in turnpromotes positive outcomes for childrenand parents (Forgatch & Patterson 2010).Recently PMTO has been tailored to addressthe needs of families in the CW system bystrengthening a focus on emotion regulationand adding mindfulness, thereby yielding atrauma-informed version of PMTO.Trauma and other adverse contexts canlead to emotional dysregulation. Parents mayreact with negative emotions, which in turncan interfere with effective parenting practices,and lead to negative outcomes for children andtheir families. Adversities such as transitions,unemployment, substance use, poverty,and discrimination can amplify caregivers’negative emotions and interfere with socialrelationships outside the family (DeGarmo &Forgatch, 1999; Patterson & Forgatch, 1990).Additionally, maltreated children in fostercare are burdened with challenges in socialemotionalcompetence (Pears, Fisher, Bruce,Kim, & Yoerger, 2010) and psychosocialdomains (Pears & Fisher, 2005).The intervention empowers parents toserve as change agents for their families.Intervention studies consistently find thateffective parenting mediates the harsh effectsof high-risk contexts on children’s adjustment.For example, a short-term longitudinal studyexamining recovery in the close aftermathof traumatic events identified parentingpractices as a key source of protection forchildren’s adjustment (Gewirtz, DeGarmo, &Medhanie, 2011). Findings from randomizedcontrolled intervention trials in samplesundergoing stressful family transitions haveshown that improved parenting practices yieldpositive outcomes for children and for theparents themselves (Forgatch & Patterson,2010; Patterson, Forgatch, & DeGarmo,2010).PMTO interventions decrease coerciveparenting and increase positive parenting(i.e., skill encouragement, problem solving,limit setting, positive involvement, andmonitoring). Improvements in parenting, inturn, buffer the effect of stressful contextson youngsters and promote healthyadjustment. More than four decades of carefulresearch with PMTO programs have shownbenefits for youngsters in terms of reducedinternalizing and externalizing behavior,deviant peer association, delinquency, policearrests, and increased academic functioningand positive peer relationships (Forgatch andPatterson, 2010). Several large-scale PMTOimplementations have been conductednationally and internationally. Adaptedversions of PMTO are being tested withdiverse populations, including English andnon-English speaking Latinos, militarypersonnel returning from the wars inAfghanistan and Iraq, Somali and Pakistanifamilies in Minnesota and in Norway, andfamilies in Mexico City.Originally, PMTO focused on parentinginterventions for child mental health issues. Inthe last decade, the intellectual contributionsof Dr. Abigail Gewirtz contributed totailoring PMTO programs to help familieswhose children have been removed for neglectand/or maltreatment. PMTO programs forCW include an intensive reunification projectin Kansas and in Detroit, Michigan. Parentslearn to integrate emotional regulation,mindfulness, communication, and problemsolving skills to improve relationships at homeand with adults in the community (e.g., othercaregivers, CW, judicial, school, employer).As parents become more effective, new doorsto healthy social environments open up forchildren and parents (Patterson et al., 2010).PMTO clinicians deliver the interventionin parent groups or individual family sessionsusing non-blaming, strength-based, activeteachingstrategies tailored to the specificneeds of families. To broaden the range ofemotional identification, practitioners usevideo and other media that elicit parents’descriptions of attributes of emotions inIntervention research must become standard practice to better understandthe role of parenting in children’s post-trauma recovery and therelationship between trauma-informed parent training and child welfare.terms of body posture, facial expression,and voice tone. To strengthen parent-childcommunication, families create an emotioncollage or play games designed to providepractice in managing common familychallenges. Clinicians engage families withtheatrics and humor, thus promoting acomfortable environment for differentiatingand expressing emotions.Families in the CW system need evidencebasedpractices to ensure enduring positiveoutcomes. Intervention research must becomestandard practice to better understand therole of parenting in children’s post-traumarecovery (Gewirtz, Forgatch, & Wieling,2008) and the relationship between traumainformedparent training and child welfare.The hardworking practitioners whose missionContinued on page 38

CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 25Cultural Adaptations of Trauma Treatments in Indian CountryWynette Whitegoat, AB, and Richard van den Pohl, PhDThe National Native Children’s TraumaCenter at the University of Montana isfunded by SAMHSA as a Treatment andService Adaptation Center within theNational Child Traumatic Stress Network.Centers such as ours are charged withreplicating evidence-based trauma treatmentswhile adapting them to meet the needs oflocal communities. Our work has focused onproviding cognitive behavioral treatments,primarily Cognitive Behavioral Interventionfor Trauma in Schools, or CBITS (Jaycox,2004), in American Indian reservationschools. We also have worked to createtrauma-informed behavioral health, juvenilejustice, and child welfare systems. Indianand non-Indian staff members’ backgroundsinclude psychology, education, social work,counseling, early childhood, law enforcement,and the military.Inclusion of traditional Native culturalactivities in evidence based trauma treatmentshas produced strong appreciation for ourwork by some tribal partners. It also hasproduced great concerns from other tribalpartners largely due to sacredness of culturalactivities. The use of traditional healingwithin the Native communities we work withis seen to be the most reasonable option inregaining health and balance. Because cultureplays a critical role in facilitating healingamong Natives, it is seen as an essentialneed toward wellbeing. Although all tribesare different in culture and hold a variety ofperspectives and philosophies, the majoritydo share similar beliefs on the importance ofwellbeing. The psychological, social, physical,and spiritual dimensions are interconnectedand should be treated as one (LaFromboise,Trimble, & Mohatt, 1990). Ceremonies andother traditional practices bring comfort,hope, and rebalance to these four dimensionsfound within individual clients and theircommunity (McCabe, 2007). Not onlydoes traditional healing provide options forrestoration but also increases opportunities forcultural preservation, reinforcement of ethnic/tribal identity, and connection to culture andthe community (Hartmann & Gone, 2012;McCabe, 2007; Ranford, 1998).While adaptation of evidence-basedtreatments may seem incompatible withhigh fidelity replication, we have foundthat adaptations can enhance acceptability,sustainability and effectiveness of traumatreatments. Most tribal communities in theUnited States experience some distrust ofoutsiders (Yellow Horse Brave Heart, 2003),particularly child welfare workers. Whethera Tribe has experienced theft of deceasedgrandparents’ remains or whether “research”has been conducted that perpetuated racialstereotypes, there are good reasons for tribalmembers to be skeptical of outside expertswho offer simplistic solutions for complexproblems (Gone & Alcantara, 2007). Whilenot conducive to short-term change, we havedeveloped three developmental approaches thatseem to support long term relationships withTribes and tribal members. First, we only workin communities where we have been invited.Second, we consider that all data resultingfrom tribal partnerships are the property ofthe Tribe; the Tribe may or may not give uspermission to disseminate those data. Third, inaddition to protecting individual identity, wedo not disclose the identity of a Tribe unlessthe Tribe asks us to do so.We also have found it valuable to engagelocal community members in participatorydialog regarding their perceptions of thevalue of treating childhood trauma, whatthe outcomes of successful trauma treatmentWhile adaptation of evidence-based treatments may seem incompatiblewith high fidelity replication, we have found that adaptations can enhanceacceptability, sustainability and effectiveness of trauma treatments.should look like, and whether there alreadyare traditional support strategies that couldbe blended with the evidence-based traumatreatment. While some local adaptationshave been procedural (e.g., inviting studentsto draw a picture to supplement their oraltrauma narrative), we also have invited localcultural experts to contribute traditionallanguage and traditional healing strategiesduring group trauma treatment.In some communities, our early effortsto include traditional Native language andculture stimulated apprehensions among ourtribal partners. One set of concerns involvedthe proprietary nature of Native languageand culture. Closely linked were perceptionsthat researchers might exploit or otherwiseprofit from information shared by healers andElders, and because we do this work as partof our university employment, we cannotcompletely nullify this perception.To date, no Tribe has refused our requestto share results of trauma treatment. However,the extent to which we discuss traditionallanguage and culture follows one of threeprotocols. The protocol that is followedis determined by Tribal Council decisionwith recommendations from Elders. In thefirst case, traditional language and healingceremonies are made available to childrenand youth who choose them, but whetherand how that occurs is not disclosed inour dissemination. In the second case, wereport that a community volunteer withexpertise in language and culture participatedin the trauma treatment program, butthe intervention(s) he or she used are notrecorded, named or described. In the thirdcase, the traditional ceremony may be namedand may be described. In every case, weinform the Tribal Council of our findingsbefore disseminating elsewhere.Child welfare (CW) workers may beperceived as “outsiders,” for example, ifthey are employed by the Bureau of IndianAffairs, a federal agency. In recent years,BIA has employed Native workers whoalso are community members—a practiceconsistent with Indian self-determination.Alternatively, Tribes can provide their ownchild welfare services. Regardless of agencytype, CW workers face enormous challengesin child protection as the families they servefrequently are both neighbors and relatives.The adoption of Differential Response (DR)services has dramatically shifted the CWworker role from investigation only to a moreintegrated approach of family support servicescoupled with ensuring child safety. SuchContinued on page 38Practice

26 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013Homeless Youth Emerging from the Child Welfare SystemArlene Schneir, MPHPracticeThe Hollywood Homeless Youth Partnership(HHYP), a collaborative of eight homelessyouth serving agencies in Hollywood,California, has been involved as a center withthe National Child Traumatic Stress Networksince 2005. As a result of our work with theNCTSN, we believe that trauma-informedpractices and evidence-based trauma focusedtreatment approaches can be more effective inhelping youth who have experienced traumaand abuse understand their experiences,develop new and healthier coping strategies,create and sustain positive attachments withcaring adults, and healthy relationships withpeers, and promote post-traumatic growth.Most importantly, we strongly believethat early and on-going trauma-focusedintervention with these young people can helpprevent them from transitioning from ourchild welfare system into youth homelessness.Unaccompanied homeless youth are foundin every urban center in the U.S. and inmany smaller cities and rural communities.Nationally, former foster care children andyouth are disproportionately represented inthe homeless population (National Alliance toEnd Homelessness, 2006). In 2007 and 2008,the HHYP conducted a multi-method needsassessment with unaccompanied homelessyouth ages 12 – 25 to better understandtheir needs and experiences. The resultingreport, “No Way Home: Understanding theNeeds and Experiences of Homeless Youthin Hollywood” (Rabinovitz, Desai, Schneir,& Clark, 2010), included rich informationabout the characteristics of homeless youth inthis community that can be useful for childwelfare systems and other public and privateinstitutions that serve these young people.Approximately half (48%) of the youthsurveyed (n=389) reported previous or currentinvolvement with the child protective servicessystem (CPS); forty percent of youth reportedhaving been removed from their homes byCPS. The mean age when youth reportedhaving been removed by CPS was 9.3 yearsold. Almost all (95%) of the youth who hadbeen removed from home had been placedin a group home at some time, and close toone-third of the youth reported they hadbeen in 6 or more group homes. Clearly, ourchild welfare system has not been effective infinding these children and youth the safe andpermanent housing they require for healthydevelopment.As part of our analysis, we compared thehomeless youth in our survey who had beenremoved from home by CPS with those whohad not and found that youth who had beenremoved from home by CPS had pooreroutcomes than their peers. Not surprisingly,youth who had been removed from homeHomeless youth who had been removed from home complained mostabout the multitude of placements and how that interfered with theirability to connect with peers and caring adults.were more likely to report all types of abuseand neglect. These youth also reportedmore episodes of homelessness (8.1 vs. 5.3);were more likely to be engaged in the streeteconomy (panhandling, shoplifting, tradingsex, selling drugs, and/or pimping) (47% vs.36%); and were more likely to have spent atleast one night on the street in a place notmeant for human habitation within the lastmonth (59% vs. 45%).In regard to mental health issues, youthwho had been removed from home by CPSreported more psychiatric hospitalization andwere more likely to report being diagnosedwith a conduct disorder, bipolar disorder, orschizophrenia. They were also more likelyto report self-injurious behavior. In regardto educational issues, youth who had beenremoved from home by CPS were also morelikely to have been diagnosed with learningproblems and enrolled in special education.In individual interviews and focus groups,homeless youth who had been removed fromhome complained most about the multitudeof placements and how that interfered withtheir ability to connect with peers and caringadults. Youth also reported they were oftenmoved from one placement to anotherwithout any warning or explanation. Inaddition, youth had many complaints aboutthe mental health services they received whenthey were involved in the child protectivesystem. They felt they were over-diagnosed,labeled, and medicated. As a result, many ofthese youth were reluctant to access mentalhealth services even after their involvementwith CPS ended.Over the past two decades, the federalgovernment and many state child protectionagencies have intensified their efforts toensure that child welfare services resultin positive outcomes for children andfamilies. However, there is clearly stillwork to be done. Based on our work withyouth experiencing homelessness, we areparticularly interested in efforts to supportpermanency for children and youth in thefoster care system. We applaud new initiativesthat make this possible, particularly for gay,lesbian, bisexual, and gender non-conformingchildren and youth.Arlene Schneir, MPH, is AssociateDirector of the Division of AdolescentMedicine at Children’s Hospital inLos Angeles. She can be reached ataschneir@chla.usc.edu.

CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 27Trauma-Informed Care Using the 3-5-7 ModelDarla L. Henry, PhD, MSW, and Amelia Franck Meyer, MS, MSW, APSW, LISWAlthough there has been an increasing focuson “trauma-informed care” for children inout-of-home care, for many, it has not beenclear exactly what “trauma-informed care”means on the practice level. For example,“What do I do differently in my day-to-dayinteractions with the youth?” “What do fosterparents do differently in the home?” UntilAnu Family Services (www.anufs.org) becameaware of the 3-5-7 Model © , the answersto these questions about the practice-levelchanges needed to address trauma were notas clear. The 3-5-7 Model © , in which alltreatment foster parents and social workersare trained at Anu, helped to concretize howto address trauma for youth in out of homecare. The 3-5-7 Model © helped to give anew perspective to the work: trauma is theexperiences that have happened to theseyouth, losses are what they experience as aresult of these multiple and complex traumas,and grieving is what social workers and fosterparents help them do to heal their losses andtrauma. Using loss as a lens by which to viewtrauma helps social workers, therapists andfoster parents to understand what needs tohappen next.The 3-5-7 Model © is a promising practicethat supports the work of children, youthand families in grieving their losses andrebuilding their relationships. The 3-5-7Model © is a strengths-based approach thatempowers children and youth to engagein activities that encourage expressions ofhurt related to losses and to give meaning tosignificant relationships towards developingpermanent connections. It supports deepertherapeutic work around the traumas ofabuse, abandonment and neglect experiencesthat is or may be provided by other clinicalprofessionals. As individuals begin to reconciletheir grief, they may more readily enter intodeeper, intensive therapies, if needed.The 3-5-7 Model © incorporates threetasks, five conceptual questions and seveninterpersonal skill elements to support thiswork. The three (3) tasks, clarification,integration and actualization, guide theactivities that support the work of grievingand relationship building. Losses will beclarified, relationships will be integrated, andpermanent connections will be actualized.Clarification means to identify and makesense out of the events of the one’s life, toprovide a factual base for understandingwhat is real and what is not real. Integrationis the process by which one develops theability to understand their connectionsand membership in numerous families.Actualization is the visualization ofpermanency, that is, the sense of feeling safeand of belonging, claiming an identity, andestablishing a place within family or otherpermanent relationship. Actualization is wellbeing.It is the ability of the child or youth tobegin to see a possible permanent future witha family, parent, or guardian as the tasks ofUsing loss as a lens by which to view trauma helps social workers,therapists and foster parents to understand what needs to happen next.clarification and integration are occurring andevolving.The five (5) conceptual questions, who amI, what happened to me, where am I going,how will I get there, and when will I know Ibelong, support the work of the three tasks.The seven (7) interpersonal abilitiesguide the efforts of professionals, counselorsand families as they support the grief work.These abilities are: engagement and listeningskills, recognizing the pain reflected inbehaviors, affirming and responding to thesebehaviors from a grief perspective, remainingpresent to these expressions of grief,creating opportunities for the perception ofsafety within the helping relationship, andrecognizing that grief work and relationshipbuilding can be done only by those who haveexperienced the loss.The 3-5-7 Model © provides tools, basedon theoretical foundations, to support thework of the child or youth. For example:Start the activity with the child byexplaining that you are going to play a specialkind of basketball, which will help them discusshappy and sad feelings. When the child throwsa ball through the hoop, they select a card froma “happy face” pile. When the child misses thehoop, they select a card from a “sad face” pile.They share their feelings, or not, at a pace thatis safe and comfortable for them (The 3-5-7Model © Workbook, p.16, 2012 Edition). Thisis a safe way for the child to identify and expressfeelings and typifies the task of clarification bysupporting them in telling the story of events thathave happened to them. Questions related toidentity and grieving are captured in this work.Through learning the techniques andtheories of the 3-5-7 Model © , workersand families become knowledgeable andcomfortable in exploring the hurts of thosethey parent and work with, learning patienceto support the expressions of their pain. Asa practice for relational work, the use of thismodel has shown that children and youthdo their work in grieving losses and are ableto move forward towards permanency inrelationships where they feel safe and secure.Darla L. Henry, PhD, MSW, MARS, isthe author of the 3-5-7 Model©, 3-5-7Model© LLC. She can be reached atdhenry@darlahenry.org.Amelia Franck Meyer, MS, MSW, APSW,LISW, is the CEO of Anu Family Services.She can be reached at afranckmeyer@anufs.org.Practice

28 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013Repacking the Invisible SuitcaseChaney Stokes As told to Johanna Zabawa, Research AssistantPerspectives“I believe that every young person should havea voice and I am striving to be that personwho gives them the strength they need to beempowered.” –Chaney Stokes.Chaney Stokes is currently the AssistantProgram Coordinator for SAYSO (StrongAble Youth Speaking Out), a non-profitorganization in North Carolina. Stokes hasbeen involved with SAYSO since enteringinto foster care at age fifteen. Since hertransition from foster care, Stokes has becomea dedicated advocate for change withinthe foster care system as well as an ally andsupport to those children and youth who havebeen through foster care placements. Below,Stokes discusses the “Invisible Suitcase,” aconcept that describes the thoughts and beliefschildren with a history of trauma may carrywith them about themselves, their caregivers,and the world at large (NCTSN.org).Tell us a little about yourselfMy name is Chaney Stokes and I amcurrently the Assistant Program Coordinatorfor SAYSO. After entering into foster care,I spent the majority of my teenage years inand out of placement. Being in foster carewas very difficult for me at first becauseI still had a lot of unanswered questionsabout my past. I could not understand whypeople were telling me “it’s not your fault,”but I had to be removed from my home, myfamily, and my friends.Tell us a little about your workwith resource parents in the fostercare system.Over the last several years, I have workedclosely with resource parents through stateand national collaboratives. I have alsobeen involved in the Resource ParentingCurriculum training (developed by the ChildWelfare Committee of NCTSN), where I ama Family-Partner co-trainer. My role as a cotraineris to support the curriculum materialusing my personal life experiences. A FamilyPartner co-trainer adds an authentic dynamicto the curriculum.You’ve mentioned the “invisiblesuitcase;” can you tell us moreabout that?In the Resource Parenting Curriculum, thereis a module which gives information about an“invisible suitcase.” The “invisible suitcase”is explained as being something that a youngperson who has experienced trauma will carrywith them. Many young people in fostercare will carry physical suitcases with themas they move from one place to another. The“invisible” suitcase is different because youcan’t see it which makes it harder to identify.How does the “invisible suitcase”affect children in foster placement?Besides the fact that a young person in fostercare has experienced trauma and may havebeen hurt by someone they love, they will alsocarry thoughts about themselves that may benegative. For most young people in foster careit is not their choice or their fault that theyhave to be removed from their home, family,and friends. With unanswered questionsabout his/her life, it becomes very easy tothink negative thoughts about yourself.What are some of the most importantthings that caregivers should knowabout the “invisible suitcase”?The best thing caregivers can know about the“invisible suitcase” is that it can be repackedwith positive thoughts. When a young personenters into care, it is best to know that he/shemay have thoughts about adults, themselves,and others that are probably negative. Thebest way to repack those thoughts is by sayingand doing the opposite of what they alreadybelieve. If a young person feels that all adultslie, a caregiver can show that young personthat not all adults lie by always telling thatyoung person the truth.What happens if thesuitcase is never addressed?If the “invisible suitcase” is never repacked, ayoung person can have a hard time coping,building new relationships, or even stayingconnected to past relationships. He or she canalso go into adulthood with negative thoughtsand possibly prevent successful achievementin their lives.How did learning about andidentifying the contents of your own“invisible suitcase” help you?The “invisible suitcase” is something I knowall too well. My “invisible suitcase” was filledwith things like “No one cares about me”, “It’smy fault”, “I’m not pretty”, “All adults willThe “invisible suitcase” is explained as being something that a youngperson who has experienced trauma will carry with them.do things for their own benefit”, “I can’t beloved”, “I will never have a family.” I wasn’tsharing this information, so no one knew howI truly felt about myself. Eventually, severaladults entered my life who took the effortto repack my “invisible suitcase.” I was ableto see that I am loved, that being in fostercare was not my fault, and, despite not beingconnected to my biological family, that I ama part of many different families and theyall love me as one of their own. Having abrand new “invisible suitcase” has helped mebecome the person I am today.For more information on “The InvisibleSuitcase” visit the National Child TraumaticStress Network at www.NCTSN.org.Chaney Stokes is Assistant ProgramCoordinator for SAYSO (Strong AbleYouth Speaking Out), in North Carolina.She can be reached at chaneyporter85@yahoo.com.

A Birth Parent’s Perspective: What Happened?Pamela TooheyAs a Parent Partner, in San Diego, I providepeer-to-peer support to parents involved withthe child welfare system and its communitypartners. I recently attended a Team DecisionMaking (TDM) meeting as support forToni*, a 20 year old mom just released fromjail with two children under the age of three.Child Welfare scheduled the TDM to findsafe and suitable out-of-home care for Toni’schildren. Four days prior, their hotel roomwas raided by police. Toni and a 17-yearold friend were prostituting from the hotelroom with two minor children present. Alsostaying in the room was Toni’s current malepartner, the father of her seven month olddaughter and a known drug dealer. Policefound proof of prostitution along with drugsand paraphernalia. The adults were taken intocustody and so were the children.Present at the TDM, besides agencyprofessionals, were ten family membersincluding aunts, uncles, and grandparents.All of the family members claimed tobe clean and/or sober ranging from sixmonths to seventeen years. All but two ofthe family members had previous childwelfare involvement, and most had criminalbackgrounds as well. Now solid members oftheir community, their pasts may still preventthem being considered for placement of thechildren.This family’s story is just one of manythat I have heard. The families might lookdifferent with different cultures and socioeconomicalbackgrounds. Their presentconditions may or may not include: substanceabuse, domestic violence, mental health issues;neglect, endangerment, physical or sexualabuse of their children; and homelessness,but each and every adult I‘ve worked withreported an average of 4-5 adverse childhoodexperiences such as neglect, physical or sexualabuse, incarcerated or substance/alcoholabusing parents (acestudy.org). Many claimedtheir parents survived adverse childhoodexperiences as well.What if we asked the parents, those adultswho proclaim parental love of their childrenin spite of the situation they find themselvesCW360 o Trauma-Informed Child Welfare Practice • Winter 2013 29in, “What happened in your life as a child?”What if instead of viewing the adults asaddicts, criminals, co-dependents, mentallychallenged, and bad parents, we looked atthem as adult children who have survivedadverse childhood experiences and viewedtheir co-occurring conditions and maladaptivebehaviors as symptoms of having survivedthese experiences? What if we explored a newkind of genogram to determine how manyfamily members and ancestors displayedor presented the same life conditions orsituations as the parent? What would we find?In 1997, I was arrested and taken intocustody, and my three year old son was placedin foster care. I was charged with being underthe influence of methamphetamine, intentto sell, and child neglect and endangerment.I had a long history of substance abuse,domestic violence, and criminal activity. Mylife was in utter chaos, and my son was therewith me.I, too, was raised in a chaotic,dysfunctional home. My father was analcoholic, who served in the Army and spentWhat if instead of viewing the adults as addicts, criminals,co-dependents, mentally challenged, and bad parents, we looked atthem as adult children who have survived adverse childhood experiencesand viewed their co-occurring conditions and maladaptive behaviors assymptoms of having survived these experiences?most of his time away from home. He leftmy sister and me in the care of my mentallyill mother. Both sets of grandparents werealcoholics. I was molested as a child; sowere both of my parents and both maternaland paternal grandmothers. My paternalgrandmother, great-grandmother, and mymaternal grandmother became involvedin prostitution. So did I. My paternalgrandparents, maternal grandparents andgreat-grandparents were all involved in someform of criminal activity. So was I. They allabused and neglected their children. So did I.When would it stop?When I was arrested, there wereprofessionals concerned about my son’sphysical safety and development. Theyordered psychological testing for my son; noone asked about me. My son went to fostercare and had physical, developmental andmental health assessments and therapy. I wentthrough all of the court ordered services:substance abuse treatment, probation,parenting classes, and in-home supportservices. I changed my life. I regained custodyof my son. Yet no one thought to ask how Iwas doing or if I needed any help.In 2000, I received the trauma-focusedtherapy and help that I needed and so didmy son. I didn’t know to ask for it, so Ididn’t go looking for it; it found me. Myson was molested by a neighborhood youthwho had been in our home many times. Ididn’t know the red flags or recognize thesigns of possible danger because no one hadintervened, assessed, or educated me on myown molestation. If I had, this could havebeen prevented.I believe that adverse childhoodexperiences and the maladaptive behaviorswe develop in order to survive areintergenerational. I have learned to take arisk, to reach out and help educate the familymembers I work with, to understand theeffects of trauma. I ask, “What happened toyou as a child?” I refer them to appropriateand immediate mental health and communityservices and offer my support for as long asit’s needed.It’s your turn to ask—not “What’s wrongwith you?” but “What happened to you?”*Name changed to protect privacy.Pamela Toohey is the Founder/CEO ofthe Birth Parent Association. She can bereached at www.birthparentassocation.com.Perspectives

30 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013PerspectivesNative Families Impacted by Historical Traumaand the Role of the Child Welfare WorkerMarilyn J. Bruguier Zimmerman, MSW and Patrick Shannon, BSWHistorical trauma is a theory first devised byYellow Horse Brave Heart as “the cumulativeemotional and psychological wounding overthe lifespan and across generations” (2003).The wounds include the loss of ancestralhomelands, religion, language and culture.Most devastating to tribes was the impactof federal assimilation policies that forciblyremoved tens of thousands of children fromtheir families to be warehoused in boardingschools. The boarding school experienceproduced generations of children strippedof their cultural and spiritual traditions. Nothaving these protective influences, manybegan to suffer from mental and substanceabuse disorders, impacting their ability toprovide their children with safe and nurturinghomes. For these parents, this is the entrypoint into the child welfare system.Child welfare in Indian Country is acomplicated amalgam of service providersand systems. The child welfare (CW) workermust understand historical trauma as well asthe unique laws and policies of tribal childwelfare practice. In 1978 Congress passed theIndian Child Welfare Act (ICWA) to “protectthe best interests of Indian children and topromote the stability and security of Indiantribes and families” (25 U.S.C. § 1902).Today, state CW workers are mandated toprovide active efforts in service delivery toenrollable Native children. The child’s tribehas the authority to presume legal jurisdictionand ensure every effort is made for kinshipplacement within the tribal community.As a CW worker, I routinely engage intraining and education about the ICWA.Unfortunately, there was a failure to connectthe ICWA’s purpose and the historicalcontext. The severity of maltreatment andcomplexity of issues which impact parents isonly increased by the fact that they are livingin tribal communities that experience theconsequences of generational and historicaltrauma.When I began to understand the impact ofhistory on my clients, I became more presentwith them, more inclined to be empathetic,and more understanding of the challengesto their well-being. The family historiestypically include drug use or unaddressedmental health issues, but I began to look atthe family in the context of their tribe. Whenmy clients begin to understand themselveswithin the framework of their tribal histories,they are able to identify the strengths of theirpeople and the strengths of their families andthemselves.In many of my cases involving Nativechildren, I began not only to address thesafety and permanency needs of the child, butalso to include tribal culture as a fundamentalneed of well-being. My treatment plans beganto include cultural activities like attendingThe CW worker must face many issues when working with tribal childrenand families experiencing historical trauma, but first we must appreciateand honor the resilience of Native families.powwows, connecting them to a tribal elder,and finding the spiritual teachers in theircommunities who provide opportunitiesfor the child and family to participate intheir tribal ceremonies (e.g. smudging,naming ceremonies or sweats). For most ofthe children I’ve served, these rich, culturalexperiences provide a reconnection with theiridentity, their family, and their tribe.I began to consult with tribal cultural andspiritual leaders, who were able to provideme with insight into the tribally specific waysof healing. The consultations allowed me todevelop treatment plans for the parents thatincluded their tribal ceremonies and culture,and the spiritual leaders became referralproviders for the parents. Reconnecting aparent to their culture as well as integratingculture into treatment has been moremeaningful for the parent, and, as a result, theparent is more engaged.Many family members serve in caregiverroles in the child’s life. This makes itnecessary to include the family members tobetter understanding of the child’s history,environment, and resources. One case comesto mind. I removed a six year old Native boyfrom the family home when both parents werearrested. I was unable to find the next of kin,yet I didn’t have to look long. Within thatsame week the child’s extended family reachedout. Through a family group conference, Iwas able to place the child in the care of hisfamily because his relatives came together sothat they each had a role in the care of thechild, but none was overwhelmed with theresponsibility. Not only did this return thechild to his family, but it empowered thefamily to advocate for their young relativesthroughout the remaining life of the case.The CW worker must face many issueswhen working with tribal children andfamilies experiencing historical trauma,but first we must appreciate and honor theresilience of Native families. It is imperativethat CW workers address historical traumain the family using child welfare best practiceand incorporate tribal kinship and culturalways to facilitate healing and lasting changeresulting in the safety, permanency and wellbeingof Native children and their families.Marilyn J. Bruguier Zimmerman,MSW, (Nakota/Dakota) is Director ofthe National Native Children’s TraumaCenter in the Institute for EducationalResearch and Service at the Universityof Montana, funded through theDepartment of Health and HumanServices, Administration for Childrenand Families, Children’s Bureau, Grant#90C01056. She can be reached atMarilyn.zimmerman@mso.umt.edu.Patrick Shannon, BSW, is Child WelfareSpecialist and a Citizen of the BandPotawatomi at the Native Children’sTrauma Center, Institute for EducationalResearch and Service at the Universityof Montana. He can be reached atPatrick.Shannon@mso.umt.edu.

CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 31Treating Child Traumatic Stress: Bearing Witness to HealingSara Younge PsyD, LPProviding evidenced-based practices,specifically Trauma-Focused CognitiveBehavioral Therapy (TF-CBT), to childrenwith symptoms of traumatic stress has beena primary focus of my clinical work for thepast five years. As all therapists who workwith children know, treating children requiresconsiderable collaboration with their manydifferent systems. As such, one of the mostimportant partnerships is that between thetherapist or mental health system and thechild welfare system.TF-CBT views the caregiver as theprimary agent of change. Part of what I enjoyabout providing TF-CBT to children is thatI get to witness significant improvement notonly within the child but also within thecontext of the parent/child relationship. As atherapist specializing in working with childrenwho have experienced trauma, people oftenask me how I can do this work and stayhealthy. The answer to the question is that Ican do this work because I get to bear witnessto the resilience of these children and theirfamilies. They heal. They get better. Theyreturn to the business of being kids ratherthan being overwhelmed or paralyzed by theirexperiences and symptoms.In the same way that the caregiver/childrelationship is central to healing, strongrelationships between mental health providersand child welfare workers are essential tothe treatment of child traumatic stress. Inmy experience, effective partnerships resultin children being referred by child welfareworkers for trauma-informed assessmentsconsistently and quickly. Trauma-informedassessments provide important information toparents, resource (foster) parents, child welfareworkers, as well as therapists about whetheror not children are experiencing significantsymptoms of traumatic stress and wouldbenefit from an evidenced -based practicesuch as TF-CBT. Another benefit to workingclosely with the child welfare system is that,over time, information is shared that bolstersthe child welfare worker’s ability to considertheir client’s complex needs through a “traumalens.” Additionally, once treatment hasbegun, the child welfare system is a therapist’smost effective and important connectionto the parents and resource parents whoare the primary caregivers for children withsymptoms of traumatic stress.A previous client of mine was placed outof the home after witnessing a horrifyingincident involving the child’s father. A childprotection worker, who I had worked withpreviously, immediately referred the childfor a trauma-informed assessment. Afterthe trauma assessment indicated significantsymptoms of traumatic stress, the childwas enrolled in TF-CBT. I met regularlywith the child’s foster parents to providethem information about trauma and theways in which they could best support thischild’s healing. Likely in part due to therelationship I had with the child welfareworker, I was allowed to meet regularlywith the child’s father to include him in thetreatment even though he did not have legalor physical custody. Throughout the courseof treatment, the young child’s symptomsdecreased significantly in large part due to thechild’s father and foster parents being activeparticipants in TF-CBT. Although this childdid not return to live with the father, childwelfare played an important role in healing byallowing the child’s father to participate.There are several ways that therapistscan create working relationships within thechild welfare system. One of the ways is toparticipate in child protection team meetings.Another place where therapists can offersupport and collaboration around issuesrelated to traumatic stress is to participate infamily planning or placement meetings.Child welfare workers sometimes ask mewhat they can do to best support the childrenand families they work with. Referring allchildren, even those under age five, who haveexperienced or been exposed to scary event(s)for a trauma -informed assessment by trainedtherapists is one of the most important thingsa child welfare worker can do. Additionally,there are excellent resources available to fosterparents and child welfare workers that provideIn the same way that the caregiver/child relationship is central tohealing, strong relationships between mental health providers and childwelfare workers are essential to the treatment of child traumatic stress.information and support related to childtraumatic stress. Those resources described inthis publication and can be found at: www.nctsn.org.Sara Younge, PsyD, LP is a licensedpsychologist at Counseling Servicesof Southern Minnesota. She can bereached at syounge1977@gmail.com.Perspectives

32 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013Training New Child Welfare WorkersRebecca Wilcox, MSW, LGSW and Kristi Petersen, MSWPerspectivesThe Minnesota Child Welfare TrainingSystem is committed to providing quality,evidence-based, and relevant training to newand experienced child protection workers inMinnesota’s 87 counties and 11 tribes. Partof our commitment includes ensuring thatworkers receive training and information oncurrent best practices that enhance safety,permanency and well-being for childrenand families. In August 2011, we had theopportunity to join the Ambit Network,an NCTSN Category III Community andTreatment Services Center, in Oklahoma Cityfor a two-day Trauma Training of Trainers(TOT). The TOT gave us a foundation fordefining child traumatic stress and methods tohelp child protection workers identify traumain children and families on their caseload.Further, the TOT provided practical strategiesthat workers could use to mitigate behaviorsoften associated with trauma in children.Perhaps the most beneficial aspect of theTOT was identification and conceptualizationof the Nine Essential Elements of Trauma-Informed Child Welfare Practice into ourtraining for new child welfare workers. Astrainers, we have taken these elements backto the classroom and presented them throughlecture and activities to child protectionworkers. Workers define the importance ofeach element and, subsequently, identifyways to implement the essential elementsin the field. For example, when workersarticulate that it is important to assist childrenin reducing overwhelming emotion, theysimultaneously engage in identifying potentialstrategies for children to ease emotionalresponses. Practice strategies for this essentialelement may include assuring that comfortitems are present, remembering ways thatthe fear response presents itself and usingappropriate de-escalation techniques, andnaming feelings. This activity helps workersrealize that they are already doing the work,and it allows opportunities for them to learnwhat others are doing around the state. Afterthe training, trainers compile the notes andsend them out to participants so they canretain the knowledge and refer back to it ifthey need additional ideas.We incorporated the DVD “HealingNeen,” which is the story of Tonier Cain, intoChild Welfare Foundation Training (CWFT).Ms. Cain’s story is referred to throughout allthree modules of the training. Her traumaresponses and subsequent journey of healinghelp us engage in critical conversationsabout parent responses to trauma and childwelfare interactions. When parents appear tobe resistant, workers can reframe resistancethrough a trauma lens and ask, “Whathappened to you?” This type of conversationcan provide key insights into parent behaviorsand open doors for possible solutions thatincrease child safety, permanency and wellbeing.CWFT trainers received a knowledgegift from a Leech Lake Band of Ojibwechild welfare worker when she taught us that“Neen” means “me” or “mine” in Ojibwe.The TOT also brought home a greaterappreciation of the need to address secondarytraumatic stress (STS) for workers duringtraining events. We dedicate time in eachtraining to engage in critical conversationsabout the impact of the work and the traumaexperiences of children and families onindividual workers. We spend time identifyingself-care techniques, and we incorporateself-care into each action plan to help workerstake time to value themselves.Knowledge of trauma is necessary forchild welfare workers because research iscontinuously demonstrating that childmaltreatment is an adverse experience forchildren, and we can help children andfamilies overcome the potential harm throughappropriate interventions. A trauma lenshelps workers be compassionate when askingquestions and seeking services. If we recognizethat trauma occurred for not only the childbut most likely for the alleged offender (theparent or caregiver), then we, as practitioners,can locate services that can provide newmeanings and positive replacementexperiences for the trauma.The TOT materials have changedour approach to training by helping usThe Trauma Training of Trainers gave us a foundation for defining childtraumatic stress and methods to help child protection workers identifytrauma in children and families on their caseload.incorporate understanding of traumathroughout the entire new worker trainingseries. We challenge workers to ask questionsaround trauma and to seek out additionalresources when necessary. We encourageworkers to always view children and familiesthrough trauma-informed lenses. Traumainformedpractice is a continuous strengthsbasedframework that, when incorporatedthroughout the life of the case, can helpchildren and families journey towards healingand increased competence.Rebecca Wilcox, MSW, LGSW and KristiPetersen, MSW are Social ServiceProgram Consultants at the MNDepartment of Human Services. Theycan be reached at Rebecca.wilcox@state.mn.us and Kristi.l.petersen@state.mn.us.

Recent studies show that as many as 702,000youth in care were identified as maltreatmentvictims (USDHHS, 2009) and that formany children in care there is a reciprocalrelationship found between behavior problemsand placement changes (Aarons et al., 2010).These studies suggest a need for more effectiveinterventions targeting children’s behavioralong with better training and support forresource parents (including foster, adoptive,therapeutic, and kinship) in order to managechildren’s emotional and behavioral problemsand to increase placement stability.The Child Welfare workgroup within TheNational Child Traumatic Stress Network(NCTSN; www.nctsn.org) developed andpiloted a new tool to help address the needfor training and support of resource parents.This tool is called Caring for Children WhoHave Experienced Trauma: A Workshopfor Resource Parents, also referred to as theResource Parent Curriculum (RPC). RPC wasdeveloped to help resource parents who maybe parenting children with complex traumahistories and equally complex behaviors andemotions.At the Center for Child and Family Health(CCFH), we began facilitating RPC as partof our proposal to SAMHSA for our NCTSNCommunity Treatment Services Center grant.Our main goals in selecting RPC were to:1. help resource parents understand howexposure to traumatic incidents as wellas placement disruptions can impactchildren’s emotions and behavior,2. provide concrete strategies for parents touse with children in their home,3. help parents try to depersonalize some oftheir child’s reactions to trauma reminders,and4. educate parents to advocate for theirchildren needing trauma-focusedtreatments. Our staff facilitators wereselected based on their extensive experiencein training other professionals toimplement evidence based treatments forchild trauma victims and their families.CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 33Lessons Learned from Implementing the ResourceParenting Curriculum with Foster and Adoptive ParentsGeorge S. Ake III, PhDWhile we understood the value of RPC andbelieved that it was well designed, I am notcertain that any of us really were preparedfor the magnitude of positive changes thatit would soon bring. Here are a few of thelessons we learned from resource parents,child welfare workers, and our trainingfaculty.Resource ParentsOverall, resource parents taught us that theirinvolvement in RPC helped them understandhow approaching problem behaviors witha trauma lens was more effective than theirprevious approaches. They commentedthat they wished they had participatedin RPC earlier and that resource parentsshould be required to complete this trainingas part of their in-service requirementsgiven the number of children in care withtrauma histories and the perceived lack ofinformation about how to address it. Whileparents came in with very different levelsof information and understanding abouttheir children’s history, most of them leftthe group having a greater appreciation forhow children’s experiences could impacttheir current behavior. In addition, parentsgenerally reported that participating in RPChelped to alleviate their feelings of isolationand frustration while helping to empowerthem to advocate for trauma-informedservices for their family.Parents reported seeing positive changesin their day-to-day approach to parenting andmany attributed this change to adjustmentsthey made to accommodate their children’strauma histories. For example, one couplewithdrew their child from water sportsdue to their new understanding of traumatriggers and their child’s history of havingprevious caregivers who used water as partof their abusive discipline. Another couplefelt like they had failed as parents of anadopted adolescent prior to RPC, but felt“enlightened” and more hopeful at the endof the group because they understood howtheir child’s complex trauma history mightbe connected to difficulties establishingrelationships with others. They also reportedthat meeting other parents with similarsituations was encouraging throughout thegroup and, hopefully, following the group.Child Welfare ProfessionalsThe North Carolina Division of SocialServices (DSS) has been a tremendous partnerin making RPC a possibility for resourceparents as part of a larger effort to make NC’schild welfare system more trauma-informed.Many of these groups were held in countyDSS offices, and the workers who werepresent for the groups commented that RPCmade a difference and that they benefittedfrom hearing how to talk with parents abouttrauma.Resource Parent Curriculum was developed to help resource parentswho may be parenting children with complex trauma histories andequally complex behaviors and emotions.Training FacultyAfter implementing this curriculum once inan eight-week group format with a traumainformedmental health clinician and a fosterparent or foster care alumni co-facilitator,we all were positive that this was the bestplatform to serve resource parents. Eachgroup we have done has been more successfulthan the last as we have incorporated qualityimprovement activities and built on lessonslearned. Currently, CCFH has a full timeRPC trainer and through various fundingsources plans on having completed a total of57 groups between 2011 and 2016.George S. Ake III, PhD is an AssistantProfessor in the Department ofPsychiatry and Behavioral Sciences atDuke University Medical Center and theAssistant Training Director at the Centerfor Child and Family Health in Durham,North Carolina. Dr. Ake can be reachedat george.ake@duke.edu.Perspectives

34 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013Using a Trauma-Informed Lens To Create A PerspectiveShift in Child Welfare Practice: One Organization’s JourneyAnn Leinfelder Grove, MSMPerspectivesSt. Aemilian-Lakeside (SAL) is a Milwaukee,Wisconsin based organization that hasintroduced trauma-informed care into childwelfare practice with positive results. Overthe past five years SAL has developed a modelfor trauma-informed philosophy and practiceacross its entire organization. Foster care,education, and mental health services are thecore business lines that annually serve 3,000+children, families, and adults throughoutSoutheastern Wisconsin. Since 2009 SALhas had the contract to provide ongoing casemanagement and intensive in-home servicesfor the Bureau of Milwaukee Child Welfare.This contract gave SAL the opportunity toinfuse its emerging success with traumainformedcare into child welfare practice.SAL’s transformation to a traumainformedperspective originated in 2007 witha goal to reduce the use of physical restraintand decrease critical incidents, but the visionquickly expanded to become an agency-wideparadigm shift that continues to evolve today.Via staff training, a focus on organizationalculture and changes in treatment deliverymomentum grew. A major milestone wasthat the agency’s clinical staff completedcertification in the use of the NeurosequentialModel of Therapeutics, an assessmentapproach developed by Dr. Bruce Perry andthe Child Trauma Academy.SAL’s journey was representative of thefact that while attention to the concepts oftrauma-informed care has grown immenselyChild welfare staff are encouraged to ask themselves for every childthey encounter “Does trauma have a part in this child’s presentation?”Starting with this question will likely help the entire team reach the rightconclusions regarding needed interventions, which can provide relief toboth the child and the entire team.in traditional “clinical” circles (outpatienttherapy, residential care systems, etc.), it isstill catching fire in core child welfare arena.SAL’s initiative was developed and nurturedin our residential, treatment foster care andday treatment programs and was introducedwithin our child welfare subsidiary two yearslater. It was in that introduction, however,that the larger system of care (Child ProtectiveServices staff working with foster parents,outpatient clinicians, etc.) truly began totransform and produce the kinds of outcomesthat the initiative is capable of delivering.This article summarizes some key learningour agency has experienced in its infusion oftrauma-informed care into core child welfarepractice.Key learning #1 reinforces a core systemicvalue that all parts of the system need to havea shared understanding for the entire systemto function effectively. Systems of care thatpersist in the belief that the entire system canbecome trauma-informed without includinga key component of that system run the riskof poor outcomes. Conversely, when all thekey stakeholders in a child and family’s lifeare trauma-informed, remarkable outcomesare possible. We have experienced numerousexamples of our child welfare staff, fosterparents, clinicians and other stakeholdersbeing on the same page regarding traumainformedpractice, producing inspiring stories.One example is Jenni’s story. Jenni is a16 year old girl served by SAL’s child welfareprogram, whose life was turned around by thecollaborative, trauma-informed efforts of hercaregiver aunt and other family members, herchild welfare case manager, and the therapistand staff at the residential facility where shewas placed due to suicidal behaviors. Theentire team understood the importance ofthe trauma-informed lens that asks “what hashappened to you “ rather than “what is wrongwith you.” and they worked together toacknowledge Jenni’s significant trauma historyof sexual abuse and to introduce interventionsthat helped guide her treatment, includingsensory activities that helped her regulate heremotions and behavior. One year later, Jenninow lives with her aunt and reports that sheis “just a normal teenager,” quite a remarkableexpression of healing.Key Learning #2 centers on a recognitionthat effective practice involves a combinationof trauma treatments by trained cliniciansand the actions of trauma-informed caregivers(parents, foster parents, service providersetc,). Historically, outpatient therapists wereviewed in the child welfare system as a keydriver in the process. Things got off trackwhen the outpatient therapist and broaderteam believed that the change process tookplace only in the weekly therapy session(s).Key neurobiological learnings regarding howthe learning and change process happensuggest that the outpatient process as thelocus of change is an incomplete model formany kids who have experienced significanttrauma. A child with significant dysregulationissues generally won’t learn how to regulatethe stress response process through conceptualtechniques taught in weekly session(s) but can

and will learn regulation in the daily processof care and coaching from their parents orfoster parents. By accepting this wisdom,outpatient therapists can play a key rolein teaching, supporting and nurturing thetargeted process between children and theircaregivers as a means of maximizing success.Much more powerful outcomes are achievedwhen the parent/foster parent—child dailylife process becomes the locus of change.Key learning #3 reflects an appreciationfor the significant prevalence of childhoodtrauma and how that understanding isapplied. The general conclusion from childwelfare staff is that nearly all children inthe child welfare system have at least beenexposed to trauma, often resulting in otherdifficulties. The application of this concept iswhere child welfare systems can see significantgain. Understanding how adjustment totrauma impacts children’s behaviors is oftenthe best and, arguably, first path to explore.CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 35Child welfare staff are encouraged to askthemselves for every child they encounter“Does trauma have a part in this child’spresentation?” Starting with this questionwill likely help the entire team reach the rightconclusions regarding needed interventions,which can provide relief to both the child andthe entire team.Key learning #4 is arguably themost significant. It is the notion that allstakeholders providing care are constantlyensuring that they approach the work andclients they serve from a place of optimalhealth and well-being. This is especiallysignificant in child welfare circles where thecontext of practice is extremely challenging.One only has to experience the process oftaking a child away from a screaming parentor to support a child through a medical examchecking for abuse to have those experiencesindelibly etched into memory. In light ofthese challenges, there are some resourcefriendly interventions that agencies can useto help (i.e. effective supervision, groupor individual de-briefings, spontaneousteam lunch events that encourage peerconnections).The need to better understand the impactof trauma on the children and families weserve is likely only going to increase overthe coming years. While the scope andsignificance of the challenge can be daunting,there is always hope that well-informed andcoordinated systems of care can rise to meetthe challenge. We are trying to do just that atSt. Aemilian-Lakeside (http://www.st-al.org/)in Milwaukee.Ann Leinfelder Grove, MSM is VicePresident of Strategy and Innovation St.Aemilian-Lakeside, Inc. in Milwaukee,Wisconsin. She can be reached ataleinfelder@st-al.org.PerspectivesAmbit Network provides insights for therapists and frontline mental healthworkers who serve children impacted by trauma. The research and knowledgeof Ambit Network is actively refined by closely monitored field work.Ambit Network benefits organizations through training,technical assistance and case consultation.Navigating research and practice in child trauma efficiently is vital;Ambit Network champions development of a new standard of care,particularly evidence-based practices.Learn the latest at www.ambitnetwork.orgor sign up for news by visiting the Contact Us pageon our website!

36 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013PerspectivesBreaking Down Barriers Across Systems:Implementing a Trauma PerspectiveBeth Barto, LMHCOver the past decade, our understanding oftrauma has evolved from a focus on adultpost-traumatic stress disorder to an emergingunderstanding of child traumatic stress,complex trauma, and developmental traumadisorders. In the past, the focus was often ontreating maladaptive behaviors rather thanunderstanding their underlying causes. Myexperience in mental health, as a practitioner,supervisor and administrator in non-profitmental health agencies, has allowed me tointerface with both the mental health providerand child welfare systems. I have witnessedthe effects of trauma on children and thesystems that strive to help them. There aretimes when these systems, although workingtoward the same goal, feel like adversariesrather than partners, casting blame andabdicating responsibility. Acknowledgingthat these systems exhibit symptoms muchlike that of a traumatized child is necessaryto realize a true collaboration. This was thesituation prior to a small step of change thathappened in Massachusetts.Massachusetts was one of the teamsselected to participate in the National ChildTraumatic Stress Network’s (NCTSN)Breakthrough Series Collaboration (BSC),“Using Trauma-Informed Child WelfarePractice to Improve Foster Care Stability”in 2010. Our team included a seniorDepartment of Children and Families (DCF)administrator, DCF area office manager anddirect service provider, LUK Inc. (mentalhealth agency) leadership and clinicians, abirth parent, youth, and foster parent, aswell as a community system partner. Wefocused on knowledge building, traumainformedassessment, and trauma-informedcase work practice. The consumers on ourteam kept us honest by candidly rating howtrauma-informed our system was at baselineand follow-up. This construct allowed usto identify needs and test solutions withoutthe usual bureaucratic constraints; thus,we created a model that was flexible andfunctional.The BSC team educated all child welfarestaff on the effects of childhood trauma,followed by advanced trauma training forall managers and supervisors in one DCFarea office. Child welfare developed capacityto provide trauma-informed curricula and,with the trauma administrator, providedthis training for another area office.Simultaneously, resource parents were trainedin an NCTSN trauma-informed resourceparent curriculum. This included a paneldiscussion by the BSC team consumers onthe importance of maintaining connectionsfor children in placement. The conceptsof this curriculum were integrated into thetraining for all new foster parents. A localpediatrician included a trauma screen intothe medical report of children in placementwith DCF. Placement reviews began, allowingDCF leadership, social workers, foster parentsand biological parents to discuss the goals ofreunification and the well-being of the child.The meetings provided a forum to discussany questions the resource and biologicalfamilies had related to the child’s adjustment.Information on the child was shared by bothcaregivers to begin a co-parenting foundationwith the hope of improved reunificationplans.For its part, the mental health systemacknowledged the need to improvecommunication. Clinicians began sharingtrauma assessments with consumers andchild welfare workers. LUK’s trauma centerreported a decrease of externalizing andinternalizing behaviors in children receivingevidence-based trauma treatment (Figure 1).One participant stated, “I have taken severalkids to therapy and this is my first experiencewith the trauma model. I never want to goback to any other style with teens in care.Truly this approach is the best I have everexperienced. ‘My child’ has made strides thatI don’t think would have been possible with atraditional approach.” The child in this casesaid, “I like therapy. It is interesting. I get totell my story and really think about it. I getFigure 1Estimated Marginal Means68676665646362CBCL:Total BehaviorProblems(n=45; p=.004)to think about what is my fault and whatisn’t. It’s like a healthy place to escape. I getto see how I could handle certain situationsdifferently…I like to tell my story becausesometimes rumors were said about me and Iwant to tell my story to someone who mightactually listen or care.”The main lesson learned was that byidentifying successes and sharing strengthsboth systems could identify and disseminateexisting trauma-informed practices. In sodoing, we did not create more work, butrather we redirected efforts toward moreeffective practices.The BSC team’s enthusiasm compelledleadership in both child welfare andmental health to apply for federal fundsto scale up trauma-informed practices inMassachusetts. The proposal was funded inSeptember 2011 through the passion andhard work of the BSC team as well as thefoundation for excellence in the treatmentof childhood trauma provided by NCTSNsites in Massachusetts. The hope is that thepartnership between mental health, childwelfare and consumers will be replicatedacross the state thus improving well-being,permanency and feelings of safety for childreninterfacing with child welfare.Beth Barto, LMHC, is the Director ofQuality Assurance and Project Directorfor the Central Massachusetts ChildTrauma Center, LUK, Inc. She can bereached at bbarto@luk.org.Baseline 3 Months 6 MonthsTimeCMCTC data set 2010-2012

CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 37The Heart of the Matter:Complex Trauma in Child WelfareContinued from page 9those being served.Two complex trauma intervention modelsbear special mention given their widespreaddissemination with ethnoculturallydiverse child welfare populations served inoutpatient, residential, specialized foster careand scholastic settings. The Attachment,Self-Regulation and Competency (ARC)model provides a comprehensive, systembasedapproach to treating complexlytraumatized children aged 3-21 (Blausteinand Kinniburgh, 2010; Kinniburgh et al.,2005). Particularly notable among publishedoutcome evaluations on the ARC modelis the finding that children involved in theAlaskan child welfare system who successfullycompleted ARC treatment exhibitedplacement stability rates over twice that ofthe state average only one year after startingtreatment. Structured Psychotherapy forAdolescents Responding to Chronic Stress(SPARCS) is a well-supported, 16-session,manualized, group-based interventionfor complex trauma that has been usedextensively with high-risk youth populations(DeRosa and Pelcovitz, 2008). A projectwith youth served by the Illinois childwelfare system found that adolescents infoster care who received SPARCS were halfas likely to run away and one-fourth lesslikely to experience placement interruptions(e.g. arrests, hospitalizations) compared toa standard of care group (Mental HealthServices & Policy Program, 2008).The child welfare system can advanceeffective intervention for complexlytraumatized children by facilitatingappropriate referrals to empirically supportedinterventions designed to treat the wholechild. This begins with education of childwelfare personnel on the overarchingtreatment needs of complexly traumatizedchildren and the specific evidence-basedtreatment models designed to target theseclinical objectives and is followed by supportof initiatives to establish and sustain localand regional service hubs trained to providecomplex trauma treatment for child welfarereferredclients.ConclusionConsideration of childhood trauma froma complex trauma framework invites asubtle but pivotal paradigm shift: from thetraditional premise that “traumatic stress”derives from exposure to one or more eventsthat lead to specific manifestations of distresswhich in turn compromise certain aspects ofa child’s otherwise normative functioning,to the recognition that under certaincircumstances the fundamental elements ofa child’s daily life can be characterized byviolations so egregious or deficits so severethat these become primary determiningfactors shaping a child’s foundationalcapacities and overall development.Cumulative exposure to trauma exponentiallyincreases the likelihood of revictimization. Inturn, maladaptive coping strategies developedin effort to survive experiences overwhelmingto the child—including running away, selfharm,aggression or substance abuse—canevolve into direct or vicarious traumaticexperiences in and of themselves for thechild, their caregiving system, and secondaryvictims. These patterns of trauma exposure,coping deficits, illness, and retraumatizationform the building blocks of intergenerationaltrauma. As prevention, detection and responseto precisely these deleterious childhoodadversities is, for better or worse, its uniquepurview, the child welfare system seeking tobecome truly trauma-informed cannot affordto overlook complex trauma. After all, it hasalways been the heart of the matter.Joseph Spinazzola, PhD is ExecutiveDirector of The Trauma Center atJustice Resource Institute. He can bereached at jspinazzola@jri.org.Mandy Habib, PsyD, is AssistantProfessor of Psychology, Hofstra NorthShore-LIJ School of Medicine.Angel Knoverek, PhD, LCPC is Director,Chaddock Trauma Initiative of WestCentral Illinois.Joshua Arvidson, MSS, LCSW, isDirector of the Alaska Child TraumaCenter, Anchorage Community MentalHealth Services and Director of thePacific Northwest Regional TrainingCenter, CTTN.Jan Nisenbaum, MSW, is DeputyCommissioner MassachusettsDepartment of Children and Families.Robert Wentworth, MSW, is AssistantCommissioner MassachusettsDepartment of Children and Families.Hilary Hodgdon, PhD, is TraumaProgramming Director at The van derKolk Center, Glenhaven Academy andAssistant Director of The Trauma Centerat Justice Resource Institute.Andrew Pond, LICSW, is President,Justice Resource Institute.Cassandra Kisiel, PhD is ResearchAssistant Professor at NorthwesternUniversity Feinberg School of Medicine.Operationalizing Trauma-Informed ChildWelfare Practice using the Child WelfareTrauma Training ToolkitContinued from page 18surveyed expert trainers on the CWTTT. Themajority of trainers responded that all trainingmodules were clear, easy to use, containedall relevant content for the child welfareworkforce, and had the correct time allotmentnecessary to cover the material. Trainerfeedback was both positive and constructivewith recommendations for revision andimprovement.CTISP is leading a sub-committee of theNCTSN to revise the CWTTT incorporatingfeedback from trainers and other professionalsin the field of child welfare. The revisionswill incorporate recent research about traumaand its treatment as well as principles ofadult learning and implementation science.These revisions include: streamlining andreorganizing the Essential Elements andstructure of the CWTTT to facilitate trainingand integration; enhancing content related totopic areas including trauma among youngchildren, the impact of trauma on braindevelopment, trauma and culture, birthparent trauma, and secondary traumatic stressin the child welfare workforce; and providingguidance and support on training delivery andimplementation. It is hoped that the revisions,which will be complete in the fall of 2012,will improve the quality of the CWTTTand its usefulness as a resource for educatingchild welfare professionals about trauma andfor teaching them how to intervene to moreeffectively help children and families healfrom traumatic experiences.Alison Hendricks, LCSW is OperationsManager for the Chadwick Trauma-Informed Systems Project at ChadwickCenter for Children and Families, RadyChildren’s Hospital, San Diego. She canbe reached at ahendricks@rchsd.org.Continued

38 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013Giving a Trauma Lens to Resource ParentsContinued from page 19Invisible Suitcase.” This exercise invites parentsto examine what unseen beliefs and valueschildren bring into their homes, includingbeliefs about self, caregivers, and the world.Caring for Children Who HaveExperienced Trauma was designed to meeta need within the child welfare communityfor a trauma-informed, application-focusedtraining for resource parents. It is not,however, designed to stand alone. Thiscurriculum is one piece of a broader effort tobuild a more trauma-informed child welfaresystem. The NCTSN also has a curriculumdesigned for child welfare staff, the ChildWelfare Trauma Training Toolkit (CWTTT),as well as a set of “Essential Elements of aTrauma-Informed Child Welfare System.”When all parties within the child welfaresystem use the trauma lens, we will, together,be more effective in our efforts to promotesafety, permanency, and well-being in the livesof children who have experienced trauma.“When I started foster parenting 14 yearsago, I thought that a lot of love and cuddleswas all the children needed. How I wish Iwould’ve had this in my tool chest at thattime. But having it today, it only enhances theparenting skills that I had before.” -Donna,Foster and adoptive parentLiz Sharda, LMSW is ProgramCoordinator for Project Return Homeat Bethany Christian Services in GrandRapids, MI. She can be reached atesharda@bethany.orgTrauma-Informed PMTO: An Adaptation ofthe Oregon Model of Parent ManagementTrainingContinued from page 24is to serve and advocate for these familiesmust receive support and training in EBPs,which have been demonstrated to work.When programs are successful, families,clinicians and communities all reap thebenefits.“Children are not something you areentitled to but a gift. And in order to givethem the best chance in life we as parents haveto be able to talk to them and understandthem. They are just like us, but in a smallerbody – little people, with feelings, opinions,bad days and even days when they don’tknow what they feel… I feel that every youngparent should experience this class.”– Father who completed parent group forreunification in DetroitLaura A. Rains, MSW, LCSW is Directorof Implementation and Training atImplementation Sciences International,Inc. She and Marion Forgatch can bereached at laurar@oslc.org.Marion S. Forgatch, PhD is ExecutiveDirector and Senior Scientist Emerita ofImplementation Sciences International,Inc.Cultural Adaptations of Trauma Treatmentsin Indian CountryContinued from page 25DR services often include referral to culturalhealers for those families who are traditional,as well as more western religious serviceproviders.Our goal at the National Native Children’sTrauma Center is to support and serveNative communities. As we continue to doso by utilizing the integration of traditionalcultural activities in evidence based traumatreatments, we find the fusion greatly benefitsNative peoples’ lives and the communitiesthey impact while increasing access to mentalhealth services in Native communities.Wynette Whitegoat, AB, served asResearch Intern with the National NativeChildren’s Trauma Center, Universityof Montana. She can be reached atwynettewhitegoat@gmail.com.Richard van den Pohl, PhD is aProfessor and Director at the Institutefor Educational Research and Serviceand the Principle Investigator at theNational Native Children’s TraumaCenter, University of Montana, fundedthrough the Department of Healthand Human Services, Administrationfor Children and Families, Children’sBureau, Grant #90C01056. He can bereached at VanDenPol@mso.umt.eduIntegrated BibliographyContinuedAarons, G. A., Fettes, D. L., Sommerfeld,D. H., & Palinkas, L. A. (2012). Mixedmethods for implementation research.Child Maltreatment, 17(1), 67-79.Aarons, GA, James S, Monn AR, Raghavan R.(2010). Behavior problems and placementchange in a national child welfare sample:A prospective study. Journal of the AmericanAcademy of Child and Adolescent Psychiatry,49, 70-80.Ackerman, P., Newton, J., McPherson,B. Jones, J., & Dykman, R. 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42 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013Weiner, DA, Schneider, A, & Lyons, JS(2009). Evidence-based treatments fortrauma among culturally diverse foster careyouth: Treatment retention and outcomes.Children and Youth Services Review, 31.1199-1205.Weiss, J. A., MacMullin, J., Waechter, R., &Wekerle, C. (2011). Child maltreatment,adolescent attachment style, and datingviolence: Considerations in youths withborderline-to-mild intellectual disability.International Journal of Mental Health &Addiction, 9, 555-576.Wekerle, C. & Wolfe, D. A. (1998). Windowsfor preventing child and partner abuse:Early childhood and adolescence. InTrickett, P. K. & Schellenbach, C. J. (Eds).Violence against children in the family andthe community (pp. 339-369). Washington,DC, US: American PsychologicalAssociation; US.Widom, C. S. (1989). Child abuse, neglect,and adult behavior: Research design andfindings on criminality, violence, and childabuse. American Journal of Orthopsychiatry,59(3), 355-367.Widom, C. S., Czaja, S. J., & Dutton, M.A. (2008). Childhood victimization andlifetime revictimization. Child Abuse &Neglect, 32(8), 785-796.Wiebush, R., Freitag, R., & Baird, C. (2001).Preventing delinquency through improvedchild protection services. OJJDP JuvenileJustice Bulletin. Washington, D.C: U.S.Department of Justice, Office of JuvenileJustice and Delinquency Prevention.Yellow Horse Brave Heart, M. (2003).Historical trauma response among Nativesand its relationship with substance abuse: ALakota illustration. Journal of PsychoactiveDrugs, 35, 7-13.Agency Discussion GuideIn order to assist busy supervisors and managers in thinking through how they might engage others around theinformation presented in this edition on trauma-informed practice, we offer several discussion questions to getthe conversation started:Between Supervisor/Workers1. What are some practice implications for child welfare workers working with very young children who have experiencedtrauma? How might early exposure to trauma impact a child (and his/her family) throughout his/her development?How can workers prepare families for the re-emergence of trauma responses throughout the developmental lifespan?See Pinna & Gewirtz, and McAlister Groves.2. How might trauma be experienced differently among children and families, based upon their diverse backgrounds(e.g. race, culture, socioeconomic status, education)? See Whitegoat & van den Pohl, and Zimmerman & Shannon.3. The “Best Practices” section highlights some trauma-informed practice interventions. Which, if any, of theseinterventions seem applicable to our work? Do you think any should be implemented in our agency? What steps canyou personally take?References4. Several of the articles in this issue focus on parents and their experience of trauma? How can we help parents andresource parents address their own trauma, as well as adopting a trauma-informed perspective in their parenting?See Tullberg, Sharda, Rains & Forgatch, Toohey, and Ake.Between Manager/Supervisor5. What does it mean to be a trauma-informed system or organization? What is agency already doing that is traumainformed?What could we be doing that would move our agency closer to become trauma-informed in all aspects ofour work? What resources would be needed to implement those changes? See Wilson, Leinfelder Grove, and Barto.6. How can we make sure our workers are well-trained on trauma-informed practice strategies? See Wilson, Hendricks,and Wilcox & Petersen.7. In thinking about the workers within your unit, as well as the agency as a whole, which interventions described in the“Best Practices” section seem to be interventions that could work here?

CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 43You may be wonderingwhy you’ve receivedCW360 oWe mail each issue to our regularsubscribers plus others whom we thinkmight be interested. If you’d like to receiveevery issue of CW360 o at no charge, call612-624-4231 or email us at cascw@umn.edu give us your name, address, email andphone number, and let us know whetheryou’d like a print copy or e-mail version.CW360 o is also published on the Web athttp://cehd.umn.edu/ssw/cascw.About CW360 oChild Welfare 360 o (CW360 o ) is anannual publication that providescommunities, child welfareprofessionals, and other humanservice professionals comprehensiveinformation on the latest research,policies and prac tices in a key areaaffecting child well-being today. Thepublication uses a multidisciplinaryapproach for its robust examinationof an important issue in child welfarepractice and invites articles fromkey stakeholders, including families,caregivers, service providers, a broadarray of child welfare professionals(including educators, legalprofessionals, medical professionalsand others), and researchers. Socialissues are not one dimensional andcannot be addressed from a singlevantage point. We hope that readingCW360 o enhances the delivery ofchild welfare services across thecountry while working towards safety,permanency and well-being for allchildren and families being served.What can you do in 90 seconds?Write a case note? Probably not.Answer an email? Possibly.Contribute to the national dialogue on child welfare practice and policy? Definitely.The Child Welfare Video WallAdd your video. Add your voice. Transform the dialogue.http://z.umn.edu/videowallCenter for Advanced Studiesin Child Welfare

CASCWSchool of Social WorkUniversity of Minnesota205 Peters Hall1404 Gortner AvenueSaint Paul, MN 55108Non-Profit OrgUS PostagePAIDTwin Cities, MNPermit No. 90155Download previousissues of CW360 0 athttp://z.umn.edu/cw360In This Issue of CW360 0• An overview of traumatic stress, includingcomplex trauma, and its impact onsystems, policies, and parents and childrenthroughout the developmental cycle fromearly childhood to adolescence• A discussion of the latest tools for traumascreening• The importance of addressing earlychildhood trauma in the context of the childwelfare system• Specific trauma-informed interventionstrategies that can be implemented by childwelfare practitioners• A discussion of cultural adaptations oftrauma interventions• The impact of trauma on homeless youthemerging from the child welfare systemand specific strategies for use with thispopulation• Personal accounts of the impact of traumaon youth in foster care, birth parents andresource parents• Using a trauma-informed lens to create aperspective shift in child welfare practiceCW360 0a comprehensive look at aprevalent child welfare issueFeature Issue: Trauma-Informed Child WelfarePractice, Winter 2013Executive Editor : Traci LaLiberteManaging Editor : Tracy CrudoGuest Co-Editors : Chris Bray andAbigail GewirtzDesign : Heidi WagnerLayout : Karen SheahanAcknowledgements: The following peoplehave been instrumental to the creation of thispublication: Scotty Daniels and Heidi Ombisa.CW360° is published annually by the Center for AdvancedStudies in Child Welfare (CASCW), School of Social Work,College of Education and Human Development, Universityof Minnesota. This issue was supported, in part, by grant#GRK%29646 from Minnesota Department of HumanService, Children and Family Services Division. This issuewas also produced in partnership with Ambit Network,Department of Family Social Science, College of Educationand Human Development, University of Minnesota.The opinions expressed are those of the authors and do notnecessarily reflect the views of the Center, School, College,University or their funding source.The University of Minnesota is an equal opportunity educatorand employer. This document is available in alternate formatsupon request.