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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
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