THRIVE, Maine`s Trauma-informed System of Care

Transcription

THRIVE
Maine’s Trauma-informed System of Care
FINAL EVALUATION REPORT
2012
Produced for
Maine Department of Health and Human Services
by
Hornby Zeller Associates, Inc.
with support from the
Substance Abuse and Mental Health Services Administration
THRIVE
Maine’s Trauma-informed System of Care
FINAL EVALUATION REPORT
Prepared by
373 Broadway
South Portland, ME 04106
(207) 773-9529
www.hornbyzeller.com
EXPRESSIONS OF GRATITUDE
The authors gratefully acknowledge the many individuals and organizations who
supported the THRIVE Evaluation.
First and foremost, we thank the Center for Mental Health Services (CMHS) and the
Substance Abuse and Mental Health Services Administration (SAMHSA) for their ongoing
support for systems of care and the trauma-informed approach.
The State of Maine Department of Health and Human Services, Children’s Behavioral Health
Services and particularly, Joan Smyrski, M.S., Director of Children’s Behavioral Health
Services and Principal Investigator for THRIVE, was a true trauma champion whose
support and dedication were critical to the success of the evaluation and assessment
efforts. Douglas Patrick, J.D., L.C.S.W., Manager of Maine’s Children's Behavioral Health
System, strongly promoted statewide implementation of the agency assessment and the
continuous quality improvement cycle for all child-serving agencies in Maine. Both these
state-level trauma champions provided more support that can be articulated here.
We thank the THRIVE Initiative both for supporting the evaluation over the years and
wanting to learn from it. Chris Copeland, L.C.S.W., Executive Director of the lead agency,
Tri-County Mental Health, played an active role both in attending the evaluation committee
and in using the information about his agency’s practices to the better of children and
families. Arabella Perez, L.C.S.W., Executive Director of THRIVE, provided consistent
grounding in trauma-informed theory and cultural and linguistic competence. Brianne
Masselli, THRIVE’s Youth Coordinator, ensured that youth voice was always present in
creating protocols or presenting findings; she was instrumental in bringing the evaluation
to THRIVE’s youth. Alice Preble and Cindy Seekins oversaw THRIVE’s Family Support
Partners and faithfully shared intake and enrollment information with the evaluation,
while THRIVE’s Family Support Partners Michelle LaPointe, Michelle Hill and Kristi Whiting
served as the first point of engagement for families. Melanie Swift, THRIVE’s Technical
Assistance Coordinator, Judith Day, THRIVE’s Clinical Coordinator for trauma-informed
trainings and evidence based treatment collaboratives, and Lisa Preney, THRIVE’s Social
Marketing Coordinator, all contributed time and expertise at various points.
Carol Tiernan, Program Director of G.E.A.R. Parent Network, faithfully co-chaired the
Evaluation Committee, seeking clarification and providing guidance to give voice to the
families she represents. G.E.A.R. eventually took responsibility for the management of
THRIVE’s family support program and took an active role in promoting ways to sustain
family support partnering in Maine.
We would also like to thank the many individuals who convened as members of the
Evaluation Committee and the Trauma-informed Agency Assessment workgroup not
mentioned elsewhere. These individuals dedicated time and energy to reviewing and
interpreting documents, providing feedback and valuable insights over the life of the
project. Virginia Jewell, MA and Family Member and Sharon Carter, Family Member
patiently and politely endured lengthy discussions about research methodology in order to
ensure that the evaluation process was family-driven. THRIVE’s youth committee led by
Brianne Masselli provided feedback to the national and local evaluation and ensured that
the process was youth guided. Mark Rains, Ph.D. brought a clinical perspective, providing
thoughtful considerations regarding the interpretation of results as well as how to
meaningfully present information. Both Chris Copeland, referenced above, and Bart Beattie,
L.C.S.W., State Executive Director of Providence Service Corps, graciously volunteered their
agencies to pilot test the assessment tool.
At Hornby Zeller Associates, we would like to thank our Family Evaluators, Kara Thurlow
and Claire Nacinovich, who spent hours learning a complex evaluation protocol, speaking
with families and recording information. Their ongoing perseverance made all the
difference. We also want to thank Lynn Kaier, Ph.D. and Jennifer Battis, M.Res., for their
assistance with analyzing claims data as well as on-going data monitoring.
Finally, we wish to thank all the children, youth and families who participated in the
evaluation. By sharing their stories, they have played a significant role in our efforts to
understand the needs of children and youth receiving mental health services. It is our
profound hope that their contributions will help to modify the existing services into a
seamless system of trauma-informed care that supports youth and family empowerment.
James Yoe, Ph.D.
Lead Investigator
Director of the Office of Quality Improvement
Maine Department of Health and Human Services
Sarah Krichels Goan, M.P.P.
Helaine Hornby, M.A.
The final evaluation report for Maine’s Trauma-informed System of Care is submitted
pursuant to Grant No. 6U79 SM57045 under the direction of the Child, Adolescent and Family
Branch, Center for Mental Health Services, Substance Abuse and Mental Health Services
Administration, United States Department of Health and Human Services.
TABLE OF CONTENTS
Executive Summary............................................................................................................................................... i
Chapter 1 – Background and Purpose ........................................................................................................... i
Why Trauma Matters ...................................................................................................................................... 1
Maine’s Trauma-informed System of Care and the Trauma-informed Approach .................. 1
Purpose of this Report.................................................................................................................................... 4
Chapter 2 – Prevalence of Trauma Exposure and Effects on Families and Youth ....................... 5
Methodology ...................................................................................................................................................... 5
Local Evaluation Instruments................................................................................................................. 5
Data Collection.............................................................................................................................................. 6
Study Participation ..................................................................................................................................... 7
Analysis ........................................................................................................................................................... 7
Findings................................................................................................................................................................ 9
Participant Demographics ....................................................................................................................... 9
Prevalence of Trauma ............................................................................................................................. 10
Effects of Trauma on Youth and Families ....................................................................................... 12
Effectiveness of the Trauma-informed Approach to Service Delivery ................................ 17
Summary Conclusions ................................................................................................................................. 19
Chapter 3 – Service Utilization and Cost Outcomes.............................................................................. 21
Methodology ................................................................................................................................................... 21
Participants...................................................................................................................................................... 22
Findings............................................................................................................................................................. 23
Service Use Patterns ................................................................................................................................ 23
Cost Effectiveness of Services .............................................................................................................. 26
Observed Differences Among Groups of Interest ........................................................................ 27
Chapter 4 – Effectiveness of Trauma-Specific Treatment .................................................................. 30
Methodology ................................................................................................................................................... 31
Participants...................................................................................................................................................... 32
Agency Participation ............................................................................................................................... 32
TF-CBT Participants at Start of Services.......................................................................................... 32
Client Level Outcomes ................................................................................................................................. 33
Fidelity to the TF-CBT Model .................................................................................................................... 33
Lessons Learned Regarding Data Collection ...................................................................................... 33
Chapter 5 – Assessing the Trauma-informed Approach to Services .............................................. 37
Formative Analysis of TIAA ....................................................................................................................... 37
Planning ....................................................................................................................................................... 37
Pilot Testing ................................................................................................................................................ 37
Refining ........................................................................................................................................................ 38
Implementing ............................................................................................................................................. 38
Essential Elements of the Assessment .................................................................................................. 38
Methodology ................................................................................................................................................... 39
Data Limitations........................................................................................................................................ 40
Initial Validation of the TIAA .................................................................................................................... 40
Results ............................................................................................................................................................... 41
Continuous Quality Improvement Process ......................................................................................... 46
Lessons Learned, Successes and Challenges....................................................................................... 48
Chapter 6 – Conclusion .................................................................................................................................... 49
References ............................................................................................................................................................ 55
Appendix ............................................................................................................................................................... 57
Trauma Instrument Description ............................................................................................................. 59
National Evaluation Instrument Descriptions ................................................................................... 63
EXECUTIVE SUMMARY
Background
Trauma has many causes — physical or sexual abuse, domestic violence, exposure to
substance abuse, violent acts, and natural disasters among others. Additionally trauma, as
it relates to emotional and behavioral health, is the effect of exposure to an acutely
distressing event or a pattern of behavior or environment that is outside the range of usual
human experience. It is estimated that three million children and adolescents in the United
States are exposed to serious traumatic events each year. Child and adolescent trauma
survivors have higher rates of mental health service use and are more likely to use acute
mental health treatment services at a higher cost. Research has also linked exposure to
trauma during childhood to many risk factors for health and social problems later in life
Maine’s THRIVE Initiative began in 2005 and was the first System of Care (SOC) for
children, youth and families with a specific focus on trauma-informed practices. The
THRIVE Initiative functioned under the auspices of the Maine Department of Health and
Human Services, Division of Children’s Behavioral Health in three counties in Maine:
Androscoggin, Franklin and Oxford. Tri-County Mental Health served as the lead agency
employing THRIVE staff and providing supervision and support. .
Based on constructs developed by Roger Fallot and Maxine Harris and outlined in Using
Trauma Theory to Design Service Systems (2001), THRIVE developed an approach to service
delivery for children’s mental health services that acknowledges and understands the
effects of trauma within each of the following components: Safety; Trustworthiness; Choice
Collaboration; Empowerment; and Language/Cultural Competency. To supplement and
enhance Maine’s service system using this approach, THRIVE advanced the traumainformed approach in five key ways:
•
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•
•
•
creating a Family Partnering Program which offered trauma-informed peer support
to families receiving children’s mental health services;
convening the Trauma-focused Cognitive Behavioral Therapy Learning
Collaborative, which trained numerous providers in this evidence based treatment
model;
providing trauma-informed technical assistance and training for agencies and direct
service staff;
developing a Trauma-informed Agency Assessment and Continuous Quality
Improvement (CQI) process by which to inform improvement and gauge progress at
the agency level; and
encouraging the development of youth and family voice by supporting the creation
and development of the Maine Alliance of Family Organizations and Youth MOVE
Maine.
THRIVE Final Evaluation 2012 – HZA, Inc.
Page i
This report presents the results of the THRIVE evaluation performed by Hornby Zeller
Associates, Inc. (HZA) a social science research firm with offices in Maine, among other
states, in cooperation with Dr. James Yoe, the Lead Investigator . The study has four major
components, each described in more detail in the full report:
•
•
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•
Prevalence of trauma exposure and its effects;
Service use and cost outcomes;
Effectiveness of trauma-specific treatment; and
Assessing the trauma-informed approach to services.
Major Findings
Prevalence of Trauma Exposure and Effects on Children, Youth and Families
Overall, 194 children and youth enrolled in THRIVE, 120 of whom participated in the study
on incidence and prevalence and 78 of whom were included in the longitudinal study.
The average age of participating children and youth was 10 years old at intake into
THRIVE; 45 percent were between the ages of seven and 11. Over two-thirds of the
children were boys and lived at home with one or both biological parents. The most
common diagnosis among participants was attention deficit/hyperactivity disorder (54%),
followed by mood disorders, oppositional defiant disorders, post-traumatic stress
disorder/acute stress disorder, and other anxiety disorders.
Prevalence of Trauma Exposure
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Most of the children were found to have experienced at least one traumatic event.
The average number of trauma experiences was three, and two out of three
reported a substantial trauma history.
Nearly one-third of the children and youth had experienced physical abuse and
almost one in five had experienced sexual abuse.
The parents and caregivers who participated in the study reported experiencing an
average of 3.5 trauma events before the age of 18, and nearly two-thirds (65 %) of
caregivers reported having experienced three or more traumatic events before the
age of 18.
Some of the most frequently cited childhood traumatic experiences for parents
included emotional abuse, being separated from their caregiver and experiencing
sexual abuse.
Forty-two percent of the families presented intergenerational trauma, meaning both
children and their caregivers had experienced three or more trauma incidents as
children.
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Effects of Trauma and Outcomes After Six Months
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Children and youth with a higher level of trauma experiences were more likely to
exhibit challenging behaviors and less likely to exhibit strengths.
Caregivers with a higher level of childhood trauma exposure were more likely to
report being stressed.
Children and youth living in families with “intergenerational” trauma were more
likely to present symptoms related to trauma as well as challenging behaviors.
Children and youth showed reduced rates of trauma symptoms and challenging
behaviors while caregivers showed reduced stress levels after working with a
trauma-informed Family Support Partner and receiving other services.
Service Utilization and Cost Outcomes
This component of the evaluation was intended to explore the patterns of services use
among THRIVE participants, the costs associated with those services, and any potential
changes after enrolling in THRIVE and even after formal services were concluded. A
secondary purpose was to compare the results of children who have had a trauma history
to those who had not. For the service and cost study, cost data from 102 participants were
analyzed.
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During THRIVE involvement the percentage of children and youth using targeted
case management increased by 14 percent, while the use of Emergency Room, crisis
support, outpatient hospital services and home-based services decreased.
The proportion of children and youth receiving inpatient mental health services was
reduced by nearly half in the period immediately after THRIVE enrollment.
There appears to be a cost-savings of just over $450,000 between the period prior
to enrolling in THRIVE and the period after program involvement. The greatest
reduction in average costs was within families where the child and parent both had
experienced trauma histories.
Effectiveness of Evidence-based Treatment
In 2006, THRIVE’s Clinical and Evidence-Based Practice Committee identified Trauma
Focused-Cognitive Behavioral Therapy (TF-CBT) as one of two evidence-based traumaspecific treatment models for children and families to be implemented in the Androscoggin,
Oxford, and Franklin County catchment area. Thirty-five clients were served by TF-CBT. At
least 10 completed TF-CBT while two dropped out; 16 participants were continuing
treatment when the final data were submitted.
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•
After participating in TF-CBT, youth expressed positive changes in resiliency and
reduced frequency of trauma-related symptoms.
There appeared to be a relationship between the positive outcomes and the
number of TF-CBT sessions.
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Assessing the Trauma-informed Approach
A major focus of THRIVE was to assist entire mental health agencies to become traumainformed in their approaches and practices. THRIVE’s answer rested in developing a
trauma-informed assessment (TIAA) to assess all aspects of the agency’s presentation and
treatment to families and children. After two years of development, two agencies piloted
the TIAA, as well as answered questions regarding the method of administering the
assessment. Youth and family members helped interpret the results and provided feedback
about the data collection methods based on their field experiences. Taking into account all
findings, the tool was modified and the standards were refined.
Once the pilots were completed, all of Maine’s System of Care agencies participated,
according to contract language implemented by Maine’s Children’s Behavioral Health
Services. The TIAA was administered twice on a statewide basis during the course of the
grant although not all contracted agencies participated in both rounds. While the two years
generally assess different agencies it is instructive to see the progression of traumainformed practice in many of the areas assessed. The key findings from those assessments
are as follows:
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•
The greatest gains from the perspective of agency staff were in the domain of
commitment to a trauma-informed approach, followed by trauma competence.
The greatest increase from the family perspective was in family empowerment and
engagement, a four percentage point increase.
Among youth, the greatest change was youth empowerment and engagement, six
percentage points, followed by trauma competence, five percentage points.
When the perceptions of agency staff, youth and families were compared, the
following patterns emerged:
o
Families reported more positive perceptions of physical and emotional safety
than youth and agency staff;
o
Agency staff perceive that they empower youth more than the youth perceive
that themselves;
o
Agency staff and family members are virtually the same in their perceptions
of family empowerment;
o
Families and youth believe the agencies display more trauma competence
than the agencies themselves perceive;
o
Youth perceptions of trustworthiness are lower than families or agency staff;
and
o
Family members and youth reported more positive perceptions than the staff
of cultural competence.
Discussion and Conclusions
As the first System of Care (SOC) project with a specific focus on trauma-informed
practices, the THRIVE Initiative has had a unique opportunity both to define what traumainformed practice means and to assess its impact on children and their families. A strong
partnership between the state sponsors at Children’s Behavioral Health Services (CBHS),
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the people developing the THRIVE Initiative in the target counties and the evaluators has
permitted and even facilitated a learning process that is now reaping benefits beyond the
Initiative itself.
The benefits first manifested themselves in the encouragement provided by CBHS to take
the learnings from THRIVE to the entire state. This has allowed other communities and
agencies to avail themselves of the training and technical assistance provided by THRIVE.
The state leaders fostered the ability of all contracted mental health agencies to conduct
their own assessments of their agency on the principles of system of care and traumainformed practices using tools and evaluation techniques developed and promoted by
THRIVE. Even the federal requirement that grantees provide matching funds helped
facilitate the dissemination of learning as the evaluator’s contribution was to go beyond the
three counties funded by the project to bring the assessment statewide.
Benefits also were derived from the state-level encouragement of the development of both
youth and family organizations whose voices could be heard beyond a system of care
project. Thus, the THRIVE Initiative, with the strong encouragement of Children’s
Behavioral Health, helped to support the development of an alliance of six family
organizations, called the Maine Alliance of Family Organizations (M.A.F.O.). Ultimately one
of the services provided by THRIVE, the trauma-informed Family Partnering program and
cultural brokering, was turned over to two family organizations to administer. It also
encouraged the development of a Youth Move chapter, Youth MOVE Maine and supported
various youth initiatives that went beyond THRIVE.
Going beyond Maine, the THRIVE Initiative and its evaluators have actively developed
materials for presentation at national forums, both in the form of workshops, and poster
sessions and even extensive institutes. Each year THRIVE’s submissions have been
approved by the national children’s mental health research conferences sponsored by the
University of South Florida and/or the by the Georgetown Institutes. At the most recent
Georgetown Institute (Orlando, 2012), the former youth coordinator for THRIVE and now
its Training and CQI Manager was a plenary speaker before 2200 people, providing a first
person perspective on growing up with trauma and how even to this day the principles of
trauma-informed practice provide comfort and assistance in addressing its impact. THRIVE
also has received awards for its innovative social marketing initiatives such as digital
stories which allow youth and family to tell their stories in their own voices using the new
media.
Recognizing the power and potential of disseminating the concepts inherent in traumainformed practice to a national audience, THRIVE was encouraged both by the state
sponsors and even its own lead agency, Tri-County Mental Health, to become its own
independent organization. Last year THRIVE was granted a federal 501 (C) 3 status as a
non-profit organization. This vehicle has allowed THRIVE to develop training and technical
assistance contracts in many states throughout the country and has even permitted the
dissemination of its Trauma-informed Agency Assessment Tool to states outside Maine
through a partnership with the evaluators. The existence of THRIVE as a separate
organization promotes the sustainability of the system of care.
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This partnership has also allowed THRIVE to make new discoveries about the nature and
impact of trauma by forging close working relationships with its evaluators. An unusual
contractual model was employed. The lead evaluation investigator is a state employee with
broad system of care experience; he is currently Director of the Office of Continuous
Quality Improvement for the State Department of Health and Human Services. But the dayto-day operations of the evaluation were contracted to Hornby Zeller Associates, Inc., a
social science research firm with offices in Maine, among other states. The partnership
worked extremely well by combining the expertise and resources of two organizations. For
example, the private firm could easily hire family evaluators who may not have had
traditional credentials associated with state service. They could be given the materials and
resources needed to operate flexibly. The private firm could obtain access to data such as
Medicaid claims files and gain expertise in its analysis from the state. The joint efforts led to
a powerful service and cost analysis. The partnership allowed investigators to develop
materials and make joint presentations to state and national audiences.
Through the evaluation, the project hoped to demonstrate both the degree to which trauma
is prevalent among the population of children with emotional disturbances and the
approaches that could mitigate the negative effects of trauma. While it has done both, the
project and its evaluation team has taken the inquiry one step further, with initial results
that may prove to be the most important evaluation contribution of the project. That was to
assess the impact of trauma from one generation to the next.
The evaluation team added three tools to those required by the national cross-site
evaluator: the Traumatic Events Screening Instrument (TESI), the Lifetime Incidence of
Traumatic Events (LITE; both parent and child versions), and the Trauma Symptom
Checklist (TSC; versions for Young Children and for Youth). By having the foresight and
ability to capture the caregiver’s own trauma history as a child using the TESI, the
evaluation permitted analyses of what we came to call “inter-generational trauma.” The
linkages from one generation to the next became apparent by using correlational analysis
techniques; these types of analyses could even be extended to the service and cost study
which ultimately demonstrated two important things: children whose parents had
childhood traumatic experiences used more expensive services for their children before
enrolling in THRIVE than those who did not, and these same parents and children realized
far greater savings in the cost of treatment six months after THRIVE services concluded,
largely due to a shift away from inpatient hospital services. The service shifts led to a cost
savings of more than $450,000 for families enrolled in THRIVE, representing more than a
30 percent reduction in cost from six months before service initiation to six months after
service termination. The greatest change amounting to more than a 50 percent cost
reduction, was among families with an intergenerational trauma history. Their savings
were far greater than parents who did not have trauma histories themselves. And the most
consistent intervention received by all these families was a Family Support Partner.
The THRIVE Initiative learned much about promoting and enhancing a trauma-informed
system. Perhaps the most salient lesson is the need for trauma champions, strong leaders
at the state and agency level who acknowledge and understand the importance of the
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question, “What happened to you,” as opposed to what is wrong with you. Whether it was
the TIAA self-assessment process or TF-CBT learning collaborative, those agencies that
were the most successful had leaders who were dedicated to implementing the traumainformed approach. Moreover, the commitment from state agency leadership was
instrumental in the statewide TIAA administration and ultimately plans to expand the
trauma-informed approach to other agencies and service systems.
The TIAA showed that agency staff members often have different perceptions of their
practices from the children and families. For physical and emotional safety domains, the
families have a higher perception of agency practices than the youth or even the agency
staff. On the question of youth empowerment, the agency staff perceive that they empower
youth more than the youth perceive that themselves. On the domain of family
empowerment, the perceptions of agency staff and family members are virtually the same.
Families and youth believe the agencies display more trauma competence than the
agencies themselves perceive. Trustworthiness is another issue that the youth have, with
their perceptions being lower than families or agency staff. On cultural competency, both
the family members followed by the youth, have a higher perception than the staff have of
their own cultural competence. These results suggest the need for agencies to work more
closely with youth and families to examine these domains, particularly in the one area
where the staff rank themselves higher than the people they serve: youth empowerment.
In conclusion, the most important independent finding of the evaluation is the connection
between a caregiver’s experience of trauma as a child and his or her own child’s
experience. These relationships affect how much a child uses expensive services before
receiving treatment. It is particularly noteworthy that providing a Family Support Partner
was most effective when the caregiver disclosed a childhood affected by trauma. While the
post-service costs for the entire sample were reduced by 30 percent, for the subgroup with
a trauma history there was a 50 percent reduction. While the sample size is small, the
results have face validity and need to be replicated with larger groups of people, preferably
using a quasi-experimental design. Future studies should be designed to pinpoint the
specific relationships between trauma experiences, trauma-informed services, children’s
outcomes and associated costs.
Even with its limitations, the overall evaluation results of the THRIVE Initiative suggest that
better outcomes and reduced costs can be achieved by providing trauma-informed parent
peer supports, offering trauma-specific treatments and taking into account the trauma
history of the entire family through a trauma-informed approach to service delivery.
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CHAPTER 1
BACKGROUND AND PURPOSE
Why Trauma Matters
Trauma has many causes — physical or sexual abuse, domestic violence, exposure to
substance abuse, violent acts, and natural disasters among others. It is estimated that three
million children and adolescents in the United States are exposed to serious traumatic
events each year (Hamblen and Barnett, 2012). Nearly one out of three adolescents has
been found to be physically or sexually assaulted by the age of sixteen (Boney-McCoy &
Finkelhor, 1995) and violent crime victimization among youth is twice as high as the rate
for adults (Hashima & Finkelhor, 1999). High rates (50-70%) of Post-Traumatic Stress
Disorder (PTSD) have been found among child, adolescent and adult public service users,
while PTSD rates among Medicaid enrollees are highest among children ages five to twelve,
at 609.5 per 1,000 (Macy, 2002; Kessler, 2000; Switzer, et al., 1999). Child and adolescent
trauma survivors have higher rates of mental health service use and are more likely to use
acute mental health treatment services, including: inpatient hospitalization, crisis services,
and residential treatment services at a higher cost (Frothingham, et al. 2000; Macy, 2002;
Newmann, et al., 1998; Blanch, 2003). Finally, the Adverse Childhood Experiences Study
(Felitti, et al. 1998) has shown a strong relationship between exposure to trauma during
childhood and many risk factors for health and social problems later in life. Other research
has suggested a relationship between parental childhood trauma and how parents interact
with their children (Appleyard & Osofsky, 2003; Bolen, 2000; Silverman & Lieberman,
1999; Ancharoff et al., 1998).
In light of mounting evidence about the impact of trauma, the federal Substance Abuse and
Mental Health Services Administration (SAMHSA) recognized violent trauma as a root
cause of pervasive, harmful and costly public health problems in January 2010. SAMHSA
has begun a strategic initiative to reduce the behavioral health impacts of violence by
integrating trauma-informed services with prevention and treatment programs.
Maine’s Trauma-informed System of Care and the Trauma-informed Approach
Maine’s THRIVE Initiative began in 2005 and was the first System of Care (SOC) for
children, youth and families with a specific focus on trauma-informed practices. In addition
to embodying the SOC principles of being family-driven, youth-guided and culturally and
linguistically competent, Maine sought to make trauma-informed a key SOC principle. The
THRIVE Initiative functioned under the auspices of the Maine Department of Health and
Human Services, Division of Children’s Behavioral Health. It operated in three counties in
Maine: Androscoggin, Franklin and Oxford. Tri-County Mental Health served as lead
agency.
Maine’s system of care application and focus was precipitated by data collected and
analyzed by James Yoe, Ph.D., the Director of the Office of Continuous Quality Improvement
Page 1
with the Maine Department of Health and Human Services, which showed that compared to
others, children and youth recipients of mental health services who have experienced and
survived trauma in Maine had greater behavioral and emotional challenges, and were at
greater risk of significant harm. The study findings also indicated that these children were
more likely to experience co-occurring physically, developmental, and substance abuse
challenges; they also had significantly greater challenges in the areas of child/youth and
parent/caregiver acceptance and engagement with service providers. An analysis of service
use and costs showed that children and youth who experience trauma were more likely to
use high-end mental health services, including psychiatric inpatient services, residential
treatment, and crisis services; they also had 73 percent higher mental health service
expenditures and 51 percent higher overall treatment expenditures.
Based on constructs developed by Roger Fallot and Maxine Harris and outlined in Using
Trauma Theory to Design Service Systems (2001), THRIVE developed an approach to service
delivery for children’s mental health services that acknowledges and understands the
effects of trauma. The resulting trauma-informed approach defines service delivery and
best practices within each of the following components:
•
•
•
•
•
•
Safety
Trustworthiness
Choice
Collaboration
Empowerment
Language/Cultural Competence
To supplement and enhance Maine’s service system using this approach, the THRIVE
Initiative advanced the trauma-informed approach in five ways: creating a Family
Partnering Program which offered trauma-informed Family Support Partners to families
receiving children’s mental health services; convening the Trauma-focused Cognitive
Behavioral Therapy (TF-CBT) Learning Collaborative, which trained numerous providers
in this evidence based treatment model; providing trauma-informed technical assistance
and training for mental health agencies and direct service staff; developing a Traumainformed Agency Assessment and Continuous Quality Improvement (CQI) process by which
to inform improvement and gauge progress in adopting trauma-informed practices at the
agency level; and using organizational structures to encourage youth and family voice. Each
of these interventions, which collectively constitute the THRIVE Initiative, is described in
more detail below.
Trauma-informed Family Partnering Program. Family Support Partners worked with
families who were referred to the THRIVE Initiative from Child Welfare, Juvenile Justice
and local mental health agencies. The Family Support Partners were a peer support,
meaning that they were themselves parenting at least one child with special needs, and
they received training in the trauma-informed approach. The overall goal of the Family
Support Partners was to build upon a family’s strengths and to increase a parent’s ability to
advocate for his or her family. While the role of the Family Support Partners varied based
on an individual family’s needs, Family Support Partners offered the following types of
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support, usually for a period of about six months:
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Providing information about local resources;
Talking and listening without judgment;
Helping articulate needs and wants to service providers;
Helping prepare for meetings; and
Attending meetings to support family members on request.
Trauma-focused Cognitive Behavioral Therapy (TF-CBT) Learning Collaborative. TF-CBT is
an evidence-based trauma-specific treatment model for children and families that typically
lasts for a period of 12 to 16 weeks. Research has shown that TF-CBT is successful with
children between the ages of three and 18 who have experienced traumatic events that are
contributing to emotional challenges. THRIVE used a Learning Collaborative approach to
bring TF-CBT to seven local mental health agencies, plus four private practitioners, serving
Androscoggin, Oxford, and Franklin Counties. Over the course of one year, participants
received three rounds of training in the model plus monthly peer consultation and on-going
support. The people who received TF-CBT as a therapeutic intervention were not the same
as those enrolled in the THRIVE Family Partnering Program.
Trauma-informed Training and Technical Assistance. To educate providers regarding the
trauma-informed approach, THRIVE provided trainings to mental health agencies,
community providers, and youth and families organizations throughout the service area. In
particular, training and assistance were offered to the 23 local entities that signed a
Memorandum of Understanding with the THRIVE Initiative. The project also developed and
disseminated a Best Practices Guide for implementing the trauma-informed approach at an
agency and developed free informational webinars outlining the core concepts. These
activities formed the core of the Continuous Quality Improvement (CQI) process being used
in conjunction with the Trauma-informed Agency Assessment, discussed below.
Trauma-informed Agency Assessment. THRIVE developed a trauma-informed agency
assessment (TIAA) and Continuous Quality Improvement (CQI) process to help agencies
determine the extent to which they were delivering trauma-informed services and to
pinpoint areas for improvement. Over the course of five years, youth, family, evaluators,
service providers and project staff worked together to develop a three-part self assessment
tool that measures Physical and Emotional Safety; Youth and Family Empowerment;
Trustworthiness; Trauma Competence; Commitment to the Trauma-informed Approach;
and Trauma-informed Cultural and Linguistic Competence. The assessment and CQI
process was implemented twice with all child-serving mental health agencies in the state of
Maine.
Youth and Family Voice. THRIVE worked actively to support the development of the Maine
Alliance of Family Organizations which helped to coalesce seven family groups with
somewhat different foci including families of children with learning disabilities as well as
those with emotional problems. THRIVE also helped to develop the Maine chapter of Youth
MOVE, which became Youth MOVE Maine. It used leadership development and social
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marketing techniques to help develop and promote the youth voice in a variety of activities.
Purpose of this Report
This report presents the results of the THRIVE evaluation performed by Hornby Zeller
Associates, Inc. (HZA) a social science research firm with offices in Maine, among other
states. The remainder of the report consists of five chapters. Chapter 2 presents trauma
history findings for children, youth and families who have participated in THRIVE’s Family
Partnering Program. Chapter 3 describes the types of services used by children and
families in THRIVE’s Family Partnership Program and the costs associated with them.
Chapter 4 documents the process and effectiveness of the Trauma-focused Cognitive
Behavioral Therapy Learning Collaborative that was instituted by THRIVE. Finally, Chapter
5 outlines how THRIVE developed a process of assessment and continuous quality
improvement for expanding and sustaining the key principles of Trauma-informed Systems
of Care while Chapter 6 provides conclusions. The report covers the time period of 2006 to
2011.
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CHAPTER 2
PREVALENCE OF TRAUMA EXPOSURE AND EFFECTS ON
FAMILIES AND YOUTH
Children and youth who experience trauma are less likely to receive a formal PTSD
diagnosis than adults. Some of the more common diagnoses found among children who
have experienced trauma include separation anxiety disorder, oppositional defiance
disorder, phobic disorders, and attention deficit/hyperactivity disorder. Symptoms of
trauma include: extreme anxiety, depression, anger, post-traumatic stress, dissociation and
sexual concerns. These and other behaviors related to traumatic stress can manifest at any
time and everywhere youth and families are found. That is, among children, the trauma
survivor population is much larger that the PTSD population (Ford et al., 2000; Husain,
Allwood, Bell, 2008; Daud & Rydelius, 2009).
In addition, the Adverse Childhood Experiences Study (Felitti et al., 1998) showed that as
the number of trauma exposures increases, the risk for a number of lifelong health and
well-being problems also increases, such as health-related quality of life, depression,
substance abuse and domestic violence.
This chapter presents trauma history findings for children, youth and families who have
participated in THRIVE’s Family Partnering Program. The primary research questions
include:
1. What was the prevalence of trauma experiences in children and youth who enrolled
in THRIVE’s Family Partnering Program?
2. What was the prevalence of trauma experiences of the families of those children?
3. What were the effects of trauma exposure on children, youth and caregivers? (Were
trauma survivors more likely to experience trauma-related symptoms and
behavioral/emotional challenges?)
4. To what extent did children and youth enrolled in the THRIVE’s Family Partnering
Program exhibit reductions in trauma-related symptoms and behaviors over time?
(Did those youth and families experiencing trauma show greater improvements?)
Methodology
Local Evaluation Instruments
To collect information regarding the prevalence of trauma exposures for children, youth
and caregivers the THRIVE Evaluation Team employed three tools: the Traumatic Events
Screening Instrument (TESI), the Lifetime Incidence of Traumatic Events (LITE; both
parent and child versions), and the Trauma Symptom Checklist (TSC; versions for Young
Children and for Youth). In addition, information from the following instruments, which are
part of the National System of Care evaluation protocol, was used in the analysis:
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•
•
•
•
•
Enrollment Demographic Information Form (EDIF)
Behavioral and Emotional Rating Scale (BERS)
Caregiver Information Questionnaire (CIQ)
Child Behavior Checklist (CBCL)
Caregiver Strain Questionnaire (CGSQ)
A full description of each evaluation instrument and the scoring methodology (where
applicable) can be found in the Appendix.
Data Collection
With the exception of the EDIF, which was collected during the intake process by the
Family Support Partner, the questionnaires were administered in person. Hornby Zeller
Associates, Inc. (HZA) employed and trained Family Evaluators to administer the local and
National Evaluation tools. The first round of interviews took place within 30 days of the
family’s start with THRIVE. One child per family was eligible for the longitudinal interviews
and not all families consented to participate in the longitudinal evaluation.
Family Evaluators were family members of a child or young person who had been involved
with the mental health system. Interviewers collected the information from families and
youth (over the age of 12) and recorded it directly into an electronic system enabled on a
tablet laptop. Data were then submitted to the National and Local evaluations once the
interviewers had verified the data.
Prior to collecting information, each interviewer was provided with three days of training
which covered the following topics:
•
•
•
•
•
•
Project overview
Evaluation protocol and timeframes
Informed consent procedures and confidentiality
Interview techniques
Question-by-question review of the evaluation tools
Role-playing
Family Evaluators received weekly supervision and support from HZA in the form of
weekly follow-up meetings for six months after the initial training. These meetings
addressed questions that arose in the field, allowed interviewers to share successes and
challenges, and ensured that data were being properly coded and submitted. Monthly
meetings occurred after the first six months, with the evaluation supervisor being available
at any time for consultation. HZA’s same two family evaluators were retained for the entire
project, which led to continuity of effort.
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Study Participation
Families, children and youth were eligible to participate in the evaluation if the following
criteria were met:
•
•
•
•
•
•
Child/youth between the ages of 0 and 18;
Child/youth diagnosed with Serious Emotional Disturbance (SED) 1;
Family lived within tri-county area (Androscoggin, Oxford, Franklin);
Family involved with at least two systems (e.g., Child Welfare plus Mental Health);
Family agreed to work with a THRIVE Family Support Partner; and
Family consented to participate in evaluation.
Table 2-1 shows the final sample for each component of the evaluation study. For the
incidence and prevalence of trauma, data were collected from 120 families (children/youth
and primary caregivers) out of 194 total children/youth who enrolled in THRIVE’s Family
Partnering Program; 78 children/youth are represented in the longitudinal study. Family
members were paid $50 for each interview in the form of a gift card. The interviews often
lasted two or more hours.
Table 2-1. THRIVE’s Family Partnering Program Evaluation Study Participation
Number Percent
Overall Enrollment in THRIVE’s Family Partnering Program
194
100%
Incidence and Prevalence of Trauma
120
62%
Longitudinal Study of Trauma Outcomes
78
40%
When families were enrolled in the program but did not participate in the evaluation
interviews, there were two primary reasons: the initial interview was not completed within
30 days of program initiation (22); the children/youth had a sibling already enrolled in the
evaluation (15). A handful of families (13) opted not to participate in the evaluation
interviews; generally the reason was a family crisis (e.g., recovering from a fire, death in the
family). For the follow-up interviews required of the longitudinal study, the primary reason
families did not participate was one of retention; that is, they were not able to be contacted
or located after the initial six-month follow-up despite multiple methods and attempts to
reach them.
Analysis
To ensure quality, data collected during the in-person interviews were cleaned and errors
corrected on an ongoing basis. This process included reconciling identification numbers,
missing data or erroneous dates. Additional steps were taken to ensure data quality for the
final analysis. For example, continuous variables such as age were re-coded into categories
and valid skip patterns were distinguished from missing data.
Serious Emotional Disturbance (SED) is defined for children (from birth to age of majority) as those who
have a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria
specified within the Diagnostic and Statistical Manual of Mental Disorders (DSM).
1
Page 7
Data were then analyzed using descriptive and correlational techniques. The results were
tested for statistical significance primarily using chi-square tests as well as independent
and paired t-tests. To facilitate the analysis, prevalence and outcome data were converted
into dichotomous indicators where the presence of an indicator or attribute was
represented by “1.” For instruments that use scaled responses, the differences between
mean scores were examined. All results were tested at the p=<.05 level (unless otherwise
stated); because the data analyses were exploratory, standards for two-tailed significance
were used.
Data were first examined to identify the extent to which children and youth were exposed
to trauma, in order to better understand trauma-related symptoms and outcomes. Trauma
exposures were identified from the responses on the LITE 2, where each exposure was
counted once and a total exposure score was calculated. To be included in the total score,
the event must have bothered the child/youth “a lot.” The exception to this rule was
exposure to physical or sexual abuse, which was always counted.
Children and youth were then divided into two groups: those experiencing three or more
exposures to different types of trauma that bothered them a lot, and those experiencing
fewer than three trauma exposures. Again, there was one exception made to this standard.
The handful of children who had at least three trauma experiences including physical or
sexual abuse among them were counted in the three plus trauma exposure group
regardless of whether the other trauma events bothered them “a lot.”
One unique feature of the evaluation study was to try to determine whether a parent
having experienced trauma him or herself had an impact on the child’s experience with
trauma. That is, does trauma exposure have an intergenerational impact? To explore this
question, the evaluators examined the exposure of caregivers to trauma independently and
then in conjunction with the child’s exposure. The analysis focused on children and youth
identified above as having three or more trauma exposures. The group was then split by
whether the primary caregiver reported on the TESI being exposed to three or more types
of traumatic events during his or her childhood (that is, before the age of 18).
Evaluators also examined trauma symptoms at intake and at six months using the Trauma
Symptom Checklist (TSC) to determine whether there were changes after THRIVE’s Family
Partnering Program enrollment. Clinical symptoms on the scales were calculated
separately according to the parameters outlined for the age-appropriate tools. Some
interview data were excluded due to under-response, hyper-response and atypical
response according to the TSC developers’ guidance. 3,4 The percentages measure whether
the child or youth scored within the clinical range on the age-appropriate tool. Throughout
2 Older youth were administered the LITE independently of their caregiver. In those cases, researchers reconciled youth and
caregiver reports of trauma. In most cases, there were no discrepancies. For instances when there was a discrepancy,
usually the youth reported something occurred but that it did not bother them. If the youth reported an incident occurred
and it bothered him/her, but the parent did not report the incident, the youth report was included in the total score.
3 Briere, J. (2005). Trauma Symptom Checklist for Young Children (TSC-YC): Professional Manual. Psychological Assessment
Resources, Inc. Odessa, FL.
4 Briere, J. (1996). Trauma Symptom Checklist for Children (TSCC): Professional Manual. Psychological Assessment Resources,
Inc. Odessa, FL.
Page 8
the analyses described above, trauma data were linked to the data collected as part of the
National System of Care Evaluation to examine other aspects of family well-being and
functioning. The results were analyzed following the parameters and methodologies
employed by the national evaluation protocol.
Findings
Participant Demographics
The children and youth participating in the evaluation study had an average age of 10 years
at intake into THRIVE’s Family Partnering Program. The ages ranged from two to 18; 45
percent were between the ages of seven and 11. Most of the children were boys (69%) and
the overwhelming majority lived at home (92%) with a biological parent (82%). As
depicted in Figure 2-1, the most common diagnosis among participants was attention
deficit/hyperactivity disorder, reported in over half of all the children and youth (54%).
This was followed by mood disorders (36%), oppositional defiant disorders (23%), posttraumatic stress disorder and acute stress disorder (17%) and other anxiety disorders
(15%).
Figure 2-1. Mental Health Diagnosis at Intake
Conduct Disorder
1%
Personality Disorders
1%
Substance Use Disorders
1%
Schizophrenia and Other Psychotic… 2%
Learning, Motor Skills,… 4%
Mental Retardation
4%
Disruptive Behavior Disorder
5%
Pervasive Developmental Disorders
5%
Impulse Control Disorders
6%
Adjustment Disorders
8%
Anxiety Disorders*
15%
PTSD and Acute Stress Disorder
17%
Oppositional Defiant Disorder
23%
Mood Disorders
36%
Attention Deficit Hyperactivity Disorder
0%
20%
40%
54%
60%
80%
100%
*NOT including PTSD or Acute Stress Disorder
The primary caregivers who participated in the evaluation tended to be female (92%) and
were, on average, 36 years old at intake. Most had at least a high school degree (81%).
Seventy percent reported that their family earned less than $50,000 per year.
Page 9
Sixty-three percent of participants were referred to THRIVE’s Family Partnering Program
by Child and Family Services (child welfare) 5, the primary referral source , and close to
one-quarter (22%) were referred by a mental health agency.
Prevalence of Trauma
This section discusses the results of the initial administration of the trauma tools.
Child and Youth Trauma Experiences
Most of the children were found to have experienced at least one traumatic event; only 11
out of 120 reported no such experiences (9%). To some degree, this is to be expected given
that the primary referral source for the program was child welfare, and abuse and neglect,
domestic violence, and placement in foster care are all considered traumatic events.
However, the prevalence and scope of experiences of the children and youth was less
expected. The average number of trauma experiences was three, and this ranged from zero
to 10. Two out of three children and youth (62%) reported a substantial trauma history,
and this was more likely among girls (62%) than boys (46%). Those who reported three or
more trauma experiences were also more likely to be over the age of 12 (37% compared to
24%).
The most frequent type of trauma experienced by the children and youth was parental
domestic violence (39%). Many also reported witnessing a bad accident (36%), having a
seriously hurt or sick family member (34%), having their parents divorce or separate
(33%), or having a close family member die (32%). Nearly one-third of the children and
youth had experienced physical abuse (32%) and almost one in five had experienced sexual
abuse (18%). Although not pictured, nine percent had been separated from their primary
caregivers. Figure 2-2 displays the prevalence of various types of traumatic experiences
reported at baseline.
Compared to the rates from the national evaluation, Maine’s participants had a higher
incidence of experiencing or witnessing abuse; for example, national evaluation estimates
showed that 30 percent of the children and youth enrolled in THRIVE had been physically
abused, compared to 21 percent nationally. 6 This makes sense given that the primary
referral source during the first year of the program was Child Welfare.
5 System of Care projects target youth who are involved with more than one service system. The THRIVE
Initiative selected child welfare as a key system partner.
6 The national evaluation instruments differ from the tools employed by Maine’s evaluation to assess trauma;
these national figures are considered less reliable but are provided here for comparative purposes.
Page 10
Figure 2-2. Prevalence of Child and Youth Trauma Experiences
Car accident
14%
Sexual abuse
18%
Other accident/sick
21%
Threatened
26%
Physically abused
32%
Family member death
32%
Parents divorced/separated
33%
Family hurt or sick
34%
Witnessed accident
36%
Parents domestic violence
39%
0%
10%
20%
30%
40%
50%
Caregiver Trauma Experiences
Primary caregivers reported experiencing an average of 3.5 trauma events before the age
of 18, and 65 percent reported having experienced three or more traumatic events before
the age of 18. Only 11 percent reported no childhood trauma history (a figure remarkably
close to the 9% among children and youth) and even fewer reported no lifetime experience
with traumatic events. Some of the most frequently cited childhood traumatic experiences
are shown in Figure 2-3 and included emotional abuse (43%), being separated from their
caregiver and experiencing sexual abuse (each 42 %). This was followed by witnessing
domestic violence, as reported by 38 percent of all caregiver respondents. Note that
witnessing domestic violence was equally frequent among the children and youth’s (39%)
and the caregivers’ own experience in childhood (38%).
Figure 2-3. Prevalence of Childhood Trauma Experiences
Witnessed violence (outside family)
19%
Been threatened to kill or hurt badly
20%
Been attacked with intent to kill/harm badly
21%
Death of close family/friend
22%
Witness bad accident
23%
Bad accident
27%
Witnessed domestic violence
38%
Sexual abuse
42%
Separated from caregiver(s)
42%
Emotionally abused
43%
0%
10%
20%
30%
40%
50%
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Intergenerational Trauma
To further understand the prevalence of trauma within the families served by THRIVE’s
Family Partnering Program, the evaluation explored intergenerational trauma, that is, the
incidence of child and youth trauma in conjunction with the prevalence of caregiver trauma
during their own childhood years ago. Evaluators were seeking to determine whether there
were statistically valid correlations between a parent having experienced trauma in his or
her own childhood and the children’s traumatic experiences as well as mental health
symptoms. The first step was to calculate the proportion of families where both the
caregiver and the child independently reported significant trauma histories. The family
member would have had to report trauma incidents in childhood. Again the standard of
three or more traumatic events was used. 7
Figure 2-4 shows that 42 percent of the families presented intergenerational trauma, while
19 percent reported a trauma history for only the child or youth. Interestingly, 22 percent
of families had a parent with a childhood trauma history, but the child/youth was not
presenting a trauma history. Chi-square analysis suggests that there is a relationship
between parental history of trauma and child’s history of trauma although, due to small
sample size, it is not statistically significant 8.
Figure 2-4. Prevalence of
Intergenerational Trauma
50%
42%
40%
30%
22%
20%
19%
16%
10%
0%
Parent & Youth
Parent Only
Youth Only
Neither
Effects of Trauma on Youth and Families
As previously described, children and youth who experience trauma are not likely to
receive a formal PTSD diagnosis; instead they often manifest that exposure to trauma in
other ways. Among adults, the risk for a number of health and well-being problems over
the lifespan increases in direct relation to the number of childhood trauma exposures. The
The extent the caregiver was bothered by the childhood trauma could not be included since the TEXI does
not measure that.
8 The same proportional difference tested with a larger sample size was statistically significant.
7
Page 12
following sections explore these concepts for participants in THRIVE’s Family Partnering
Program.
Youth Trauma Symptoms, Behaviors and Strengths
Children and youth who reported more trauma experiences in their lives displayed a
higher likelihood of experiencing clinical symptoms of trauma when they first enrolled in
THRIVE’s Family Partnering Program. For example, as Figure 2-5 shows, children and
youth with extensive trauma histories were significantly more likely to exhibit symptoms
of anxiety (25% compared to 7%) and post-traumatic stress (40% and 9%), 9 both of which
were statistically significant at the .05 level. Other observed differences were not
statistically significant.
Figure 2-5. Child/Youth Trauma Symptoms,
By Number of Trauma Experiences
50%
40%
30%
40%
38%
36%
30%
27%
26%
25%
20%
9%
10%
19%
14%
7%
7%
0%
Depression
Anxiety
Anger
< 3 Trauma Experiences
PTS
Dissociation
3+ Trauma Experiences
Sexual
Concerns
These results are not overly surprising, as children with a trauma background exhibit
higher rates of trauma symptoms. However, the effects of youth trauma experiences were
observed in other measures as well. For example, those with a higher level of trauma
experiences were more likely to exhibit challenging behaviors and less likely to exhibit
strengths. This is demonstrated in Figure 2-6, which shows the percentage of children and
youth whose reported behaviors placed them within the clinical range on indicators
captured by the Child Behavior Checklist (CBCL). For example, compared to children and
youth reporting fewer trauma experiences, those reporting a higher incidence of trauma
were much more likely to present social problems (52% compared to 28%), withdrawn or
depressive behaviors (41% compared to 17%), somatic complaints (38% versus 14%) and
aggressive behaviors (67% compared to 44%). These were all statistically significant
differences.
This does not indicate a formal diagnosis of post-trauma stress disorder, merely symptoms associated with
such a diagnosis.
9
Page 13
Figure 2-6. Child/Youth Challenging Behaviors,
By Number of Trauma Experiences
100%
80%
52%
60%
40%
43%
28%
41%
17%
20%
38%
64% 60%
42% 44%
28%
54%
39%
67%
44%
14%
0%
<3 Trauma Experiences
These children and youth were also less likely to report strengths than their counterparts
who did not have significant trauma in their histories. This is demonstrated in Figure 2-7,
which depicts child and youth scores on six measures of strengths captured on the
Behavioral and Emotional Rating Scale (BERS). When compared to other children and
youth enrolled in THRIVE’s Family Partnering Program, those with extensive trauma
histories were less likely to demonstrate interpersonal strengths (ability to control
emotions or behaviors in social situations), affective strengths (ability to express emotion
and accept affection), family involvement strengths (participation and involvement with
family) or intrapersonal strengths (outlook on self competence and accomplishments).
Again, these were statistically significant differences, with intrapersonal strengths
significant at the p<= 0.1 level (the observed differences in school functioning and career
strength were not significant).
Figure 2-7. Child/Youth Strengths,
By Number of Trauma Events
10.0
8.0
6.0
7.3
8.0
7.5
6.1
6.4
8.9
6.9
7.7
6.1 5.9
7.2
7.9
4.0
2.0
.0
< 3 Trauma Experiences
Page 14
Caregiver Stress and Health
To determine whether the ACES findings held true within the THRIVE population of
caregivers, the effects of caregiver trauma experiences were explored in terms of stress and
health problems. The Caregiver Strain Questionnaire asks questions about the stress levels
of caregivers and calculates scores for a series of scales. Scores range from 1 to 10 whereby
higher scores indicate more stress. As demonstrated by Figure 2-8, caregivers with a higher
level of childhood trauma exposure were more likely to report being stressed than
caregivers who did not report an extensive history of childhood trauma. For example, they
exhibited an average score of 8.4 in terms of overall strain, compared to 6.8 among
caregivers who reported a less extensive trauma history.
Similarly, the same group of caregivers was also more likely to report that someone in their
household had recurring physical health problems, 69 percent compared to 33 percent,
although this was not necessarily the primary caregiver. All the findings for stress and
health were statistically significant.
Intergenerational Trauma Effects
Although there is existing research that demonstrates the effects of trauma on children and
the effects of childhood trauma on adults, there is little research that explores how the
trauma combined experiences of youth and primary caregivers affect families, that is, that
tests the compounding effects of intergenerational trauma on trauma survivors within a
family. To explore this more fully, the evaluation study created an additional comparative
layer that compared the symptoms and behaviors of youth with a trauma histories by
whether their primary caregiver also reported a significant history of trauma. 10
Figure 2-8 below shows the proportion of children/youth scoring in the clinical range for
trauma symptoms among those who had experienced three or more trauma experiences. It
is comparing two groups: those where both the children/youth and the caregiver had
experienced three of more trauma events and those where only the youth had experienced
three or more trauma events.
It shows that children and youth living in families with “intergenerational” trauma were
more likely to score in the clinical range for symptoms related to trauma. For example,
among youth who experienced trauma and lived with a caregiver who had also experienced
trauma, 42 percent showed clinical symptoms of depression, compared to only five percent
among youth who had experienced three or more trauma exposures but did not live with a
caregiver who had an extensive trauma history. The observed differences were statistically
significant among the symptoms of depression, sexual concerns and anger (the last being
significant at the p<= 0.1 level).
10
For more detailed definitions, please refer to the methodology section of this chapter.
Page 15
Figure 2-8. Trauma Symptoms Among Traumatized
Children/Youth, by Parent Trauma History
50%
40%
42%
37%
37%
30%
30%
25%
18%
20%
15%
16%
15%
16%
10%
10%
5%
0%
Depression
Anxiety
Anger
PTS
Parent and Youth
Dissociation
Sexual
Concerns
Youth Only
The findings were similar for caregiver stress and child behaviors. For example, caregivers
of youth with higher levels of trauma exposure who also had their own trauma history
were more likely to be stressed (9.2 average score, compared to 6.8). As demonstrated by
Figure 2-9, youth with trauma who lived with a primary caregiver who also had a trauma
history were more likely to exhibit challenging behaviors; this was statistically significant
for all the indicators except the scale for withdrawn/depressed behaviors; somatic
complaints are significant at the p<= 0.1 level.
100%
Figure 2-9. Behaviors Among Traumatized Children/Youth,
by Parent Trauma History
80%
60%
70%
65%
63%
58%
48%
45%
42%
37%
40%
20%
80%
75%
26%
21%
32%
26%
16%
11%
0%
Parent & Youth
Youth Only
Page 16
Effectiveness of the Trauma-informed Approach to Service Delivery
In addition to receiving Family Support Partner services, families enrolled in the program
also benefited from the changes occurring within the service delivery system as a result of
THRIVE’s training, technical assistance and assessment opportunities that were provided
to local service agencies over the course of the project. The following section explores the
observed changes in trauma-related symptoms and other behaviors among 78 families for
whom data collected at intake could be linked to an interview conducted six months after
enrollment.
Trauma Symptoms
After working with a trauma-informed Family Support Partner, as well as receiving other
mental health and support services for six months, children and youth for whom data were
available showed reduced rates of clinical symptoms for trauma. This is demonstrated in
Figure 2-10 below.
Figure 2-10. Child/Youth Trauma Symptoms at Baseline
and 6 Months
50%
40%
35%
33%
29%
30%
20%
24%
21%
22%
21%
19%
17%
12%
10%
12%
10%
0%
Depression
Anxiety
Anger
Baseline
PTS
Dissociation
Sexual
Concerns
6-Months
The chart shows that the rates of clinical symptoms related to depression, anxiety, anger
and dissociation decreased, all of which were statistically significant declines (depression
and anger are significant at the p<= 0.1 level). For example, the rate of children and youth
showing clinical signs of depression decreased from 33 percent to 21 percent; those
exhibiting signs of anger decreased from 35 percent to 21 percent. Interestingly, the
proportion of children and youth exhibiting signs of post-traumatic stress changed little,
perhaps because youth and families were addressing their trauma history, rather than
focusing on behavioral or related symptoms. Although the numbers are too small to draw
conclusions, it appears that the majority of improvement was experienced among children
and youth who had experienced more traumatic events in their lifetimes.
Page 17
Strengths, Stress and Challenging Behaviors
The findings observed for trauma-related symptoms continue when examining the
measures of child/youth strengths as well as other challenging behaviors. For example, the
average strength scores of children and youth increased in all areas (from 5.63 to 6.50),
although only school-based strengths were statistically significant. Similarly, among
caregivers, stress and strain indicators also showed modest improvements. For example,
the average score for overall stress decreased from 7.7 at baseline to 7.3 six months later, a
statistically significant change.
Figure 2-11 illustrates how challenging behaviors among children and youth decreased six
months after enrollment. Notably, the proportion of children exhibiting thought problems
decreased from 71 percent to 55 percent, while those challenged with social problems
declined from 45 percent to 31 percent, both of which were statistically significant findings.
Children exhibiting attention problems and somatic complaints also decreased significantly
at the p<= 0.1 level.
Figure 2-11. Child/Youth Challenging Behaviors at Baseline
and 6 Months
100%
80%
71%
60%
45%
45%
40%
20%
58%
55%
35%
29%
24%
25%
42%
35%
31%
60%
35%
24%
15%
0%
Baseline
6-Months
Intergenerational Trauma and Outcomes
Mirroring the previous analysis on the prevalence of intergenerational trauma at program
intake, the evaluators wanted to see if there were any reductions in the trauma symptoms
Page 18
of youth who experienced trauma and lived with a caregiver who also had a trauma history,
compared to youth who have experienced trauma but do not live with a caregiver who had
a trauma history. Although the numbers were again quite small (the two groups had 23 and
12 cases, respectively), the data yielded some interesting results that are shown in Figure
2-12.
Figure 2-12. Change in Child/Youth Trauma Symptoms,
by Intergenerational Trauma
50%
43%
39%
40%
42% 42% 42%
39%
35%
30%
30%
26%
26%
22%
22%
20%
25%
22%
17% 17% 17%
17%
17%
13%
9%
10%
8% 8%
8%
Parent & Youth
Sexual Concerns
Dissociation
PTS
Anger
Anxiety
Depression
Sexual Concerns
Dissociation
PTS
Anger
Anxiety
Depression
0%
Youth Only
Baseline
6-Months
In the both groups, there was a statistically significant reduction in symptoms associated
with dissociation. This was a decrease from 22 percent to nine percent in the group
consisting of parents and children/youth who had experienced trauma histories. In the
second group, which consisted of youth who had experienced trauma who lived with a
caregiver who had not, symptoms of dissociation declined from 42% to 17%. The
differences observed after six months between the two groups in terms of improved
depression symptoms were statistically significant at the p<= 0.1 level.
Summary Conclusions
The majority of children and families enrolled in THRIVE’s Family Partnering Program
experienced notable amounts of trauma and trauma significantly influenced child and
family outcomes. Children and youth who experienced trauma exhibited trauma-related
symptoms and faced other behavioral and functional challenges at higher rates than
Page 19
children and youth who did not report significant trauma histories. The study also
demonstrated that the trauma experiences of parents and/or primary caregivers,
particularly events that occurred during childhood, appeared to affect youth symptoms as
well as overall family functioning.
Moreover, THRIVE data strongly suggest that participation in the Trauma-informed System
of Care resulted in improved outcomes and symptom reduction among youth and family
with trauma histories, despite their higher likelihood of exhibiting clinical trauma
symptoms at intake when compared to youth and families who do not report trauma
backgrounds. Specifically, THRIVE’s Family Partnering Program appeared to have a
positive effect on child/youth trauma symptoms such as depression and dissociation,
particularly in families experiencing intergenerational trauma.
Overall, the findings suggest that service providers who take into account the trauma
history of the entire family as a whole, not just the child/youth who is the subject of
services, will achieve better outcomes. This does not necessarily mean that direct clinical
services must be provided to the whole family, but rather that the trauma-informed
approach to service delivery, which in this case included Family Support Partners, may well
improve service engagement and ultimately parental functioning. Future systems of care
should be closely aligned with the trauma-informed approach.
Page 20
CHAPTER 3
SERVICE UTILIZATION AND COST OUTCOMES
Performing a Services and Cost analysis was another component of THRIVE’s Family
Partnering Program’s overall evaluation plan. This chapter outlines the purpose of the
study, the research questions, the types of information collected, and the observed findings
from the final study sample.
The primary purpose was to describe the types of services used by children and families
and the costs associated with them. A secondary purpose was to explore the relationships
among service use and costs as they related to the period of enrollment in THRIVE’s Family
Partnering Program. Lastly, the evaluation aimed at comparing the results of children who
have had a trauma history to those who had not. To address the study areas described
above, the evaluation team developed the follow research questions:
1. What services are used by children and their families who are enrolled in THRIVE’s
Family Partnering Program?
a. What are the service use patterns before, during and after participation?
b. How much do services cost before, during and after participation?
2. What is the cost effectiveness of services in terms of cost savings?
3. In each of the areas described above, is there an observable difference between
those with trauma histories and those without?
Methodology
Medicaid claims data were provided for this study by the State of Maine’s Department of
Health and Human Services Office of Continuous Quality Improvement. Information for all
children enrolled in the project’s descriptive study through June 2010 and who consented
to participate in this additional study were matched to Medicaid claims data covering FY
2007 (July 2006) through FY 2010 (June 2010). Children were identified based on first
name, last name, date of birth and county of residence; a successful match was made for
147 children (76% of all children enrolled).
Using diagnostic codes, the file was then split into two groups. The first file constituted
physical health (or medical) claims, meaning that the services were unrelated to a mental
health diagnosis. The second file contained mental health claims, meaning that at least one
diagnosis associated with each claim was related to mental health. Mental health diagnoses
included all the DSM and V codes that comprise Serious Emotional Disturbance (SED)
which are used to determine system of care eligibility. 11 The distinction between medical
11
The Diagnostic and Statistical Manual of Mental Disorders (DSM) provides a common language and
standard criteria for the classification of mental disorders; V codes (codes V01–V91) are medical codes used
to describe encounters with the healthcare system due to circumstances other than disease or injury (e.g.,
assessment due to exposure to abuse). The same list of DSM and V codes provided by the National Evaluation
Team for completing the Enrollment and Demographic Information Form (EDIF) were used here.
Page 21
and physical health claims was made based on diagnostic code, as opposed to the
procedural codes, to reflect that some physical health procedures may in fact be related
primarily to a mental health condition; for example, medication management often
involves drawing blood samples (a “medical” procedure) to monitor medications
prescribed for a mental health condition.
The procedural codes were then grouped into service categories following the guidance
employed by the Data Infrastructure Grant (DIG) in Maine. Additional re-coding was
completed to categorize procedure codes that were used in Maine prior to 2009
(specifically, Z codes), and codes used by entities that provide mental health services that
are not directly overseen by the children’s behavioral health system but are nonetheless
billable mental health services (e.g., services provided by schools or juvenile justice).
Episodes of care received at hospitals were also recoded, relying upon a combination of
items to determine the overall type of episode, including provider type, facility type,
procedure and primary diagnosis. Hospital classifications were further examined and
coded so that medical procedures related to a mental health episode were rolled up into
the primary mental health service, an important step for capturing the costs associated
with mental health and psychiatric hospitalizations.
Since a comparison group was not available, the study employed a cost effectiveness
analysis in which the costs in monetary units were compared over the three following time
periods:
•
•
•
six months before enrollment (“prior”);
six months immediately after enrollment (“immediate”), and
six months after the immediate period of enrollment (“post”) during which families
were discharged (the majority were discharged around six months).
To determine the cost-effectiveness, the study examines observed differences in service
utilization and costs associated with the prior, immediate and post periods by family
trauma history and functional outcomes.
Participants
The majority of children and youth in the services and cost study were male (61%) and 60
percent were under the age of 12 when they enrolled; one quarter were between the ages
of 15 and 18. Just over half had a diagnosis of attention deficit hyperactivity disorder,
followed by mood disorders (38%), post-traumatic stress and acute stress disorders
(21%), other anxiety disorders (17%) and oppositional defiant disorder (15%). Just under
half had more than one diagnosis. The caregivers were female (91%) and three out of four
were under the age of 40.
To ensure that the timeframes and services were comparable, the original 143 cases were
limited to only those cases where the enrollment date allowed for a full six months in each
Page 22
period (even if no services were received), yielding 102 children and youth in the final
sample. 12
Findings
Service Use Patterns
The concept of “service use patterns” was operationalized to encompass the following two
factors: the kinds of services families received and the number of service types received in
each period. For all three time periods, targeted case management was the most common
service used by families as demonstrated in Figure 3-1 on the following page.
This was followed by outpatient services, medication management and school-based
supports (non-rehabilitation). All these services were provided in relation to a mental
health diagnosis. The percentage of families using targeted case management increased
during the period after enrollment by almost 10 percentage points, representing nearly a
14 percent increase. School-based services also increased slightly. The services in which
use decreased immediately after enrollment were Emergency Room (from 25% of families
to 20%); crisis support, from 24 percent to 14 percent, a 42 percent decrease; outpatient
hospital services, from 17 percent to nine percent, a 47 percent decrease; and home-based
services, from 10 percent to five percent (a 50% decrease). All of these decreases were in
the desired direction. While these rates rebounded somewhat during the post period when
contact with the Family Support Partner ended, they remained lower than in the period
prior to enrollment.
12 One case was removed because the family moved out of state shortly after enrollment and had no service
records after that point.
Page 23
Figure 3-1. Percentage of Children/Youth Using Community Services,
by Time Period
71%
Targeted Case Management
73%
Outpatient Services
49%
Medication Management
27%
58%
58%
38%
34%
35%
37%
32%
School-based Support (non-Rehabilitation)
32%
27%
34%
Community Supports (Sec 65M, 65G and M&N)
31%
31%
32%
Federally Qualified Health Clinic
25%
20%
24%
Emergency Room/Department
Crisis Support
14%
11%
Outpatient Hospital Services (MH)
9%
11%
24%
17%
11%
14%
13%
School-based Rehabilitation
Home Based Services
5%
1%
Case Management - Other
4%
2%
10%
9%
8%
12%
Psychiatric/Psychological Services
5%
6%
2%
1%
Transport (any)
6%
Day Treatment
13%
9%
Day Habilitation
6%
5%
4%
Substance Abuse Services
5%
6%
2%
Education-related Early Intervention Therapy
2%
2%
1%
Assertive Community Treatment (ACT)
1%
1%
0%
Community Integration
1%
2%
1%
0%
Prior
80%
20%
Immediate
40%
60%
80%
100%
Post
Page 24
Figure 3-2 examines the percent of children and youth who received out-of-home care
related to a mental health diagnosis by three service types: residential care at a Private
Non-Medical Institution (PNMI), inpatient psychiatric hospitalization; and inpatient
hospitalization related to mental health.
Figure 3-2. Percent of Children/Youth with Hospitalizations Related to
Mental Health, by Time Period
25%
20%
18%
15%
10%
6%
5%
9%
8%
7%
7%
5%
4%
5%
0%
Private Non-Medical Institution
(Residential)
Inpatient Psychiatric Hospital
Prior
Immediate
Inpatient Medical Hospital
Post
The proportion of children or youth who received residential services at a PNMI fluctuated
only slightly across the three time periods. However, the percent who received inpatient
mental health services from either a psychiatric hospital or a medical hospital was reduced
by nearly half in the period immediately after enrollment. Most notably, inpatient
hospitalizations at a medical hospital decreased from 18 percent to nine percent. These
trends are sustained in the post period, meaning that one year after THRIVE’s Family
Partnering Program enrollment, the incidence of inpatient hospitalizations among children
and youth remained lower than in the six months prior to enrollment. The rate differences
observed between the prior period and the other two periods are statistically significant
for inpatient hospitalization.
The service array also changed immediately after enrollment. As demonstrated in Figure 33, the percentage of children and youth who were receiving more than five different types
of services decreased from 26 percent to 17 percent; more than half were receiving
between three and five different types of services. This pattern appears to be sustained one
year after enrollment in THRIVE’s Family Partnering Program.
Page 25
Figure 3-3. Percentage of Children and Youth, by Number of
Service Types and Time Period
100%
80%
59%
60%
52%
44%
40%
25%
26%
25%
21%
20%
5%
17%
16%
7%
4%
0%
Prior
None
Immediate
Less than 3
3 to 5
Post
More than 5
Cost Effectiveness of Services
Overall, there is a Medicaid claims cost savings of just over $450,000 between the period
prior to enrolling in THRIVE’s Family Partnering Program and the period after program
involvement, or an average savings of $4,436 per participant. This is demonstrated in Table
3-1. In terms of monthly participant costs, the average cost per month was $2,452 in the
period prior to enrollment, compared with $1,665 in the post period for an average
monthly savings of $787 per person. Whether examining total savings, per participant
savings or average monthly costs, the results demonstrate an overall reduction in costs of
just over 30 percent (31 and 32 percent, respectively).
Table 3-1. Total Costs, Per Participant Costs and Average Monthly Costs,
By Time Period
Total Costs
Costs Per Participant
Average Monthly Costs
Prior
$1,469,063
$14,402
$2,452
Immediate
$1,143,353
$11,209
$1,869
Post
$1,016,581
$9,966
$1,665
Savings (Post-Prior)
($452,481)
($4,436)
($787)
Page 26
The majority of the costs savings appears to be related to the shift away from higher cost
services such as inpatient hospitalizations and residential services as shown in Table 3-2,
which breaks out the total by service category. This shift (away from hospitalizations) was
also observed in the utilization patterns described previously. For example, costs
associated with inpatient psychiatric hospitalization decreased by about $122,000, for a
savings of 51 percent. Moreover, costs associated with visits to the Emergency
Room/Department decreased by 40 percent and it appears that inpatient stays resulting
from an Emergency Room visit decreased in the immediate and post periods.
Table 3-2. Total Costs, by Service Category and Time Period* for Serving 102 Families
Service Category
Assertive Community Treatment (ACT)
Case Management - Other
Community Integration
Community Supports (Sec 65M, 65G and M&N)
Crisis Support
Day Habilitation
Day Treatment
Education-related Early Intervention Therapy
Emergency Room/Department
Federally Qualified Health Clinic Services
Home Based Services
Inpatient Hospitalization
Inpatient Psychiatric Hospitalization
Medication Management
Outpatient Services
Outpatient Hospital Services
Private Non-Medical Institution (Residential)
Psychiatric/Psychological Services
School-based Rehabilitation
School-based Support (non-Rehabilitation)
Substance Abuse Services
Targeted Case Management
Transport (any)
Total
Prior
Immediate
Post
$10,850
$5,939
$368
$155,141
$37,130
$45,398
$27,910
$3,534
$42,098
$40,991
$38,478
$208,942
$242,568
$15,512
$64,225
$8,265
$281,656
$5,414
$9,703
$32,097
$27,977
$159,238
$5,629
$1,469,063
$4,055
$1,926
$3,199
$120,319
$11,310
$71,303
$52,947
$2,520
$21,134
$16,255
$33,548
$76,308
$113,047
$15,846
$66,235
$3,331
$295,052
$12,074
$5,258
$25,495
$18,731
$172,613
$846
$1,143,354
$0
$1,281
$4,878
$119,840
$7,849
$58,862
$58,737
$3,180
$25,266
$21,443
$3,871
$87,031
$119,817
$9,262
$60,985
$3,275
$220,524
$4,372
$10,319
$32,071
$8,952
$154,445
$322
$1,016,582
Savings
(Prior-Post)
($10,850)
($4,658)
$4,510
($35,301)
($29,281)
$13,464
$30,827
($354)
($16,832)
($19,548)
($34,607)
($121,910)
($122,751)
($6,250)
($3,240)
($4,990)
($61,132)
($1,042)
$617
($26)
($19,025)
($4,793)
($5,307)
($452,481)
*A time period represents six months of service costs.
Page 27
Observed Differences Among Groups of Interest
When average monthly costs are examined by the presenting trauma histories of child,
youth and families, interesting trends emerge that mirror the findings observed in the
outcomes study. This is illustrated in Figure 3-4 which shows that the greatest reductions
in average costs were within families where the parent had a trauma history, or where the
child and parent both had trauma histories.
Figure 3-4. Average Monthly Costs by Interval and Trauma History
$5,000
$3,395
$1,694
$1,553
$1,694
$1,650
$1,271
$1,349
$1,775
$1,000
$1,884
$2,000
$2,224
$2,882
$3,000
$3,621
$4,000
$Parent & Youth
Parent Only
Prior
Youth Only
Immediate
Neither
Post
These findings are even more notable when considered within the context of THRIVE’s
Family Partnering Program. That is, THRIVE provided trauma-informed training to its
Family Support Partners in an effort to assist families whose children had severe emotional
disturbances, but particularly those with a trauma background. And it appears that those
are the people who had the greatest cost savings. These data, for the first time, show that
the greatest cost savings were observed with the families where the child and the parent
both presented a trauma history. In those instances there was a reduction in average
monthly costs of $1,847 between the period prior to THRIVE enrollment and the period
after discharge, a 51 percent decrease.
Conversely, there were actually marked increases in average monthly costs in cases where
only the child had a trauma history, or neither the child nor the parent presented a trauma
history. The majority of these changes were attributable to shifts in the utilization of
inpatient hospital services, residential care, day habilitation, day treatment and community
supports. These findings suggest that even more savings can be realized if Family Support
Partners are targeted to families with trauma histories.
Page 28
Summary Conclusions
Families who participated in THRIVE’s Family Partnering Program were most likely to
receive targeted case management services both before and after enrollment. The
utilization of emergency room services, crisis support and outpatient hospital services all
decreased immediately after enrollment, as did the proportion of children and youth using
inpatient mental health services. These shifts in service utilization had a desired effect in
reducing costs by more than 30 percent one year after enrollment, for a total savings of
$450,000 and averaging $787 monthly per participant.
The findings also suggest that THRIVE’s Family Partnering Program was most effective at
serving families with an intergenerational trauma history. Moreover, the children of adult
trauma survivors appear to be more effectively served by other community-based services
when their parents have access to peer supports such as trauma-informed family support
partners, and at an overall lower cost. Isolating the families where one or both family
members had experienced trauma the average cost savings are even greater. For those
where both the caregiver and the child experienced trauma the savings was 51 percent six
months after services were over whereas when the parent alone had experienced trauma it
was 53 percent for the same time period.
As demonstrated in the previous chapter, children and youth enrolled in THRIVE’s Family
Partnering Program showed improved outcomes in reduced trauma symptoms. This
chapter has shown that achieving better outcomes was also associated with a shift away
from inpatient hospital services, which resulted in a total cost-savings among children and
youth enrolled in THRIVE’s Family Partnering Program. Moreover, the average cost-savings
was greatest among families where the parent had experienced trauma as a child, again
demonstrating the need for aligning children’s mental health services with the traumainformed approach, and one which addresses and supports all family members.
Page 29
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Page 30
CHAPTER 4
EFFECTIVENESS OF TRAUMA-SPECIFIC TREATMENT
In 2006, THRIVE’s Clinical and Evidence-Based Practice Committee identified Trauma
Focused-Cognitive Behavioral Therapy (TF-CBT) as one of two evidence-based traumaspecific treatment models for children and families to be implemented in the Androscoggin,
Oxford, and Franklin County catchment area. The Learning Collaborative, between THRIVE
and its community partners, was open to licensed clinicians and clinical supervisors who
actively worked with children and families in the catchment area. Participation required a
year-long commitment and offered clinicians and supervisors an opportunity to learn a
trauma-focused, evidence-based treatment model. Also included were an organizational
readiness assessment; formal clinical training; monthly peer consultation; and on-going
support for implementation.
A further mission of the Tri-County Learning Collaborative was to document the
effectiveness of the TF-CBT treatment through structured data collection adapted from the
TF-CBT protocol employed by the National Childhood Traumatic Stress Network. The
purpose of this study component was threefold:
•
•
•
To describe the population that received TF-CBT as part of the Learning
Collaborative in terms of both demographics and trauma experiences;
To present findings of client-level outcomes that may be linked to TF-CBT; and
To identify areas where the data collection process did not work well and make
recommendations for improvements for the future.
Methodology
The evaluation protocol consisted of the following tools: a Baseline Demographics form
that collected participant characteristics; the Lifetime Incidence of Traumatic Events (LITE)
to collect trauma history from the parent and the youth; a form (Measurements of
Resiliency) to capture participants’ key resiliency factors, collected from the parent and the
youth; and the UCLA PTSD Index that captured trauma-related symptoms, collected from
youth.
At the beginning of treatment clinicians administered the data collection tools to each
client who participated in TF-CBT and again upon completing the treatment. It is important
to note that TF-CBT clients participating in this study did not participate in any of the
evaluation studies previously described, nor did they work with a Family Support Partner.
The evaluation identified the following key questions:
•
•
•
What does the population receiving TF-CBT look like?
What type of traumatic events have clients experienced?
What impact has TF-CBT had on clients’ trauma-related symptoms?
Page 31
Additionally, the evaluation collected monthly process measures from each clinician which
included the number of consultations with the Collaborative; the amount of agency
supervision received; and the number of TF-CBT sessions for each client. Lastly, clinicians
completed a form after each session measuring fidelity to the TF-CBT model, as well
pinpointing where successful adaptations occurred. Data were collected by all participating
clinicians between April 2007 and June 2009 and submitted to HZA, THRIVE’s contracted
evaluators via an electronic data submission system.
Participants
Agency Participation
Forty staff from seven agencies plus four private practitioners received a total of 176 hours
of supervision related to TF-CBT; agencies with more clients participating in TF-CBT
generally reported more hours of supervision.
TF-CBT Participants at Start of Services
Thirty-five clients were served by TF-CBT as reported on any data collection tool although
not all tools were used for each client. Data received for 20 participants indicated that
those served were predominantly female (70%) ranging in age from seven to age 17 and 55
percent were over the age of 12. All participants were white, U.S. citizens and spoke English
as their primary language. Seventeen out of 20 (85%) participants lived at home with a
parent while three lived in residential treatment group homes.
Ten youth reported frequent occurrences of eight or more indicators of trauma
symptoms 13. Specifically, more than 50 percent indicated frequent occurrences of the
following trauma symptoms at the beginning of treatment:
•
•
•
•
•
•
•
•
I watch out for danger or things that I am afraid of.
When something reminds me of what happened, I get very upset, afraid or sad.
I have upsetting thoughts, pictures, or sounds of what happened come into my mind
when I do not want them to.
I feel grouchy, angry or mad.
I try not to talk about, think about, or have feelings about what happened.
I have trouble concentrating or paying attention.
I try to stay away from people, places, or things that make me remember what
happened.
I have arguments or physical fights.
13 Note that the list was derived from the UCLA PTSD Index which employs somewhat different factors from
the Trauma Symptom Checklist referenced in the prior chapters.
Page 32
Client Level Outcomes
Data indicated that at least 10 clients completed TF-CBT while two dropped out; the
remaining participants (16) continued treatment as the final monthly data was submitted.
Clients who completed TF-CBT received the treatment for an average of four months, with
a range from three to six months.
Two primary client level outcomes were identified: 1) youth expressed positive changes on
the measures of resilience after participating in TF-CBT; and 2) youth reported decreases
in the frequency of trauma-related symptoms. In two instances, youth and the parent
reported positive improvements on four or more aspects of the resiliency scale after
participating in TF-CBT; however, results for other youth were less definitive. Overall,
youth rated themselves higher in resilience than their parents rated them. In three cases,
parents reported positive changes by the end of TF-CBT while youth reported negative
changes.
Eight participants completed the UCLA PTSD Index at the beginning and end of TF-CBT.
Five reported significant declines on four or more trauma symptom indicators, but results
from the remaining three respondents were mixed.
Fidelity to the TF-CBT Model
Overall, it appears that clinicians remained faithful to the model according to the fidelity
checklists that were submitted. Among the 13 people who completed 10 or more sessions,
only three indicated that any aspect of the TF-CBT model had not been utilized during at
least one session. Those components were: the development of a desensitization plan,
addressing the child’s sense of safety, and teaching problem-solving skills. Interestingly,
though the clinicians were different, the same three components were skipped in all three
cases.
The majority of adaptations dealt with timing and flexibility or sensitivity to client needs
(e.g., one clinician lengthened the sessions, one extended the number of sessions, and
another slowed down the typical trajectory of dealing with issues as the patient and family
felt overwhelmed). Furthermore another adaptation was displayed by a session in which
the parent gave the child permission to share his or her trauma history. The trauma had
been a secret in the past, but this session helped to assuage the child’s fear that the parent
would be angry with the child for talking about the trauma.
Lessons Learned Regarding Data Collection
With a small number of participants and only fair data quality, it is difficult to draw
definitive conclusions from this aspect of the evaluation. However, the evaluators
developed suggestions for increasing data quality in for future learning collaboratives.
Foremost, the tools should be revisited focusing on their usefulness and feasibility, both in
a clinical setting and as an evaluation measure. Table 4-1 summarizes assessments and
recommendations regarding data collection tools.
Page 33
Table 4-1. Assessment of the Data Collection Tools
Tool
Baseline
Demographics
Lifetime
Incidence of
Traumatic
Events (LITE)
Measures of
Resiliency
UCLA PTSD
Index
Monthly
Metrics
Fidelity Tool
Pros
Easy to
administer
Important to
understand who
is being served
Easy to
administer
Asks both youth
and the parent
for a trauma
history
Easy to
administer
Set a positive
tone
Easy to
administer
Captures 22
symptoms
Provided basic
data on the
number of
clients served
and hours of
training
Captured useful
information
about program
components
and adaptations
Cons
Detailed
demographics
(e.g. income level,
number of
children) were
not useful
None identified
Results were
inconclusive
Provided mixed
results
Was not
submitted
regularly
Usefulness
Recommendation
Useful for
evaluation only
Tool should be simplified
for a future learning
collaborative
Useful both
clinically and for
evaluation
Unless the Uniform
Trauma Screening Tool
(currently under
development) is adopted
the LITE should be used
again for a future learning
collaborative
The utility both
to clinicians and
to the
evaluation is
doubtful
Questionable
clinical use
Tool may not
accurately
capture the
areas impacted
by TF-CBT
A future learning
collaborative should
examine other symptom
tools such as Trauma
Symptom Checklist.
Useful for
evaluation only
Tool should be simplified
and included as part of a
future learning
collaborative.
Useful clinically
and for the
evaluation
Tool should be revised and
used as part of a future
learning collaborative.
Some found it
confusing
Difficult to
analyze
This tool should not be
used for a future learning
collaborative.
Some clinicians indicated that reviewing data protocols after two days of intense training
was overwhelming. It may be useful to provide additional training on the data collection
protocol, or to introduce it at a different point. Providing training in smaller doses and at
different stages may also be helpful. Additional training may address many of the common
data errors such as missing or incomplete forms; incorrect identification numbers; and
Page 34
transposition of identification numbers. Simplifying the numbers, or using a number
already being utilized, may make more sense.
Electronic data submission worked well for some clinicians but others experienced
complications; many were simply more comfortable with paper. Consequently, various
easier methods should be considered. An obvious choice would be using paper-based
packets that can be pre-numbered; this method might alleviate some of the data errors
outlined above, but would then require data entry. An alternative is a web-based system
although that would not be possible to complete during a therapy session itself.
Lastly, agencies with strong supervisory buy-in for the data collection process produced
better data results. To obtain high quality data from learning collaborative participants, it is
imperative to train supervisors in the data collection protocol, about the benefits derived
from data collection, and in the importance of their role in monitoring data collection.
Summary Conclusions
Findings from Maine’s TF-CBT Learning Collaborative support a continued offering of TFCBT as an effective treatment for trauma survivors. Overall, TF-CBT participants were wellmatched with the treatment; each reported having experienced multiple traumas in their
lifetimes. More importantly, five out of eight cases resulted in clear and consistent
improvements on PTSD indicators, while others showed milder improvements. More data
are needed to fully gauge the impact of TF-CBT on Maine’s population of young people who
have experienced trauma, and a larger sample of complete pre- and post- data would likely
produce more conclusive results. However, TF-CBT should continue to be offered as a key
element of the service array for THRIVE and other trauma-informed efforts.
Page 35
Page 36
CHAPTER 5
ASSESSING THE TRAUMA-INFORMED APPROACH TO SERVICES
A major focus of THRIVE was to assist entire mental health agencies to be trauma-informed
in their approaches and practices. That is, not only should the treatments take trauma into
account but a child and family’s experience interacting with its mental health provider
should be nurturing and empowering and generate a sense of safety. At the very least, the
interaction should not contribute to the trauma already experienced in other contexts. The
question taken on by THRIVE was how to assess the degree to which an entire agency had
adopted a trauma-informed approach. THRIVE’s answer rested in developing a traumainformed agency assessment (TIAA) which could be used to assess all aspects of the
agency’s presentation and treatment to families and children. This chapter provides a
formative analysis of the assessment and the results that were achieved during the life of
the project.
Formative Analysis of TIAA
The development process for the TIAA occurred over a two-year period. Youth and family
members were instrumental partners during each phase.
Planning
A group of key stakeholders, including youth and family members working with THRIVE,
created the conceptual framework for the TIAA, as well as brainstormed methods for
collecting the information needed to complete it. The initial content was based on TraumaInformed Systems Theory (Fallot & Harris, 2006) and system of care principles. The first
major decision was which domains to include from the two conceptual bases. The planning
group determined where the domains overlapped and which additional ones were critical
to both trauma-informed practice and system of care principles. The result was selection of
six domains which are defined in the next section: physical and emotional safety; youth and
family empowerment; trustworthiness; trauma competence; cultural competence; and
commitment to trauma-informed philosophy.
A workgroup reviewed the literature, collected and examined existing tools, and drafted
potential questions. Sets of questions were written for each perspective being assessed:
managers, clinicians, family members and youth. The idea was that multiple perspectives
would give agencies the most complete view of their trauma-informed performance. They
then developed uniform standards which provided the basis on which to assign a score. A
larger group of stakeholders reviewed and vetted the results of the planning phase.
Pilot Testing
Two agencies pilot tested the TIAA, as well as answered questions regarding the method of
administering the assessment. Initially the stakeholders wanted people outside of the
agency to administer and score the tool. During the pilot phase, paired teams (an evaluator
Page 37
and a trained youth/family member) conducted interviews with agency administrators and
supervisors, staff, family members and youth. Interviewers scored responses according to
the standards articulated during the planning phase. The information was analyzed, and
the results presented to the stakeholder group.
Refining
Youth and family members helped interpret the results of the pilot and provided feedback
about the data collection methods based on their field experiences. Stakeholders also
determined that it was overly labor-intensive to have external evaluators (including family
members and youth) conduct the assessment face to face. Moreover, this approach was not
sustainable once funding was concluded. Taking into account all findings, the tool was
made into a self-assessment or, in the case of the youth and family, an assessment of the
agency. In addition, the tool was developed in a web-based version. Youth and families
provided invaluable guidance on the most compelling ways to present the results to
various audiences. During the next phase, people were given the option of completing the
TIAA electronically through the web, or on paper.
Implementing
Once the pilots were completed, all of Maine’s System of Care agencies in the three project
counties participated, according to contract language implemented by Maine’s Children’s
Behavioral Health Services.
Essential Elements of the Assessment
The TIAA measures the following domains derived from both system of care and traumainformed guiding principles.
•
•
•
•
•
•
Physical and Emotional Safety assesses whether secure reception/waiting areas,
non-judgmental treatment and flexible scheduling, among others, promote a sense
of safety.
Youth and Family Empowerment is whether policies and practices empower
clients through strength-based participation and/or community-based partnerships.
Trustworthiness is whether factors such as consistency, accessibility of staff and
interpersonal boundaries foster trust between an agency and the consumer.
Trauma Competence is the extent to which staff, policies, procedures, services and
treatment serve the unique experiences and needs of trauma survivors.
Cultural Competence is the extent to which staff, policies, procedures, services and
treatment accommodate the cultures, traditions and beliefs of youth and family
consumers.
Commitment to Trauma-Informed Philosophy is the extent to which all agency
staff members with consumer contact integrate a trauma-informed philosophy in
everything they do.
Page 38
Three modules were used to gauge the level of trauma-informed services provided by an
agency:
•
•
•
Agency Staff Self-Assessment: for all staff with consumer contact, including, but
not limited to: receptionists, bus drivers, case managers, clinicians, human
resources and administrators.
Family Questionnaire: for family members receiving services directly or who are
caregivers of a young person receiving services.
Youth Questionnaire: for those ages 12 to 20 receiving services from the agency.
Methodology–
The TIAA used a fairly simple metric to
determine final scores. Each question employed
a five-point scale, whose anchor is illustrated at
right. All questions are equally weighted. The
evaluators mapped specific questions to
domains for the family and youth versions, as
the organization was not made obvious.
Agency
Assessment
1- Low
2 - Low-moderate
3 - Moderate
4 - Moderate-high
5 - High
Family and Youth
Assessment
1 - NO!!
2 - No.
3 - Neutral.
4 - Yes.
5 - YES!!
Evaluators used the following components for calculating a score within each trauma
domain for an individual survey response: individual raw score, individual total potential
score and individual final score. First a raw score was calculated, representing the sum of
all the responses within each domain.
Second, the individual total potential score was calculated by counting the number of
questions answered in that domain and multiplying by five. Evaluators did not include
blank or skipped questions or responses of “Doesn’t apply.”
Third, the individual final score was calculated by dividing the raw score by the total
potential score and multiplying by 100.
To create the overall score for the agency, the evaluators applied a similar process to all the
“valid” survey responses within a domain. The following steps were used to calculate the
scores:
•
•
•
Raw score: the sum of all the raw scores calculated within each domain from all
individual surveys;
Total potential score: the sum of all the total potential scores calculated in each
domain for all individual surveys; and
Final score: divides the raw score by the total potential score and multiplies it by
100.
To create a statewide average or overall score for multiple agencies, evaluators applied the
same methodology used for a single agency. That is, HZA calculated a raw score, the total
Page 39
potential score and final score by summing all the “valid” individual survey responses
within a domain.
Data Limitations
Domains in which three or more questions were blank or answered “Doesn’t apply” were
not included with the exception of the multiple questions on the family and youth survey
related to a respondent’s safety plan. No matter how many answered “Doesn’t apply” on
that item, the safety domain score could be calculated; however, “Doesn’t apply” responses
were excluded from the total potential score calculation.
At least five responses were considered necessary in each category of respondents to
create an overall agency score for a given domain. For example, at least five youth
respondents were necessary to calculate a reliable youth score for trustworthiness even
though this small N may not be truly representative of the entire agency.
Initial Validation of the TIAA
The development process itself established the face validity of the tool. A panel of experts,
including youth and family members, created the survey and provided multiple
perspectives, including cultural and linguistic perspectives. Two additional validation
analyses were performed once data was returned: Cronbach’s alpha and Principal
Component Factor Analyses.
Cronbach’s alpha is a measure of internal consistency, and reliability; it is used to
demonstrate how closely related a set of items is as a group and the extent to which the
items “hang together” and contribute to the measurement of the same concept. Cronbach
alpha coefficients above .70 generally indicate an acceptable level of internal consistency.
When tests were performed on the data collected during the first statewide
implementation, the results of the TIAA for each of the six domains ranged between 0.80
and 0.93, as illustrated in Table 5-1. This suggests that the TIAA domains have relatively
high internal consistency reliability.
Table 5-1. Cronbach Alpha Scores by TIAA Module
Scale
Physical and Emotional Safety
Youth Empowerment
Family Empowerment
Trauma Competence
Trustworthiness
Commitment to Trauma-Informed Approach
Cultural Competence
Agency
(n = 1,441)
.855
.832
.823
.887
.847
.931
.906
Youth
(n = 213)
.838
.923
—
.869
.911
—
.912
Family
(n = 574)
.882
—
.899
.876
.905
—
.912
Page 40
The item analysis also found that most items in each domain contributed to the overall
scale score and exhibited moderate inter-correlations; they are all measuring a similar
concept (e.g., youth empowerment) but measure slightly different aspects. After reviewing
the analyses, the TIAA workgroup determined that in many of the instances where
questions were related, they ultimately captured different aspects of the domain and
should be monitored separately.
A series of exploratory Principal Component Factor Analyses were conducted to assess the
underlying structure of the data and the extent to which the individual items corresponded
to conceptual trauma-informed domains. All 42 items from the agency module were
included in the initial principal component analysis. The results revealed seven
independent groups of items. These factor groupings were found to align closely with the
TIAA conceptual domains, in some cases, exactly. The domains for youth and family
empowerment were the least cohesive; this made sense because empowerment occurs in
areas that relate to all the other domains. For example, that informed consent is reviewed
with the consumer in easy to understand language makes it part of empowerment; that the
consent process fully discloses agency expectations for services and grievance policies is a
measure of trustworthiness.
The Factor Analysis results were less conclusive for the youth and family modules where
Exploratory Principal Component analysis on all 42 items yielded 10 component factors
which crossed the TIAA domains. When the analysis was limited to five factors, the same
number of domains measured by the youth and family modules, the results continued to
suggest that youth and family responses did not distinguish between and among the
domains of safety, trustworthiness and empowerment. More validation work is needed on
the youth and family surveys to determine the extent that the items in each domain, as
currently defined, measure singular traits of trauma-informed practice from the
perspective of youth and families.
In summary, the preliminary validation analyses suggested that the scale items that make
up each trauma domain show high internal consistency and reliability for all three TIAA
modules. The factor analyses provided preliminary support for the conceptual trauma
domains used in the tool for the agency staff module. Further validation efforts are needed
to determine the extent to which the youth and family module adequately captures each
trauma domain.
Results
After the initial testing of the TIAA in the three project counties, the assessment was
administered twice on a statewide basis during the course of the grant in the states’ sixteen
counties; included were all agencies, numbering around 130, which had service contracts
with Children’s Behavioral Health, the state mental health authority. While not all the
agencies participated, the use of the tool statewide far exceeded the grant requirements.
The second statewide TIAA administration was a “corrective action,” encompassing
Page 41
agencies that did not participate adequately in the first statewide round. 14 The second
round results, therefore, should not be viewed strictly speaking as gains (or losses) from
the first round but more as a continuum of statewide adoption of trauma-informed
practices, stimulated by THRIVE training and technical assistance that also broadened to
statewide exposure after the initial project years.
The table below displays the statewide results for both rounds, employing the statewide
methodology for analysis discussed above. The number represents the number of surveys
completed for the given module while the percent represents the proportion of the total
potential score by constituent group (agency staff, parent/family members and youth).
Table 5-2. TIAA Statewide Results
2010
Module
Number
Agency Staff Module
Youth Empowerment and Engagement
Family Empowerment and Engagement
Trauma Competence
Trustworthiness
Commitment to Trauma-informed Approach
Cultural Competence and Trauma
Parent/Family Module
Trauma Competence
Trustworthiness
Youth Module
Trauma Competence
Trustworthiness
2011
Percent
Number
Percent
1,480
1,474
1,477
1,479
1,482
1,475
1,463
80%
79%
81%
72%
84%
69%
74%
938
938
938
938
938
938
938
82%
78%
81%
75%
85%
73%
75%
541
n/a
542
537
542
n/a
540
83%
n/a
79%
84%
87%
n/a
86%
825
n/a
825
817
828
n/a
809
84%
n/a
83%
86%
88%
n/a
86%
213
210
n/a
209
213
n/a
207
77%
70%
n/a
74%
77%
n/a
80%
945
941
n/a
933
944
n/a
935
79%
76%
n/a
79%
80%
n/a
82%
While the two years generally assess different agencies it is instructive to see the
progression of trauma-informed practice in many of the areas assessed. The greatest gain
from the perspective of agency staff was in the domain of commitment to a traumainformed approach, with a four percentage point increase, followed by trauma competence.
14
However, agencies that wanted to participate both times were permitted.
Page 42
From the family perspective the greatest increase was in family empowerment and
engagement, a four percentage point increase. Among youth, the greatest change was youth
empowerment and engagement, six percentage points, followed by trauma competence,
five percentage points. These results are encouraging and are a testament to the growing
commitment of agencies to embrace trauma-informed principles and practices.
It is interesting to compare the perceptions of agency staff, youth and families on how
trauma-informed the agency is. The following graph summarizes the results for 2010 and
2011 combined. In some instances there is no score; that is because questions such as
youth empowerment are not completed by family members and family empowerment is
not assessed by the youth. In addition, commitment to a trauma-informed philosophy, as a
separate domain, is not assessed by youth or families.
For physical and emotional safety, the families have a higher agency perception than the
youth or even the agency staff. On the question of youth empowerment, the agency staff
perceive that they empower youth more than the youth perceive that themselves. On the
domain of family empowerment, the perceptions of agency staff and family members are
virtually the same. Families and youth believe the agencies display more trauma
competence than the agencies themselves perceive. Trustworthiness is another issue that
the youth have, with their perceptions being lower than families or agency staff. On cultural
competency, both the family members followed by the youth, have a higher perception
than the staff themselves have of their own cultural competence.
The differences in all categories except family empowerment are statistically significant.
Figure 5-1. Comparison of
Agency, Youth and Family Scores
Cultural Competency
82%
74%
Commitment to TI Philosophy
86%
70%
Trustworthiness
80%
Trauma Competence
73%
78%
Family
87%
84%
Youth
85%
Agency
81%
81%
Family Empowerment
Youth Empowerment
75%
79%
84%
79%
81%
Physcial/Emotional Safety
50%
60%
70%
80%
90%
100%
Page 43
Figures 5-2 through 5-4 graph results from the agency, parent/family and youth
perspectives, arrayed by the domains assessed by each group. The figures reflect total
responses from the two administrations of the TIAA. The five data points are condensed to
three, with responses of 1 and 2 grouped as low-moderate and 4 and 5 grouped as
moderate-high.
The graphs show that agency staff members rank themselves highest on trustworthiness
followed by physical and emotional safety and lowest on commitment to a trauma
informed philosophy. Since these are statewide results, and THRIVE’s major focus was
three counties, it stands to reason that more work needs to be done to increase the
commitment around the state.
Figure 5-2. Frequency of Agency Staff Ratings,
by TIAA Domain
Cultural Competency
14%
Commitment to TI Philosophy
25%
17%
Trustworthiness 4%
Trauma Competence
61%
29%
53%
16%
80%
16%
25%
59%
Family Empowerment
12%
19%
69%
Youth Empowerment
12%
18%
70%
6%
0%
Low-Moderate
20%
20%
74%
40%
Neutral
60%
80%
100%
Moderate-High
The youth provide the highest scores to cultural competency and the lowest to youth
empowerment. No domain drops below two-thirds approval however.
Page 44
Figure 5-3. Frequency of Youth Ratings,
by TIAA Domain
Cultural Competency
6%
Trustworthiness
14%
9%
Trauma Competence
15%
11%
Youth Empowerment
80%
17%
18%
76%
72%
15%
11%
67%
15%
0%
20%
Low-Moderate
74%
40%
60%
Neutral
80%
100%
Moderate-High
Family members tend to be higher overall than both agency staff and youth. More people
give high marks to the agencies for trustworthiness than any other domain and the lowest
for family empowerment. Thus, both youth and family members provide lower scores on
empowerment than any other domain.
Figure 5-4. Frequency of Family Ratings,
by TIAA Domain
Cultural Competency
4% 9%
Trustworthiness
4% 7%
Trauma Competence
6%
Family Empowerment
89%
84%
10%
78%
8%
14%
7%
87%
82%
11%
0%
Low-Moderate
20%
40%
Neutral
60%
80%
100%
Moderate-High
Page 45
Continuous Quality Improvement Process
The results of the TIAA were first disseminated in August of 2010. Agencies reviewed these
results, attended THRIVE-sponsored trainings that were co-facilitated by youth and family
leaders and began to create technical assistance plans that identified strengths and
challenges in the areas of family driven and youth guided care. Youth MOVE Maine and
G.E.A.R., Maine’s Federation of Families for Children’s Mental Health, were identified as the
partners who would provide education to agencies.
THRIVE also worked with DHHS to incorporate the TIAA results into a state-sponsored CQI
process whose goal was to make service providers more trauma-informed. Figure 5-5
illustrates this cycle.
Figure 5-5. Continuous Quality Improvement Cycle
Conduct
TIAA
Assessment
Prioritize
Areas of
Need
Implement
CQI Plan
Create CQI
Plan
In many agencies either the administrators and their staff or a designated “Change Team”
examined their results which were provided by the evaluators across domains, across
respondent groups and in comparison to the statewide averages. Using questions posed by
THRIVE as a guide, the Change Team then prioritized the agency’s needs, developed a CQI
plan using the Agency Template provided below and in many cases implemented it. Part of
this process entailed identifying areas where additional technical assistance or training
was needed which was subsequently provided by THRIVE staff.
Page 46
Continuous Quality Improvement Plan: Agency Template
Create steps for each trauma-informed domain that needs improvement.
What trauma-informed
domain do we want to
change?
Which target group is
most affected? Why
did we choose this
domain?
What steps will we
need to take to
improve?
Who will be
responsible?
By when do we
want to
accomplish these
changes?
1.
2.
3.
Page 47
How will we
know that we
have
accomplished our
objectives?
Lessons Learned, Successes and Challenges
From this process of developing and administering the TIAA, THRIVE learned several
things. First, it is possible to articulate criteria and standards for assessing traumainformed practices. Using source documents and their own knowledge and experiences,
clinical staff, administrators, family members, youth and evaluators were able to hone the
domains, questions, and standards that others could be used in assessing agency practice.
Second, it is possible to apply these questions and standards to a tool that could be
validated for both internal validity and reliability, as well as for data structure. It was easier
to do this for the agency version of the tool than for the youth and family versions because
youth and family members generally have a more singular vision of the agency from their
contact as consumers; therefore there is somewhat more overlap in the domains. The
domains for youth and family empowerment were found to be the least cohesive; this made
sense because empowerment occurs in areas that relate to all the other domains,
particularly safety and trustworthiness (reviewing an informed consent document in easy
to understand language is rated under empowerment but the same process, which fully
discloses agency expectations for services and grievance policies, is a measure of
trustworthiness.) The project did not have an opportunity to test whether other types of
questions would make for clearer distinctions.
Third, THRIVE learned that a self assessment process by agency staff with comparable
input from families and youth was a more realistic way to garner widespread participation
than having an outside party conduct interviews. The latter was tried in the pilot period. It
was too labor intensive and expensive. The use of anonymous questionnaires produced
results that were usable and could be validated.
Methods of administration should continue to promote web-based processes, again for
sustainability. While youth and family members still tend to gravitate towards written
questionnaires, the data entry process makes this approach prohibitive in the long-run. As
people become more computer savvy over time and individuals have increased access to
computers and internet connections this problem should be resolved.
Fourth, THRIVE learned that many agencies want to be trauma-informed and found the
results of this type of assessment very useful, especially because it considered the youth
and families perspectives. Over time agencies in the second round were able to garner
higher scores from youth and family members on engagement and empowerment, critical
domains to promoting trauma-informed practice.
The challenge for the future is to maintain the momentum established during the system of
care initiative for assessing trauma-informed practices and for working with agencies to
implement CQI plans to address their areas needing change. State administrators have
demonstrated a commitment to these practices by requiring all agencies with children’s
mental health contracts to participate in the assessment. In addition, the evaluators are
preparing the web-based tools to turn over to the state for later administration. These
steps should help assure continuation and growth of trauma-informed approaches.
Page 48
CHAPTER 6
CONCLUSION
Since the start of Maine’s THRIVE Initiative in 2005, the behavioral health impacts of
trauma have gained prominence and focus in the national dialogue about children’s mental
health services. When people are introduced to the concept of trauma and how it can affect
a child’s behavioral or mental health, the logic is obvious and easily understood. Youth,
family members and clinicians can all relate. Yet the evidence behind what services are
effective has not been well established, with the exception of a handful of clinical
treatments such as Trauma-focused Cognitive Behavioral Therapy. The problem with the
limited response to trauma up to now is two-fold. First, not every agency has clinicians who
are trained in specific therapies and second, even if excellent treatment is provided in a
clinical setting, other people and events who are close to the child can negate the good that
is done in therapy by insensitive actions or simply doing things as usual. The response to
trauma needs to be broader.
As the first System of Care (SOC) project with a specific focus on trauma-informed
practices, the THRIVE Initiative has had a unique opportunity both to define what traumainformed practice means and to assess its impact on children and their families. A strong
partnership between the state sponsors at Children’s Behavioral Health, the people
developing the THRIVE Initiative in the target counties and the evaluators has permitted
and facilitated a learning process that is now reaping benefits beyond the Initiative itself.
The benefits first manifested themselves in the encouragement provided by the state to
take the learnings from THRIVE to the entire state. This has allowed other communities
and agencies to avail themselves of the training and technical assistance provided by
THRIVE staff. The state leaders fostered the ability of all contracted mental health agencies
to conduct their own assessments of their agency on the principles of system of care and
trauma-informed practices using tools and evaluation techniques developed and promoted
by THRIVE. Even the federal requirement that grantees provide matching funds helped
facilitate the dissemination of learning as the evaluator’s contribution was to go beyond the
three counties funded by the project to bring the assessment statewide.
Benefits also were derived from the state-level encouragement of the development of both
youth and family organizations whose voice could be heard and applied beyond a system of
care project. Thus, the THRIVE Initiative, with the strong encouragement of Children’s
Behavioral Health, helped to create an alliance of six family organizations, called the Maine
Alliance of Family Organizations (M.A.F.O.). Ultimately one of the services provided by
THRIVE, the trauma-informed Family Partnering Program, was turned over to one of the
family organizations to administer. The partnership also encouraged the development of a
youth move chapter, Youth MOVE Maine and supported various youth initiatives that went
beyond THRIVE.
Going beyond Maine, the THRIVE Initiative and its evaluators have been very active in
developing materials for presentation at national forums, both in the form of workshops,
Page 49
and poster sessions and even extensive institutes. Every year since the first full year of
operation, THRIVE’s submissions have been approved by the national children’s mental
health research conferences sponsored by the University of South Florida and/or the by the
Georgetown Institutes. At the most recent Georgetown Institute (Orlando, 2012), the
former youth coordinator for THRIVE and now its Training and CQI Manager was a plenary
speaker before 2200 people, providing a first person perspective on growing up with
trauma and how even to this day the principles of trauma-informed practice provide
comfort and assistance in addressing its impact. THRIVE has also received awards at these
venues for its innovative social marketing initiatives such as digital stories which allow
youth to tell their stories in their own voices using the new media.
Recognizing the power and potential of disseminating the concepts inherent in traumainformed practice to a national audience, THRIVE was encouraged both by the state
sponsors and even its own lead agency, Tri-County Mental Health, to become its own
independent organization. Toward the end of the project, THRIVE applied for and was
granted a federal 501 (C) 3 status as a non-profit organization. This vehicle has allowed
THRIVE to develop training and technical assistance contracts in many states throughout
the country and has even permitted the dissemination of its Trauma-informed Agency
Assessment Tool to states outside Maine through a partnership with the evaluators.
This partnership has also allowed THRIVE to make new discoveries about the nature and
impact of trauma by forging close working relationships with its evaluators. An unusual
contractual model was employed. The lead evaluation investigator is a state employee with
broad system of care experience; he is currently Director of the Office of Quality
Improvement for the State Department of Health and Human Services. But the day to day
operations of the evaluation were contracted to Hornby Zeller Associates, Inc., a social
science research firm with offices in Maine, among other states. The partnership worked
extremely well for various reasons. First, the evaluation team as a whole brought more
than one perspective and set of experiences to the effort. Second, it provided some
flexibility in conducting the evaluation. For example, the private firm could easily hire
family evaluators who may not have had traditional credentials associated with state
service. They could be given the materials and resources needed to operate flexibly. Third,
the private firm could obtain access to data such as Medicaid claims files from the state
which is not always easily accessed. The joint efforts led to a powerful service and cost
analysis. Fourth, the partnership allowed investigators to develop materials and make joint
presentations to state and national audiences.
Through the evaluation, the project hoped to demonstrate both the degree to which trauma
is prevalent among the population of children with emotional disturbances and the
approaches that could mitigate the negative effects of trauma. While it has done both, the
project and its evaluation team has taken the inquiry one step further, with initial results
that may prove to be the most important evaluation contribution of the project. That was to
assess the impact of trauma from one generation to the next.
The evaluation team added three tools to those required by the national cross-site
evaluator: the Traumatic Events Screening Instrument (TESI), the Lifetime Incidence of
Page 50
Traumatic Events (LITE; both parent and child versions), and the Trauma Symptom
Checklist (TSC; versions for Young Children and for Youth). By having the foresight and
ability to capture the caregiver’s own trauma history as a child using the TESI, the
evaluation permitted analyses of what we came to call “inter-generational trauma.” The
linkages from one generation to the next became apparent by using correlational analysis
techniques and significance tests; these types of analyses could even be extended to the
service and cost study which ultimately demonstrated two important things: children
whose parents had childhood traumatic experiences used more expensive services before
enrolling in THRIVE than those who did not, and these same parents and children realized
far greater savings in the cost of treatment six months after THRIVE services were largely
ended. Their savings were far greater than parents who did not have trauma histories
themselves to start with. And the most consistent intervention received by all these
families was a Family Support Partner. Again, the concept of peer support and parent
partnering is gaining traction across the country but efforts to demonstrate the
effectiveness of this approach have been sparse. THRIVE provides a nice entre to
demonstrating the effectiveness of parent support partners where the parents themselves
may have unresolved issues from childhood trauma.
The THRIVE Initiative came to be defined by its multiple efforts, operating at different
levels of systems change:
•
•
•
•
•
Trauma-informed Family Partnering Program provided Family Support Partners to
work with families referred to the THRIVE Initiative from Child Welfare, Juvenile
Justice and local mental health agencies. The Family Support Partners provided peer
support from the perspective of personal experience with a child with special needs.
This engagement generally lasted about six months.
Trauma-focused Cognitive Behavioral Therapy (TF-CBT) Learning Collaborative was
organized by THRIVE for agencies using this evidence-based trauma-specific
treatment model for children and families that typically lasts for a period of 12 to 16
weeks.
Trauma-informed Training and Technical Assistance was offered to educate
providers regarding the trauma-informed approach, THRIVE provided trainings to
mental health agencies, community providers, and youth and families organizations
throughout the service area with a focus on the 23 local entities that signed a
Memorandum of Understanding with the THRIVE Initiative.
Trauma-informed Agency Assessment was developed so that the 23 agencies initially
and the rest of CBHS contractors in subsequent years could determine the extent to
which they were delivering trauma-informed services and to pinpoint areas for
improvement within specific domains. The accompanying CQI process helped
agencies develop specific steps for improving their practices.
Youth and Family Voice. THRIVE worked actively to support the development of the
Maine Alliance of Family Organizations which helped to coalesce seven family
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groups with somewhat different foci including families of children with learning
disabilities as well as those with emotional problems. THRIVE also helped to
develop the Maine chapter of Youth MOVE, which became Youth MOVE Maine. It
used leadership development and social marketing techniques to help develop and
promote the youth voice in a variety of activities.
The THRIVE Initiative learned much about promoting and enhancing a trauma-informed
system. Perhaps the most salient lesson is the need for trauma champions, strong leaders
at the state and agency level who acknowledge and understand the importance of the
question, “What happened to you,” as opposed to what is wrong with you. Whether it was
the TIAA self-assessment process or TF-CBT learning collaborative, those agencies that
were the most successful had leaders who were dedicated to implementing the traumainformed approach. Moreover, the commitment from state agency leadership was
instrumental in the statewide TIAA administration and ultimately plans to expand the
trauma-informed approach to other agencies and service systems.
The evaluation studies found that the majority of children and families enrolled in
THRIVE’s Family Partnering Program had experienced significant amounts of trauma.
Behavioral and functional symptoms, including trauma-related symptoms, were higher
among those with a trauma background. Perhaps most importantly, the study also showed
that the trauma history of parents and/or primary caregivers had a direct effect on youth
outcomes and family functioning. When trauma-informed services were delivered to these
families through the THRIVE Initiative, the children and youth showed improved outcomes
and symptom reduction.
Achieving better outcomes was also associated with a shift away from inpatient hospital
services among children and youth enrolled in THRIVE’s Family Partnering Program. These
shifts in service utilization had a desired effect in cost savings of more than $450,000 for
families enrolled in THRIVE, representing more than a 30 percent reduction in cost from
six months before service initiation to six months after service termination. Again, the
greatest change was among families with an intergenerational trauma history.
The TIAA showed that agency staff members often have different perceptions of their
practices from youth and families. For physical and emotional safety domains, the families
have a higher perception of agency practices than the youth or even the agency staff. On the
question of youth empowerment, the agency staff perceive that they empower youth more
than the youth perceive that themselves. On the domain of family empowerment, the
perceptions of agency staff and family members are virtually the same. Families and youth
believe the agencies display more trauma competence than the agencies themselves
perceive. Trustworthiness is another issue that the youth have, with their perceptions
being lower than families or agency staff. On cultural competency, both the family members
followed by the youth, have a higher perception than the staff have of their own cultural
competence. These results suggest the need for agencies to work more closely with youth
and families to examine these domains, particularly in the one area where the staff rank
themselves higher than the people they serve: youth empowerment.
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The most important independent finding of the evaluation is the connection between a
caregiver’s experience of trauma as a child and his or her own child’s experience. These
relationships affect how much a child uses expensive services before receiving treatment. It
is particularly noteworthy that providing a Family Support Partner was most effective
when the caregiver disclosed a childhood affected by trauma. While the post-service costs
for the entire sample were reduced by 30 percent, for the subgroup with a trauma history
there was a 50 percent reduction. While the sample size is small, the results have face
validity and need to be replicated with larger groups of people, preferably using a quasiexperimental design. Future studies should be designed to pinpoint the specific
relationships between trauma experiences, trauma-informed services, children’s outcomes
and associated costs.
Even with its limitations, the overall evaluation results of the THRIVE Initiative suggest that
better outcomes and reduced costs can be achieved by providing trauma-informed parent
peer supports, offering trauma-specific treatments and taking into account the trauma
history of the entire family through a trauma-informed approach to service delivery.
Page 53
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REFERENCES
Appleyard, K. & Osofsky, J. D. (2003). Parenting After Trauma: Supporting Parents and
Caregivers in the Treatment of Children Impacted by Violence. Infant Mental Health Journal.
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Bolen, R. (2000). Validity of Attachment Theory. Trauma, Violence and Abuse. 1(2): 128153.
Ancharoff, M. R., Munroe, J.F., & Fisher, L.M. (1998). The legacy of combat trauma: Clinical
implications of intergenerational transmission. In Y. Danieli (Ed.), International Handbook
of Multigenerational Legacies of Trauma (pp. 257-276). New York: Plenum Press.
Blanch, A. (2003). Developing Trauma-Informed Behavioral Health Systems. Alexandria,
VA: National Technical Assistance Center for State Mental Health Planning (NTAC).
Boney-McCoy, S. & Finkelhor, D. (1995). Psychosocial sequelae of violent victimization in a
national youth sample. Journal of Consulting and Clinical Psychology, 63(5):726-736.
Daud, A. & Rydelius, P.A. (2009). Comorbidity/overlapping between ADHD and PTSD in
relation to IQ among children of traumatized/non-traumatized parents. Journal of Attention
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Felitti, V.J., Anda, R.F., Nordenberg, D. et al. (1998). The relationship of adult health status to
childhood abuse & household dysfunction. American Journal of Preventive Medicine
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Ford, J. D., Racusin, R., Ellis, C. G., Daviss, W. B., Reiser, J., Fleischer, A., et al. (2000). Child
maltreatment, other trauma exposure, and posttraumatic symptomatology among children
with oppositional defiant and attention deficit hyperactivity disorders. Child Maltreatment,
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Frothingham, T., Hobbs, C., Wynne J., Yee, L., Goyal, A., & Wadsworth, D. (2000). Follow up
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Hashima, P. & Finkelhor, D. (1999). Violent Victimization of Youth Versus Adults in the
National Crime Victimization Survey. Journal of Interpersonal Violence. 14(8):799-820.
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Husain, S.A., Allwood, M.A., & Bell, D.J. (2008). The Relationship Between PTSD Symptoms
and Attention Problems in Children Exposed to the Bosnian War. Journal of Emotional and
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Kessler, R.C. (2000). Post-traumatic stress disorder: The burden to the individual and to
society. Journal of Clinical Psychiatry, 61(5):4-12.
Macy, R.D., (2002). On the epidemiology of posttraumatic stress disorder: period prevalence
rates and acute service utilization rates among Massachusetts Medicaid program enrollees:
1993-1996. Doctoral Dissertation. Union Institute and University (ISBN: 0-493-7354-0).
Newmann, J., et al. (1998). Abuse histories, severe mental illness, and the cost of care. In
Levin, B., et al. (Eds.) Women’s Mental Health Services. Thousand Oaks, CA: Sage
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Silverman, R. C., & Lieberman, A. F. (1999). Negative maternal attributions, projective
identification, and the intergenerational transmission of violent relational
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Switzer, G.E., Dew, M.A., Thompson, K., Goycoolea, J.M., Derricott, T., & Mullins, S.D. (1999).
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Expenditures for Children with Emotional & Behavioral Challenges. Poster Presentation to
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APPENDIX
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Trauma Instrument Description
Traumatic Events Screening Inventory (TESI)
The trauma history of the primary caregiver impacts a child’s reaction to and recovery
from trauma (Appleyard and Osofsky, 2003). Therefore, the adult version of the Traumatic
Events Screening Instrument (TESI) is used to identify whether the primary caregivers of
children enrolled in the longitudinal study have themselves experienced trauma. The TESI
screen for trauma history in adults in clinical or research settings and can be administered
as a semi-structured interview. It screens respondents for a wide range of potentially
traumatic events, including accidents, hospitalizations, physical or sexual abuse, natural
disasters, community violence, witnessing domestic violence, and interpersonal losses due
to severe illness or injury. While only the child and parent versions of the instrument have
been validated (not the adult screener), Ford and Rogers (1997) found that the kappa
scores for interrater reliability for the TESI-C ranged from .73 to 1.00. The kappa scores for
retest reliability for both the TESI-C and TESI-P ranged from 50 to 70 over a two- to fourmonth period. Please note that, unlike the other instruments listed here, this tool is only
administered during the baseline interview.
Lifetime Incidence of Traumatic Events (LITE)
Child trauma is increasingly recognized as both widespread (Pynoos, 1990) and
detrimental to psychosocial development and quality of life (Terr, 1991). Children exposed
to extreme distress, such as occurs in natural disaster or violent incidents, will probably be
traumatized (Terr, 1991), and they often have difficulty recovering unless special
assistance is provided (Sugar, 1989). Such assistance first of all depends upon
identification of those in need. However, reliable identification of traumatized children has
typically been cumbersome, involving extended clinical interviewing (McNally, 1991).
Some currently available measures are useful and psychometrically sound, but also have a
variety of limitations. For example, the Impact of Events Scale (IES; Horowitz, Wilner, &
Alvarez, 1979) is widely used with adults following a critical incident, and eight of the
items have survived norming with children (Dyregrov & Yule, 1995). Children exhibit a
much broader spectrum of post-traumatic symptoms than those covered in the IES
(Fletcher, 1993; Terr, 1991); the IES is also limited in that an identified trauma is required
as a reference point for all questions.
However, a precipitating or predisposing event is not always recognized a priori as the
source of a child's problems. Children often exhibit symptoms which may be trauma-based,
but which mimic other conditions, including somatic disturbances, Attention Deficit
Hyperactive Disorder, learning problems, anxiety, depression, oppositional behaviors, and
conduct disorders (Green, 1983; Terr, 1991).
The Trauma Symptom Checklist for Children (TSCC; Briere, 1996) does not address some
important aspects of child trauma symptomatology, such as somatic complaints and
pessimistic future. The Los Angeles Symptom Checklist (LASC; Foy, King, King, & Resnick,
1995) is not quite as long with 43 items, and is fairly comprehensive, but has only been
Page 59
normed downwards to adolescents. The adult-oriented content would make further
downward extension inappropriate. The Children's Impact of Traumatic Events Scale
(CITES; Wolfe, Gentile, Michienzi, Sas, & Wolfe, 1991) is shorter, with only 20 items, but
fails to address many types of child trauma symptoms. Furthermore, the brevity of the
CITES is deceptive, since it is derived from a much longer, copyrighted instrument (Child
Behavior Checklist; Achenbach & Edelbrock, 1984) and cannot be used independently (T.
Achenbach, personal communication, 11/93).
A correlational analysis between the Child Report of Post-traumatic Symptoms (CROPS),
the Parent Report of Post-traumatic Symptoms (PROPS) and LITE revealed that the
correlations between the total scores on each measure and the clinician ratings remained
strong after controlling for age, gender, ethnicity, parent education level, and location
(urban vs. rural). This was determined in a hierarchical multiple regression analysis in
which the LITE rating was entered last, after entering the other five variables. Before
entering the LITE rating, the multiplier was .325 for the PROPS and .226 for the CROPS.
After entering the LITE rating, the multipliers increased to .553 and .602, respectively. The
criterion validity variable (i.e., the LITE rating) accounted for 20 percent of the variation in
PROPS scores (r2 increased from .11 to .31) and for 31 percent of the variation in CROPS
scores (r2 increased from .05 to .36) beyond the contribution of the other five variables.
Trauma Symptom Checklists (TSC)
The Trauma Symptom Checklist for Young Children (TSC-YC) is a standardized, 90-item
caretaker-report instrument that can be used to assess trauma symptoms in children from
ages three to 12. It is normed separately for males and females and for three age groups:
(a) 3-4 years, (b) 5-9 years, and (c) 10-12 years. Caregivers rate each symptom on a fourpoint scale according to often it has occurred in the previous month. Unlike most other
parent/caretaker measures, the TSC-YC contains specific scales to ascertain the validity of
caretaker reports and evaluates a wide range of potentially posttraumatic symptoms. The
TSC-YC contains eight clinical scales (i.e. Anxiety, Depression; Anger/Aggression;
Posttraumatic Stress-Intrusion; Posttraumatic Stress-Avoidance; Posttraumatic StressArousal; Dissociation; Sexual Concerns; and a summary posttraumatic stress scale. Because
the TSC-YC is a secondary report, it includes features to assess the caretaker’s rating style
and actual familiarity with the child. The TSC-YC contains two validity scales that assess
potential caretaker over report and underreport of the child’s symptoms.
The Trauma Symptom Checklist for Children (TSC-C) is a self-report measure of
posttraumatic distress and related psychological symptomatology in older children and
youth. It is intended for use in the evaluation of children who have experienced traumatic
events, including childhood physical and sexual abuse, victimization by peers (e.g. physical
or sexual assault), major losses, the witnessing of violence done to others, and natural
disasters. The various scales of the TSCC assess a wide range of psychological impacts and
consists of 54 items that yield two validity scales (Underresponse and Hyperresponse); six
clinical scales (Anxiety, Depression, Anger, Posttraumatic Stress Dissociation [with two
subscales], and Sexual Concerns [with two subscales]; and eight critical items. While no
data that indicate exposure to the TSC-C is especially stressful, the author of the
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instruments recommends that a mental health practitioner should be available to the child
for cases when debriefing might be necessary. Accordingly, the family evaluators and the
evaluation participants will have access to the Tri-County Mental Health Services 24-hour
crisis hotline in case of emergency (see below).
Both the TSC-C and the TSC-YC can be administered and scored by individuals who do not
have formal training in clinical psychology, counseling psychology, or related fields.
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National Evaluation Instrument Descriptions
Enrollment and Demographic Information Form (EDIF)
The EDIF gathers demographic, diagnostic, and system of care enrollment information on
all children receiving CMHS-funded system of care services. Information for the EDIF is
gathered from record review and caregiver report. It includes such topics as demographic
information, diagnostic information and referral information It consists of 16 questions
with subparts and is completed at baseline.
Caregiver Information Questionnaire (CIQ)
The CIQ is administered to caregivers and gathers additional demographic information, as
well as information on risk factors, family composition, custody status, service use history,
and presenting problem(s) for children enrolled in the Longitudinal Child and Family
Outcome Study. It consists of 39 questions that cover risk factors, family composition,
physical custody, service use, employment status, presenting problems and parental
attitudes regarding services.
Caregiver Strain Questionnaire (CGSQ)
The CGSQ assesses the extent to which caregivers are affected by the special demands
associated with caring for a child with emotional and behavioral problems. The CGSQ is
comprised of three subscales which range in severity from zero to five. Objective Strain
refers to observable disruptions in family and community life (e.g., interruption of personal
time, lost work time, financial strain). Subjective Externalized Strain refers to negative
feelings about the child such as anger, resentment, or embarrassment. Subjective
Internalized Strain refers to the negative feelings that the caregiver experiences such as
worry, guilt, or fatigue. Higher scores on each of these scales indicate greater strain. A
Global Strain score is calculated by summing the three subscales (i.e., Objective Strain,
Subjective Externalized Strain, and Subjective Internalized Strain) to provide an indication
of the total impact of the special demands on the family. Global Strain scores range from
zero to 15. As with the individual subscales, higher scores indicate greater strain.
Child Behavioral Checklist (CBCL)
The CBCL 1.5–5 is administered to caregivers and measures behavioral and emotional
problems in children between the ages of 1.5 and 5. The CBCL 1.5–5 produces seven
narrow-band syndrome scores; Emotionally Reactive, Anxious/Depressed, Somatic
Complaints, Withdrawn, Sleep Problems, Attention Problems, and Aggressive Behavior;
two broadband syndrome scores: Internalizing and Externalizing; and a Total Problem
score. T-scores between 65 and 69 (93rd and 97th percentile) on the narrow-band syndrome
scales are in the borderline clinical range. T-scores greater than 69 are in the clinical range.
T-scores between 60 and 63 (83rd and 90th percentile) on Internalizing, Externalizing, and
Total Problems are in the borderline clinical range. T-scores above 63 are in the clinical
range.
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The CBCL 6–18 is administered to caregivers and measures behavioral and emotional
problems in children between the ages of 6 and 18. The CBCL 6–18 produces eight narrowband syndrome scores; Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints,
Social Problems, Thought Problems, Attention Problems, Rule-Breaking Behavior, and
Aggressive Behavior; two broadband syndrome scores: Internalizing and Externalizing;
and a Total Problem score. T-scores between 65 and 69 (93rd and 97th percentile) on the
narrow-band syndrome scales are in the borderline clinical range. T-scores greater than or
equal to 70 are in the clinical range. On the Internalizing, Externalizing, and Total Problems
scales, T-scores between 60 and 63 (84th and 90th percentile) are in the borderline clinical
range. T-scores above 63 are in the clinical range.
The CBCL is also comprised of three competency subscales, as well as a total competency
scale. Higher scores on the competency scales indicate greater competence. The three
competence subscales have a T-score range from 20 to 65, with scores under 30 in the
clinical range (i.e., less competence) (2nd percentile), scores between 31 and 36 in the
borderline clinical range, and scores over 36 below the clinical range (i.e., greater
competence). The Total Competence scale has a T-score range from 10 to 80, with scores
under 37 in the clinical range (i.e., less competence), scores between 37 and 40 in the
borderline clinical range, and scores over 40 below the clinical range (i.e., greater
competence).
Behavioral & Emotional Rating Scale (BERS)
The BERS–2C is administered to caregivers. It measures children’s emotional and
behavioral strengths in six different areas: Interpersonal Strength, Family Involvement,
Intrapersonal Strength, School Functioning, Affective Strength, and Career Strength. Scaled
scores on the strength subscales range from 1 to 16, with an average score between eight
and 12. Higher scores indicate greater strengths.
A strength index can be calculated and is based on the sum of the subscale scores, excluding
career strength. The strength index ranges from 38 to 161, with an average index in the
90–110 range. A higher index indicates greater overall strengths.
The BERS–2Y is a youth version of the BERS–2C. It is administered to youth 11 years and
older. As with the caregiver version, the BERS–2Y measures children’s emotional and
behavioral strengths in six different areas: Interpersonal Strength, Family Involvement,
Intrapersonal Strength, School Functioning, Affective Strength, and Career Strength. On the
youth version, however, scaled scores on the strength subscales range from one to 18, but
the average range remains the same at 8–12. The calculation, range, and average score of
the strength index remain the same as well (i.e., 38 to 161, with an average index between
90 and 110). Higher subscale scores and strength indexes indicates greater overall
strengths.
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THRIVE, Maine`s Trauma-informed System of Care

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