The impact of trauma on children in care poster

THE IMPACT OF TRAUMA ON CHILDREN
IN PROTECTION AND CARE:
AN APPROACH TO UNDERSTANDING TRAUMA THROUGH
THE USE OF ASSESSMENT AND OUTCOME MEASURES
1
Carly Black , Margarita Frederico2, Annette Jackson1, Trish McCluskey1 1Take Two,
Berry Street, Victoria, Australia, 2La Trobe University, Victoria, Australia
DESCRIPTION OF TAKE TWO
KEY FINDINGS CHILDREN’S HISTORY
TRAUMA SYMPTOM CHECKLIST FOR CHILDREN
Take Two is a therapeutic service for child protection clients who have suffered trauma
as a result of serious maltreatment. It is Australia’s first dedicated therapeutic service
for children in the child protection system. The service is funded by the Victorian
Department of Human Services and has been in operation since January 2004. Take
Two is auspiced by Berry Street, a child and family welfare organisation; in partnership
with the Austin Hospital Child and Adolescent Mental Health Service; School of Social
Work and Social Policy, Faculty of Health Sciences, La Trobe University; Mindful, Centre
for Training and Research in Developmental Health; and the Victorian Aboriginal Child
Care Agency (VACCA).
Referral information reveals that these children, even at a young age, have extensive
histories of involvement with child protection and multiple placements. The majority
of children (59%) had five or more previous placements at the time of being referred
to Take Two. Placement changes frequently included unsuccessful attempts at
reunification; 94% of those who had been reunited had been removed from home at
least one more time after being reunited with their family (Frederico, Jackson, & Black,
2006). Data from the HCA reveals that nearly all children have experienced multiple
types of trauma.
Analysis of the TSCC revealed that the majority of children had a clinically elevated
score on one or more scales indicating the serious intra-personal impact of trauma.
Repeated measures completed during Take Two intervention reported a declining trend
in mean t-scores across all of the TSCC scales, with significant reductions in mean
anxiety and anger scores. This trend was also reflected in a smaller sample of Trauma
Symptom Checklists for Young Children (TSCYC) with parents and carers reporting
lower scores across all of the sub-scales, with significant reductions in Anger and
Sexual Concerns.
WHO ARE THE CLIENTS?
ASSESSMENT AND CLINICAL MEASURES
A specific assessment measure developed by Take Two, the Harm Consequences
Assessment (HCA) is completed by the referrer providing a cumulative picture of what
has happened to the children over their lifetime in terms of abuse and neglect, as well
as the emotional, behavioural and developmental consequences. Outcome measures
used include the Strengths and Difficulties Questionnaire (SDQ; Goodman, 1999); the
Trauma Symptom Checklist for Children (TSCC; Briere, 1996); the Trauma Symptom
Checklist for Young Children (TSCYC; Briere, 2005) and Social Network Maps (Tracy
& Whittaker, 1990). Taken together, these outcome measures provide insight into
the children’s emotional and behavioural presentation, trauma-specific symptoms and
their perception of their social world.
SHANES STORY
Gerry
58yrs
Erik
65 yrs
Liz
54 yrs
Prue
60 yrs
100
84%
Percentage of Take
Two clients
Infants, children and adolescents in the child protection and out-of-home care system
have been identified as a highly vulnerable population in need of more than just
protection and care. Since 2004 over 1000 children have been accepted into the
Take Two program. The children are aged from infancy to 17 years, and the majority
are live in some form of out-of-home care. Aboriginal children are over-represented.
Seventeen percent of the clients are Aboriginal and yet Aboriginal children make up
only one percent of Victoria’s childhood population.
Type of maltreatment according to the HCA prior
to referral for Take Two clients in 2004 & 2005
(N = 558)
97%
83%
80
62%
60
41%
40
20
0
Abandonment
Physical abuse
Sexual abuse
Emotional abuse Developmental
abuse
Type of maltreatment
Percentage of Children in the Clinical Range of the TSCC
Scales at Time 1 and Time 2 (n = 24)
%
Time
Time
TSCC scales
1
2
Anxiety
16.7
4.2
Depression*
29.2
4.2
Anger
16.7
12.5
Posttraumatic stress
12.5
8.3
Dissociation
20.8
12.5
Dissociation – overt subscale
20.8
16.7
Dissociation – fantasy subscale
16.7
12.5
Sexual concerns (n = 23)
25.0
17.4
Sexual concerns – preoccupation
subscale
20.8
17.4
Sexual concerns – distress subscale
20.8
8.7
INTERVENTIONS
SOCIAL NETWORK MAPS
Major findings regarding Take Two interventions include the successful engagement of
the large majority of children and/or their networks (94% of clients). This is notable
given traumatised children have been reported in the literature as being difficult to
engage in therapeutic intervention.
Interventions include individual child therapy; interventions with the child and parent/
carer; parent and/or carer work; and work with other aspects of the service system,
such as schools and care teams.
Analysis of the social network maps revealed the children often have extremely limited
social networks. The children’s descriptions of their networks frequently highlight an
absence of parental figures. Siblings and extended family were a key presence even
when they did not live with the child. Some children also included pets or deceased
relatives as part of their social network. Examination of the social networks over time
reveals an increase in the number of people described by the child as being close to
them, and providing them with emotional support and information/advice.
OUTCOMES - SDQS
Amy
30 yrs
Cameron
35 yrs
Olivia
3 yrs
Rachel
38 yrs
Shane
13 yrs
Mason
16 yrs
Chris
41 yrs
Crystal
15 yrs
Ruby
12 yrs
SHANE’S PRESENTATION:
Shane is a 13-year-old boy who lived in foster care. He presented to Take Two with a long
history of verbal and physical aggression and disruptive and oppositional/defiant behaviours.
He was considered to have a high probability of future placement breakdown. Shane had
been diagnosed with ADHD. Shane attended several schools and had multiple suspensions
and expulsions.
WHAT HAPPENED TO SHANE?
During his infancy Shane lived with his mother and two of his siblings. Little is known about
Shane’s early development but reports from three years of age indicated that Liz did not
provide supervision and failed to meet his physical and emotional needs, including overt
rejection and physical neglect. Shane had many placements due to his difficult behaviour.
Once placed in foster care by Liz at the age of six her contact with Shane was sporadic.
When he was 11 years old, Liz told Child Protection that she no longer wanted to see him.
During Take Two’s involvement Liz resumed contact with Shane. The Child Protection case
plan was changed to reunification and Shane returned to her full-time care.
WHAT TAKE TWO DID:
The Take Two clinician saw Shane every week, on the same day, at the same time and the
same place, for almost two years, to create some predictability. The process of engagement
was slow and Shane was initially resistant to attending sessions. The clinician made them
as fun and non-confrontational as possible. Shane began to engage with the clinician at a
deeper level. When he moved back with his mother, he continued to attend weekly sessions,
and his mother attended half of each session with him. This way Shane could verbalise his
hurt to her about the rejection he felt and it allowed his mother to acknowledge this and her
own hurt.
Regular care team meetings occurred and were attended by Child Protection, the Community
Service Organisation, his mother, professionals from family support services, a psychiatrist,
education support services and teachers. This ensured that the complexity of the case was
given consideration and the communication within the system worked effectively. Without a
stable and functioning care team, the clinician considered that the progress made in Shane’s
case would have been greatly reduced.
The clinician met with the school regularly to develop strategies to manage Shane’s difficult
behaviours. The focus was on assisting Shane to develop appropriate peer skills and reduce
his aggression. The clinician met regularly with Shane’s foster carers to support and stabilise
the placement until he returned home.
THE OUTCOMES:
Shane completed a Social Network Map at time of initial assessment and then at closure.
Although there were slightly fewer people in the second map, family members, especially
his mother, had moved from the outer rim of his life to being described as ‘very close’.
Shane changed from thinking of his mother as ‘hardly ever’ to ‘almost always’ emotionally
supportive. Most professionals listed had moved from ‘not very close’ to ‘sort of close’.
The SDQs were completed by Shane, his carers and teachers. In comparing the SDQs completed
by the carers at the initial assessment and review period, they recorded that Shane was no
longer in the clinical range in terms of total difficulties score and hyperactivity. Over the three
assessment periods, Shane’s SDQs also recorded a reduction in his overall difficulties score,
and in relation to the hyperactivity scale. Apart from improving in hyperactivity, teachers
were the only respondents who noted clinical concerns for Shane at time of closure.
The first TSCC was invalid due to under-reporting and the second and third (closure)
measures both showed Shane in the normal range regarding anxiety, anger, posttraumatic
stress symptoms and dissociation.
When Take Two ceased involvement with Shane he had attended school full-time for 15
months, with minimal disruption. Although he was still displaying some difficult behaviour,
the school was more able to manage these. Shane’s carers reported that over the time
he had been with them his aggressive outbursts became less frequent, although just as
severe. When Shane reunited with his mother after six years in care, he was having regular
contact with his family. Shane has developed a few significant friendships despite continuing
difficulties in relating to peers and has developed more insight into himself and some capacity
to reflect on his experiences. This in turn led to a reduction in difficult behaviours. Shane
continues to be emotionally vulnerable as a result of his past experiences but has shown
considerable improvement in his personal functioning and relationship with his mother.
Analysis of the SDQs revealed that most respondents, including the children themselves,
reported significant emotional and behavioural problems. Over 50% of the children
were reported by parents and carers to be in the borderline or clinical range of all SDQ
scales at initial assessment, particularly for conduct and peer problems. Self reports
also indicated that 62% of children felt they were in the borderline or clinical range for
conduct problems and hyperactivity. Teachers were less likely than parents or carers
to report emotional difficulties, focussing more on behavioural based problems like
conduct and hyperactivity.
Comparison with repeated measures SDQs, completed during Take Two intervention,
showed a significant decrease in the number of children reported to be in the borderline
or clinical range of the SDQ scales. Carers reported a significant improvement across
all SDQ scales, and parents and teachers noted significant improvements in the child’s
conduct and peer problems. The total difficulties score reported by 100% of parents at
initial assessment were in the borderline or clinical range for children. After Take Two
involvement this figure was reduced to 73.7%. The children themselves also reported
a significant reduction in total difficulties from 58% in the clinical/borderline range to
32%, signifying the positive impact Take Two intervention has had on the emotional
and behavioural difficulties experienced by these children.
30
Mean SDQ total difficulties score at time 1 and 2
by type of respondent (N = 85)
The adapted social network grid (Part 2 of the Social Network Map)
Child
Mean total difficulties
score
Jessica
32 yrs
The social network circle (Part 1 of the Social Network
Map) (Tracy & Whittaker, 1990)
25
20
15
26
Parent
Carer
Client’s
Name
Area of Life
Concrete
Support
Emotional
Support
Info /
Advice
Critical
Direction
of help
Cultural
background
Date
1.Household
2.Other family
3.Work/School
4.Organisations
5.Other friends
6.Neighbours
7.Professionals
8.Other
1.Hardly
ever
2.Some
times
3.Almost
always
1.Hardly
ever
2.Some
times
3.Almost
always
1.Hardly
ever
2.Some
times
3.Almos
t always
1.Hardly
ever
2.Some
times
3.Almos
t always
1.Goes
both ways
2.You to
them
3. Them
to you
1. Same as
me
2. Different
to me
3. Don’t
know
Teacher
21
20
17
18
17
16
14
Names of
significant
people
Closen
ess
1.Not
very
close
2.Sort
of close
3.Very
close
How often
seen
0.Does not
see
1.Few
times/yr
2.Monthly
3.Weekly
4.Daily
How
long
known
1.Less
than 1
yr
2. 1-5
yrs
3.More
than 5
yrs
Age
10
CONCLUSIONS
5
0
Time 1
Time 2
Time period
The trends in all the outcome measures suggest that Take Two has a positive impact
on child wellbeing. There are strengths and limitations of the outcome measures for
both clinical practice and for research and evaluation. Completing outcome measures
at time of assessment, six-monthly reviews and closure allows for both the impact of
the trauma and the impact of therapeutic interventions to be explored. Having the
outcome measures completed by the child and key people in the child’s world allows
for useful comparisons. The outcomes data is also able to be compared with other
research both within Australia and internationally. This provides a broader context
within which to interpret the results from the Take Two service.
KEY REFERENCES
Frederico, M., Jackson, A. & Black, C. (2005). Reflections on complexity –
Take Two first evaluation summary report. Bundoora: La Trobe University
(www.berrystreet.org.au)
Frederico, M., Jackson, A. & Black, C. (2006). Give sorrow words. – A Language for
Healing, Take Two – Second Evaluation Report 2004 – 2005, Bundoora: School of
Social Work and Social Policy, La Trobe University (www.berrystreet.org.au)
CONTACT:
Carly Black, Berry Street, 1 Salisbury Street, Richmond, AUSTRALIA,
Tel. + 61 3 9479 2742, [email protected]
Additional authors: Margarita Frederico, Annette Jackson, Trish McCluskey