Issue Brief #31
May 8, 2014
Improving Care for Children Through Trauma Screening
Suffering in Silence
Trauma screening improves early identification of children who are suffering from exposure to trauma, including violence, physical abuse, sexual abuse, and the loss of a loved one. Unfortunately, more than 71% of all children are exposed to a traumatic event by the age of 17, and 15% have experienced at least six different events 1. Rates of trauma exposure are even higher for youth in the child welfare (85%)(2) and juvenile justice systems (90%)(3). Exposure to trauma can disrupt brain development(4) and can result in behavioral health problems including posttraumatic stress disorder (PTSD), delinquency, school problems, substance abuse, and suicide. Childhood trauma exposure is also associated with chronic health and mental health problems through adulthood, including heart disease, obesity, diabetes, emphysema, and premature death(5). The lifetime costs associated with child maltreatment have been estimated at $210,012 per child(6).
Too often, child victims of trauma exposure are left to suffer alone because the extent of their trauma exposure or reactions is unknown to others. Children may avoid disclosing trauma out of fear, shame, guilt, or the belief that nobody can help them. Caregivers and child-serving professionals may avoid discussing trauma with children because they are not sure what to say or have the well-intentioned but misguided belief that doing so will cause further distress.
Many hallmark features of traumatic stress are not inherently disruptive to others, including hypervigilance, avoidance, and flashbacks or nightmares. Thus, children experiencing these reactions are less likely to be identified and referred for mental health services. Traumatic stress reactions, including irritability, anxiety, inattention, depression, and substance use, share features with many other mental health concerns and can be easily misdiagnosed, resulting in referrals for inappropriate, ineffective, or even contraindicated services, including psychotropic medication.(7)
Trauma screening is an effective method of quickly identifying youth in any child serving setting who may be in need of a clinical trauma assessment or treatment. Trauma screening can be conducted by non-clinical staff and children rarely become overly distressed when asked about trauma exposure(8). CHDI has worked collaboratively across the behavioral health, child welfare, juvenile justice, education, and medical systems to train thousands of professionals to identify children suffering from trauma and connect them to needed care.
Best practices for trauma screening are that it is:
- Conducted using a brief, standardized, and validated measure
- Used transparently as an engagement strategy
- Administered universally and at least annually
- Includes questions about trauma exposure and reactions
- Conducted by staff trained to manage disclosure and available referral options
A number of trauma exposure and reaction measures exist(9), but the lack of a very brief, no-cost measure has been a barrier to widespread use of trauma screening. As part of a federal trauma grant awarded to the Connecticut Department of Families and Children, CHDI and The Consultation Center at Yale are developing a brief trauma screening measure of 10 items or less for use across any child- serving setting.
Fortunately, for children who screen positive, there are effective treatments available in Connecticut. Trauma Focused Cognitive Behavioral Therapy (TF-CBT), a short-term, family-focused treatment supported by strong research, is available at 29 community-based agencies across the state(10). These agencies have provided TF-CBT to more than 3,500 children since 2007 with excellent outcomes demonstrating marked improvement in PTSD and depression symptoms. Other evidence-based trauma- focused treatments, including TARGET and EMDR are also available for children (as are treatments for adult caregivers, who may have their own unaddressed history of trauma exposure in childhood(11)).
Regardless of the measure used, trauma screening can help child-serving professionals engage children and families by asking "what happened to you?" rather than focusing on "what's wrong with you?”. Knowledge about trauma exposure and distress gleaned from screening can contextualize a child's behavior and functioning through a trauma-informed lens and inform decisions about service planning. Trauma screening can also improve early identification of children who are suffering from exposure to trauma and will ultimately connect more children in need with effective treatment.
For more information on CHDI’s work to build a comprehensive trauma-informed system of care, which includes screening and treatment, please see Issue Brief 27: Building a Statewide Trauma-Informed System of Care (12/5/13), visit our website at www.chdi.org or contact Jason Lang (firstname.lastname@example.org).
1 Finkelhor, Turner, Shattuck, & Hamby (2013). Violence, Crime, and Abuse Exposure in a National Sample of Children and Youth: An Update. JAMA Pediatrics, 167(7), 614-621.
2 Miller, E., Green, A., Fettes. D., and Aarons, G. (2011). Prevalence of Maltreatment Among Youths in Public Sectors of Care, Child Maltreatreatment,16, 196-204.
3 Arroyo, W. (2001). PTSD in children and adolescents in the juvenile justice system. In J.M. Oldham & M.B. Riba (Series Eds) & S. Eth (Vol. Ed.), Review of Psychiatry Series: Vol. 20, Number 1. PTSD in Children and Adolescents (pp. 59-86). Washington DC: American Psychiatric Publishing.
4 Nemeroff, CB. (2004). Neurobiological consequences of childhood trauma. Journal of Clinical Psychiatry, Vol 65(Suppl1), 18-28.
5 Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M.P., Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med, 14(4), 245-258.
6 Fang, X., Brown, D. S., Florence, C. S., & Mercy, J. A. (2012). The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse and Neglect, 36(2), 156-165
7 Weinstein, D., Staffelbach, D., Biaggo, M. (2000). Attention-deficit hyperactivity disorder and posttraumatic stress disorder: Differential diagnosis in childhood sexual abuse. Clinical Psychology Review, 20(3), 359–378.
8 Finkelhor, D., Turner, H. A., Shattuck, A., & Hamby, S. L. (2013). Violence, crime, and abuse exposure in a national sample of children and youth: an update. JAMA Pediatrics, 167(7), 614-621
9 For more information: https://www.childwelfare.gov/responding/screening.cfm
10 A list of Connecticut TF-CBT providers is available at: http://www.kidsmentalhealthinfo.com/admin/uploads/resources/TFCBTproviders.pdf
11 A directory of adult trauma treatment services is available at the Women’s Consortium, http://www.womensconsortium.org/trauma_directory_about.cfm