Issue Brief 75 -Screening Youth in the Child Welfare and Juvenile Justice Systems for Trauma

August 12, 2020

Screening Youth in the Child Welfare and Juvenile Justice Systems for Trauma:

Data from Connecticut Show it is Practical, Useful, and Effective 

Children involved in the child welfare and juvenile justice systems have high rates of traumatic stress and many can benefit from trauma-focused behavioral health treatment. Universal trauma screening is an important component of a trauma-informed approach, particularly among the high-risk youth involved in these systems. Screening improves the identification of children experiencing traumatic stress and should ensure referrals to effective treatment for those who need it. A common barrier to screening is addressing staff concerns about its feasibility and utility, including the potential discomfort that may be experienced by youth and caregivers who are asked about trauma. An analysis of evidence from screening efforts in Connecticut suggests that trauma screening is feasible, helpful for providing effective services, and is rarely associated with significant distress.

Childhood Trauma is Common, but Often Not Identified

More than 60% of youth nationally report direct exposure to violence, crime, or abuse in the past year.¹ The COVID-19 pandemic is likely to increase rates of trauma exposure, as risk factors for abuse, such as increased stress and a lack of connection to community supports, have increased.² Of those exposed to trauma, 15.9% will develop post-traumatic stress disorder (PTSD) and many more will experience symptoms of PTSD or other traumatic stress reactions.³ This would suggest that among Connecticut’s 753,000 youth,⁴ approximately 452,000 have experienced trauma in the past year, 72,000 will develop PTSD, and many more will experience significant symptoms that could benefit from treatment or other support. Among youth in the child welfare and juvenile justice systems, rates of trauma exposure and traumatic stress are much higher, meaning that a significant proportion of the approximately 36,000 youth being seen in the child welfare system⁵ and 9,000 youth referred to juvenile court each year⁶ may be experiencing PTSD or significant trauma symptoms. Unfortunately, for all youth, trauma exposure is not often disclosed to primary care providers, mental health providers, other staff supporting the family, or even to parents and caregivers.⁷

Commonly Reported Concerns about Trauma Screening

While screening has been identified as an important component of a trauma-informed approach to improve early identification, support, and connection to services across child-serving systems, several concerns about screening have been raised. Common concerns include:

1. The feasibility of screening in a particular program or system, including the time screening takes⁸ and the ability of staff who are not clinically trained to discuss trauma with families.
2. The usefulness of screening, including whether screening elicits new information and whether services are available to youth who screen positive.⁸
3. Concerns that children or caregivers will be re-traumatized or overly distressed when asked about trauma.⁸

The limited research on trauma screening suggests that these concerns about time, usefulness, and distress are not generally warranted. For example, a recent systematic review of trauma screening measures identified six that could be completed in ten minutes or less.⁹ Several studies have found extreme distress to be very rare during trauma screening.^10,11 And while service availability varies by geographic region, in Connecticut evidence-based interventions for children experiencing traumatic stress have been available in at least 269 sites, including community-based agencies and schools. Providers currently offering these interventions are listed in Connecticut’s Evidence-Based Practices Directory.

Juvenile Justice and Child Welfare Workers’ Perceptions of Screening Youth for Trauma

CHDI has partnered with the Connecticut Department of Children and Families (DCF) and the Court Support Services Division (CSSD) of the Judicial Branch to implement trauma screening for youth in the child welfare and juvenile justice systems, respectively. Throughout this work, some staff have expressed common concerns about trauma screening. To address this, CHDI, DCF, and CSSD gathered staff feedback from those administering the Child Trauma Screen (CTS) as part of routine practice. The CTS is a validated, 10-item measure that assesses trauma exposure and symptomology among youth between the ages of 6-17 that can be administered to both youth and their caregivers.¹² More than 1,300 staff responses to a brief quality improvement survey were received after staff administered the CTS to youth and caregivers, with some staff completing the survey multiple times. Staff responses were obtained mostly from screening justice-involved youth (96%). As shown in Table 1, staff generally reported high rates of feasibility and utility, and low rates of perceived discomfort among youth and caregivers.

Table 1: Staff Reports of Feasibility, Utility, and Discomfort Following Trauma Screening

 

Recommendations for Advancing Trauma Screening in Child-Serving Systems

Research and information from Connecticut’s juvenile justice and child welfare system suggests that trauma screening is feasible to administer and often helpful to practice, and that significant distress among youth and caregivers is rare. Trauma screening can also be implemented in other child-serving systems as they strive to be trauma-informed, including schools, primary care, and early childhood. The following recommendations are made for advancing trauma screening in Connecticut and nationally across child-serving systems:

1. Invest in Workforce Development: Staff who are already screening for trauma should ensure they are screening using best practices, such as those described for the child welfare system.¹³ CHDI recently received a 5-year SAMHSA grant to develop online training in best practices for trauma screening for staff across child-serving systems, which is anticipated to be available in late 2021. In the meantime, program administrators should provide adequate training and support to conduct screening, which includes addressing staff reluctance regarding screening, providing accurate information about trauma to families, offering feedback, managing distress when it does occur, supporting positive caregiver-child communication and support, and ensuring service needs are met.
2. Identify and Address Secondary Traumatic Stress and Staff Wellness: Secondary traumatic stress can occur when professionals talk with children and families about distressing or traumatic events. Program administrators should develop procedures to regularly check in with staff who are discussing trauma with children and families, and address staff wellness through training, policy changes, and other supports. The National Child Traumatic Stress Network has extensive resources on recognizing and managing secondary traumatic stress.¹⁴
3. Address Barriers to Screening Unique to Child-Serving Settings: Each child-serving system will need to address different barriers to screening. For example:
   • Schools must address issues of parental consent when parents may not be physically present and whether and how to conduct universal screening with larger populations of youth.¹⁵
   • Primary care providers must consider how to include screening in the workflow of a primary care practice.
4. Conduct Additional Research on Trauma Screening: Research is needed to: 1) understand staff perceptions, barriers, and facilitators of trauma screening in various child-serving systems, such as schools and pediatric primary care; and 2) understand the most effective approaches to screening (e.g., interview vs. self-report) and how screening results in service connections and improvements in child health and mental health.
5. Ensure Adequate Reimbursement for Trauma Screening across Systems: Policymakers should ensure that state and private insurers reimburse for trauma screening in pediatric behavioral health, primary care, and other healthcare delivery settings. 

REFERENCES

1. Finkelhor D, Turner HA, Shattuck A, Hamby SL. Prevalence of childhood exposure to violence, crime, and abuse: Results from the national survey of children’s exposure to violence. JAMA Pediatrics 2015; 169(8): 746-54.
2. Rosenthal CM, Thompson LA. Child Abuse Awareness Month during the coronavirus disease 2019 pandemic. JAMA Pediatrics 2020.
3. Alisic E, Zalta AK, Van Wesel F, et al. Rates of post-traumatic stress disorder in trauma-exposed children and adolescents: Meta-analysis. The British Journal of Psychiatry 2014; 204(5): 335-40.
4. United States Census Bureau. ACS demographic and housing estimates. n.d. https://data.census.gov/cedsci/table?d=ACS%205-Year%20Estimates%20Data%20Profiles&table=DP05&tid=ACSDP5Y2018.DP05&g=0400000US09.
5. Connecticut Department of Children and Families. Child and family services plan 2020 - 2024 2019.
6. State of Connecticut Office of Policy and Management. Facts and figures on Connecticut's juvenile justice system. n.d. https://portal.ct.gov/OPM/CJ-JJYD/Facts-About-Juvenile-Justice/CT-Facts--Figures-Download.
7. Lemaigre C, Taylor EP, Gittoes C. Barriers and facilitators to disclosing sexual abuse in childhood and adolescence: A systematic review. Child Abuse & Neglect 2017; 70: 39-52.
8. Finkelhor D. Screening for adverse childhood experiences (ACEs): Cautions and suggestions. Child Abuse & Neglect 2018; 85: 174-9.
9. Eklund K, Rossen E, Koriakin T, Chafouleas SM, Resnick C. A systematic review of trauma screening measures for children and adolescents. School Psychology Quarterly 2018; 33(1): 30.
10. Finkelhor D, Vanderminden J, Turner H, Hamby S, Shattuck A. Upset among youth in response to questions about exposure to violence, sexual assault and family maltreatment. Child Abuse & Neglect 2014; 38(2): 217-23.
11. Skar A-MS, Ormhaug SM, Jensen TK. Reported levels of upset in youth after routine trauma screening at mental health clinics. JAMA Network Open 2019; 2(5): e194003.
12. Child Health and Development Institute of Connecticut. Screening Children for Trauma. n.d. www.chdi.org/our-work/mental-health/trauma-informed-initiatives/ct-trauma-screen-cts.
13. Lang JM, Ake G, Barto B, et al. Trauma screening in child welfare: Lessons learned from five states. Journal of Child & Adolescent Trauma 2017; 10(4): 405-16.
14. The National Child Traumatic Stress Network. Secondary traumatic stress. n.d. https://www.nctsn.org/trauma-informed-care/secondary-traumatic-stress.
15. Stein BD, Jaycox LH, Langley A, Kataoka SH, Wilkins WS, Wong M. Active parental consent for a school‐based community violence screening: Comparing distribution methods. Journal of School Health 2007; 77(3): 116-20.

This Issue Brief was prepared by Brittany Lange, DPhil, MPH, Senior Project Coordinator at CHDI and Jason Lang, PhD, Vice President for Mental Health Initiatives at CHDI. For more information, contact Brittany Lange at lange@uchc.edu or visit www.chdi.org.

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