Children are profoundly impacted by repeated traumatic experiences. Over time, when left unaddressed, these traumas can interfere with children’s ability to form secure attachments to caregivers, to think, learn, and concentrate, and to control impulses. Traumatic events that are unaddressed and ongoing can cause stress levels to escalate to a toxic level, causing physical and long-lasting damage to children’s developing brains. These effects have been linked to a wide range of issues later in life, including addiction, depression, and anxiety, as well as risk-taking behavior, a greater likelihood of chronic disease, and even early death.

Children and families who come in contact with child protective services (CPS) often have experienced trauma associated with maltreatment. Involvement with CPS often is another stressful event, particularly if it results in family separation, which adds the additional trauma of uncertainty and disconnectedness. As a result, many child protection agencies have come to recognize the importance of providing trauma-informed care and services when they intervene to address children and families’ safety, permanency, and well-being. Connecticut’s Department of Children and Families (DCF) is an example of one state agency that has embedded trauma-informed care principles and values into all of its policies, programs, and practices, working to ameliorate the impact of trauma on the state’s most vulnerable citizens.

CONCEPT: Strategies and Lessons Learned

In 2011, DCF was awarded a $3.2 million, five-year federal grant to integrate trauma practices into all levels of the child welfare system, and CONCEPT — the Connecticut Collaborative on Effective Practices for Trauma — was born. Through CONCEPT, DCF has engaged multidisciplinary partners,¹ including the Child Health and Development Institute (CHDI), which serves as the Coordinating Center, and the Consultation Center at Yale University, which serves as evaluator. Together, they developed the core components of CONCEPT, and have built and advanced a statewide trauma-informed system of care.

DCF learned many lessons during the creation and implementation of CONCEPT, and these strategies and considerations hold promise for other child protection agencies interested in a system wide integration of trauma-informed principles.

Generating statewide stakeholder support

CONCEPT implementation was intentionally multi-pronged and built into a network of state partnerships. DCF leaders knew they had to gain support from stakeholders both internally (administration and staff) and externally (private providers, schools, and other agencies). A previously established steering committee assessed community readiness and secured community feedback by meeting with and listening to families, faith-based organizations, and grassroots groups across the state. The meetings and feedback helped define the development of CONCEPT. To support rollout, four ongoing workgroups were established: Screening and Workforce Development; Learning Collaboratives; Policy and Procedures; and Data and Evaluation.

Creating trauma screening and referral procedures

DCF was among the first jurisdictions to begin trauma screening in child welfare. The validated Child Trauma Screen, created by an interdisciplinary workgroup led by CHDI and Yale, is now utilized to screen all children, age 7 and older, who are placed into care as part of the agency’s “Multi-Disciplinary Evaluation.” A second screen, for children ages 3 to 6, also has been developed and implemented. In addition, DCF requires trauma screening of all youth receiving court-ordered evaluation, and continues to test strategies for expanding trauma screening to more children involved across the child welfare system.² There are trauma-informed screening initiatives in schools, behavioral health, and pediatric practices.

After a lengthy review and feedback process, project partners streamlined the screening tool from 60 questions to 10 in order to make it more user-friendly. The current tool is structured in an interview format, takes approximately 10 to 20 minutes to administer, has separate child and caregiver versions, and probes trauma history, PTSD, mental health, and substance use. The newest version builds on the core components of previous versions but is streamlined to support a higher likelihood of completion. It expands the universe of individuals able to administer the tool and supports the rapid development of findings that can be used quickly to inform service provision.

The caseworker integrates the child report, caregiver report, and the record review/collateral information, and then enters the information into the Statewide Automated Child Welfare Information System (SACWIS). If appropriate, an assessment referral then is recommended, with local providers delivering evidence-based treatment, and a standardized mental health referral form is generated using the results of the screening. All staff across agencies that may be involved in the case have access to the screening results.

Developing trauma-informed staff at all levels

Due to the diversity and volume of staff and stakeholders that needed to be engaged, cross-training was key. Everyone – commissioners, program managers, providers, constituents, and family advocates — received the same trauma-informed training. In 2012, DCF began requiring comprehensive trauma training using the National Child Traumatic Stress Network’s (NCTSN) Child Welfare Trauma Training Toolkit, which is now a pre-service requirement for all new staff. CHDI established a Learning Collaborative to bridge gaps and build a common language between DCF and its community partners about trauma-informed care. “Trauma Champions” were established to provide information to the community through local meetings and products, and to promote trauma‐informed care and activities within DCF offices. These ambassadors met quarterly to share their experiences and familiarize themselves with new materials or research findings on the lifelong impacts of childhood trauma.

DCF leadership describes the paradigm shift as moving from “a head change” to “a heart change.” A turning point in cementing this shift occurred through training staff on the neuroscience of trauma, as it helped them better understand how trauma impacts the brain and manifests itself both physically and behaviorally. Participant disclosures occurred periodically in the classroom as staff came to terms with their own personal and secondary trauma. Leadership realized that they had to take care of staff members’ emotions that arose not only during the trainings but also in their daily work with children and families.

DCF leadership had not anticipated those workforce impacts. But based on the emotional stories and experiences of participants during the training, leaders reviewed and refined the curriculum to incorporate secondary trauma language, created health and wellness teams in all DCF offices, and set up wellness rooms, nutrition groups, and informational speakers. DCF also changed its employee assistance program to a provider that had a more holistic approach and was proactive in reaching out to staff. Leaders say “a trauma-informed system acknowledges that how you support your workforce is a parallel process to how you support your families.”³

Implementing evidence-based interventions

CONCEPT supported training of 30 agencies and more than 600 clinicians to offer Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and the Child and Family Traumatic Stress Intervention (CFTSI). Project partners, using an implementation science framework, instituted Learning Collaboratives based on the model from the Institute for Healthcare Improvement’s Breakthrough Series Collaborative, to disseminate information, increase adoption of trauma-informed processes and therapies, and ensure effective and sustained implementation. Key components included clinical consultation from model developers, regular learning sessions, implementation support, data collection and reporting, and quality improvement activities. Ultimately, the Learning Collaboratives helped to increase the availability of TF-CBT, embed TF-CBT teams within each agency, and build a sustainable network of providers. Six regional multi-disciplinary Learning Collaboratives were created, which included practitioners, parents, supervisors, and administrators. All of the teams participated in quarterly in-person trainings and monthly phone calls. Recognizing the importance of a robust service system at various stages of engagement, DCF expanded service options to include Modular Approach to Therapy for Children, Cognitive Behavior for Trauma in Schools, and Bounce Back.

Assessing system-level change to deliver trauma-informed care was a key focus of the CONCEPT evaluation. A stratified random sample of staff were asked to complete an online survey offering their perception of the agency’s capacity to use trauma-informed principles and practices to support children, families, and the workforce. Significant improvements in trauma-informed knowledge, practice, and collaboration were found across the DCF workforce, and across nearly every domain assessed.⁴

Institutionalizing trauma-informed policies

From its infant stages, CONCEPT was developed and designed to ensure sustainability. DCF incorporated its trauma-informed approach into its mission statement, practices, and policies. DCF leadership developed a policy team, which issued the agency’s Trauma-Informed Practice Guide and applied a trauma and racial justice lens to every single agency policy and practice guidance. Language and content was updated as appropriate. Instead of inserting routine language, the team reviewed each policy and practice and adjusted content to align with the agency’s commitment to trauma-informed care. CONCEPT has contributed to modifications of more than 37 different DCF policies and practice guides to better address childhood trauma, and all future policies will undergo the same level of review. For example, policies related to immigrant children, foster and adoptive services, and transgender youth and caregivers have been revised to ensure that DCF caseworkers consider children’s exposure to trauma and how it may affect their current functioning.⁵ DCF also:

• Adopted a Strengthening Families Practice Model.
• Hardwired trauma-informed practice into pre-service training for all new employees.
• Adopted a new training curriculum for foster parents, TIPS-MAPP (Trauma Informed Partnering for Safety and Permanence — Model Approach to Partnerships in Parenting).
• Continues to train and coach its Trauma Champions to provide coaching to staff and providers on trauma-informed-care.

Impact

To date, DCF’s CONCEPT approach has:⁶

• Trained more than 9,000 providers and clinicians across many fields on childhood trauma, including the importance of using evidence-based interventions to address trauma symptoms.
• Developed a child-trauma screening tool that can and has been applied across the various sectors and settings that serve children across the state, including child welfare, behavioral health, early childhood programs, education, juvenile justice,
  and pediatrics.
• Screened trauma symptoms for more than 20,000 children entering care.
• Developed a menu of evidence-based practices to provide effective trauma-informed treatment for children and families.
• Ensured that more than 10,000 children have received evidence-based treatment for trauma.

To date, 80 percent of children completing Trauma-Focused Cognitive Behavioral Therapy through CONCEPT showed a likely remission of PTSD diagnosis.

DCF also continues to explore other indicators and formulas in order to evaluate outcomes related to trauma-informed initiatives, such as “reduction in problem severity.” Outcomes include decreased recurrence of maltreatment and re-entry into care, as well as behavioral indicators like PTSD recovery and remission.

CONCEPT has undergone an evaluation by Yale’s Consultation Center that examined numerous components of the approach, including system-level readiness and capacity, implementation activities and fidelity, and the effects on workforce development. The evaluation highlights the effects of trauma screening and assessment on child welfare outcomes and service referrals.

1 Partners include Connecticut Department of Children and Families (DCF); CT Center for Effective Practice/Child Health and Development Institute of CT (Coordinating Center); The Consultation Center at Yale University (Evaluators); Yale Child Study Center (CFTSI Developer); Judith Cohen, MD (TF-CBT Developer); Community Provider Agencies; Family Partners; and the National Child Traumatic Stress Network (NCTSN) National Center at Duke University.
2 Lang, J., Campbell, K., Vanderploeg, J. (2015). Advancing Trauma-Informed Systems for Children. Farmington, CT: Child Health and Development Institute of Connecticut. Retrieved from http://www.chdi.org/files/7514/4405/4524/Trauma_IMPACT_-_FINAL.pdf
3 Interview with Kristina Stevens, Deputy Commissioner, Connecticut Department of Children and Families, and Jodi Hill-Lilly, Director of Academy for Workforce Development, April 10, 2018.
4 Lang, J., Campbell, K., Shanley, P., Crusto, C., and Connell, C. (2016). Building capacity for trauma-informed care in the child welfare system: initial results of a statewide implementation. Child Maltreatment, 21, 113-124.
5 Child Health and Development Institute of Connecticut. (2016). Building a Trauma-Informed Child Welfare System: Issue Brief #49. Retrieved from: https://www.chdi.org/publications/issue-briefs/issue-brief-49/
6 Child Health and Development Institute of Connecticut, Inc. (CHDI). (2017). Infographic on addressing child trauma. Retrieved from https://www.chdi.org/index.php/publications/resources/infographic-addressing-early-childhood-trauma