Lisa Conradi, Psy.D.Rady Children’s Hospital – San Diego

Chadwick Center for Children and Families

Objectives of Today’s Presentation

Audience PollDo you currently conduct a mental health or

trauma-focused screening in your agency?• If so, what do you use? Who does the screening?

What kinds of questions does it contain? How is the information used?

Do you or your partners currently assess for trauma and behavioral health needs within your practice or agency? If so, what kinds of tools do you use? Who does

the assessment? How is the information used?What have been your successes? Your

challenges?

Screening and Assessment

• Screening?• Assessment?• Evaluation?

• These terms are often used interchangeably, but what are they? When it is appropriate to use one vs. the other?

Screening• Screening refers to a brief, focused inquiry

to determine whether an individual has experienced specific traumatic events or reactions to trauma and if they need trauma-focused mental health treatment.

• Done by front-line workers, such as Child Welfare and, in some cases, mental health.

• Usually includes questions regarding a child’s exposure to trauma and his/her symptoms

Assessment• Assessment is a more in-depth exploration of the nature

and severity of the traumatic events, the impact of those events, current trauma-related symptoms and functional impairment.

• Usually done by a mental health provider to drive treatment planning.

• A good assessment usually occurs over at least 2-3 sessions of therapy and includes a clinical interview, use of objective measures, behavioral observations of the child, and collateral contacts with family, caseworkers, etc.

• Domains covered include:Basic demographicsFamily historyTrauma history (comprehensive, including events

experienced or witnessed)Developmental historyOverview of child problems/symptoms

Prior to Embedding a Screening or Assessment Process• Provide broad training on the following topics:

• Mental and behavioral health in children• Child traumatic stress. This includes training on

different trauma types (sexual abuse, physical abuse, exposure to domestic violence, emotional abuse, etc.) and various traumatic stress reactions that children may exhibit, including internalizing and externalizing behavior problems.

Prior to Embedding a Screening or Assessment Process, cont’d• Establish a relationship with your mental health

partners and is actively work with them to build their capacity to provide trauma-focused mental health treatment when appropriate.

• Have a mechanism in place to address secondary traumatic stress within child welfare workers and supervisors. Integrating a system for preventing and addressing secondary traumatic stress is critical.

Where Does Screening Fit into the Process?

Why Screen?• Screening provides information on broad symptoms that

the child may be experiencing that warrant a more comprehensive assessment.

• In many cases, workers are already gathering this information, but they don’t have a process to make sense of the information that they are gathering.

• Screening assists caseworkers in identifying the types of events or situations that may potentially trigger symptoms for the child. This information can be conveyed to the foster parent and can ultimately help the foster parent manage the difficult behaviors and minimize placement changes.

• Screening plays a critical role in case planning and referral to the appropriate mental health services, if appropriate.

Systemic Decision-Making Process for Selecting and Implementing Screening Tools

Client-level Decision-Making Process for Selecting and Implementing Screening Tools

Child-Completed Tool

• If a child has the developmental capacity to read and complete a screening tool (usually ages 8 and above, but will vary significantly across children)

• Questions/items are given in writing or verbally administered in an interview format.

Child-Completed Tool:Strengths and Challenges• A benefit to this strategy includes providing the

child with an opportunity to verbalize their responses aloud.

• CW worker should take great care in asking highly personal and sensitive questions and be aware that a child may be sharing their experiences for the first time or be hesitant to share them at all.

• It may be difficult for both the child to share their experiences and for the caseworker to hear.

• Training and support on asking these questions in a sensitive manner is critical.

Caregiver-Completed Tool• For infants, toddlers, and young children (ages

0-–8) or children with developmental delays, it may be more appropriate to have a caregiver complete a trauma screening tool either by providing written responses to the questions/items or through an interview by the CW worker.

Caregiver-Completed ToolStrengths and Challenges• This strategy is particularly helpful for detecting

exposure to trauma for young children who cannot verbalize information themselves.

• Birth parents may be cautious in sharing detailed information about all of the child’s traumatic experiences given how this may impact decisions about placement, visitation, and reunification.

• Foster parents may not know the child’s trauma history and may over- or underreport trauma symptoms based on their experiences fostering other children in their care.

Provider Completed Tool• An information integration tool can be

completed by the caseworker or clinician as he or she reviews and integrates all available information on a child, including court reports, interviews with caregivers and teachers, other questionnaires, and behavioral observations.

Provider Completed Tools Strengths and Challenges• This integration strategy is particularly helpful in

allowing the caseworker to make sense of a wealth of information that is available for children in all age groups and can be used to screen infants and toddlers.

• However, if they have not asked the child or caregiver specific questions, they may not have the complete picture of the child’s unique experiences.

Child Behavior Checklist (CBCL)Developed by Achenbach (2001)Contains 113-itemsVersions for both the parent/caretaker to complete

and a teacher version2 versions: 1.5-5 years; 6-18 yearsProvides information on child behavioral and

emotional problems, and competenciesEstablished reliability and validityAvailable in Spanish10-15 minutes to administer

Pediatric Symptom ChecklistPsychosocial screen designed to facilitate the recognition

of cognitive, emotional, and behavioral problems so that appropriate interventions can be initiated as early as possible.

Designed for children 4-18 years.Consists of 17 items that are rated as “Never,”

“Sometimes, ” or “Often” present. A value of 0 is assigned to “Never”, 1 to “Sometimes,” and 2 to “Often”.

The total score is calculated by adding together the score for each of the 17 items.

A PSC-17 score of 15 or higher suggests the presence of significant behavioral or emotional problems.

Correlates highly with the Child Behavior Checklist.Can be downloaded for free at http://

www.massgeneral.org/psychiatry/services/psc_home.aspx

Strengths and Difficulties Questionnaire (SDQ)A brief behavioral screening questionnaire for 3-

16 year olds. Is readily accessible and has strong reliability and

validityIt exists in several versions to meet the needs of

researchers, clinicians and educators.It contains 25 items covering 5 scales:

Emotional symptomsConduct problems Hyperactivity/inattention Peer relationship problems Pro-social behavior

Can be downloaded for free at www.sdqinfo.com

Child and Adolescent Needs and Strengths (CANS) - Trauma• A shorter version of the CANS can be incorporated

as a screener tool that can gather basic information on whether any trauma experiences have occurred and whether problems with adjustment to this trauma impact a child’s current functioning.

• If this initial information suggests that the child is experiencing problems with adjustment to trauma, this often indicates the need for a more detailed trauma assessment on a range of needs and strengths of the child and caregiving system, either by using a comprehensive version of the CANS or other relevant tools.

Brief Assessment ChecklistDeveloped by Tarren-Sweeney (2007)20-item caregiver-report psychiatric rating scaleDesigned to screen for and monitor clinically-

meaningful mental health difficulties experienced by children and adolescents in various types of care;

Also designed to be used as brief casework monitoring tools by foster care and adoption agencies, and for treatment monitoring in CAMHS.

Available in two versions:The Brief Assessment Checklist for Children (BAC-C

for 4-11 years)The Brief Assessment Checklist for Adolescents (BAC-

A for 12-17 years).

Trauma Symptom Checklist for Children (TSCC)

Developed by Briere (1996)54-itemsBoys and girls (ages 8-12 and 13-16 years; normative

adjustments for 17 year olds)Child completed trauma measureTwo validity scales (underresponse and overresponse)Six clinical scales (anxiety, depression, pts,

dissociation, anger, sexual concerns)Completed by mental health professionals with

training in psychometricsApprox. 10 minutes to complete

Child PTSD Symptom Scale (CPSS)Developed by Foa, Johnson, Feeny, and Treadwell

(2001)Designed for children ages 8-18This self-report measure assesses the frequency of

all DSM-IV-defined PTSD symptoms and was also designed to assess PTSD diagnosis.

The first 17 items measure PTSD symptomatology and yield a total Symptom Severity score.

Seven additional items assess daily functioning and functional impairment.

Available for free

UCLA PTSD Reaction Index• The UCLA PTSD Index for DSM-IV is a 48-item

semi-structured interview that assesses a child’s exposure to 26 types of traumatic events and assesses PTSD diagnostic criteria from the DSM-IV.

• It includes 19 items to assess the 17 symptoms of PTSD as well as two associated symptoms (guilt and fear of event’s recurring).

• This tool may be used as a screening tool on its own, or part of a larger trauma-informed assessment or psychological evaluation.

Traumatic Events Screening Inventory (TESI)• The TESI-PRF-R is a 24-item parent-

administered interview that assesses a child’s experience of a variety of potential traumatic events including current and previous injuries, hospitalizations, domestic violence, community violence, disasters, accidents, physical abuse, and sexual abuse.

• Additional questions assess exposure to traumatic events and other additional information about the specifics of the event(s).

Child Welfare Trauma Referral Tool• Questions about the child’s history and presenting

problems guide the caseworker in identifying whether the reactions are directly related to the child’s traumatic experiences, or existed before the traumatic event.

• Based on the answers, the caseworker determines whether to make a general mental health referral, a referral to a specialized program such as a hospital or substance abuse program, a trauma-specific mental health referral (i.e., trauma assessment), or no mental health referral.

Strategies to Integrate Screening into Practice• Research the available measures and identify a couple

that meet your needs. Ask staff to pilot test various measures to find the one that is most helpful and easy to administer, based on your system.

• Consider embedding trauma screening practices into the already existing system in a more formalized manner. • Integration of questions into Structured Decision-Making• Weaving into existing practices and initiatives• Important to consider how critical reliability and validity is

in this process.• Have multiple strategies available, based on the age of

the child and education level of the workforce.

Why is Trauma-Informed Assessment Important ?

How Client/Family Engagement in Assessment Process is of Benefit

What to Assess: Key Components and Perspectives

Child Developmental history History of trauma/adverse experiences Needs/symptom presentation – including risk behaviors and functional impairment Strength and resources/supports Perception of trauma and coping mechanisms

Caregiver / Family Relationships / allegiances Caregiver needs/problem presentation Knowledge of child/ability to support and supervise Strengths and resources/supports Perception of trauma and coping mechanisms

Environment / System Levels of system involvement (child welfare, legal) Cultural perception or understanding of the trauma Deficits or contributions to problems Areas of Support

Factors to Consider when Identifying Assessment Strategies

Assessment Based Treatment for Traumatized Children: A Trauma Assessment Pathway (TAP)

The TAP Model is a treatment model that incorporates assessment, triage, and essential components of trauma treatment into clinical pathways.

It helps treatment center staff incorporate standardized assessments into the intake and ongoing treatment process.

It is directed by the uniqueness of the child and his or her family.

It provides guidelines for clinicians to make decisions regarding trauma treatment strategies based upon the child’s unique presentation.

Three Components of TAP

Integrating Assessment Data into Treatment Planning

Consider All Assessment Feedback

Engage Client and Family through Review of Assessment Results

Symptom ChangeOver Time

Treatment goals are written at this stage and will reflect:

Use of Trauma-Informed

Assessment Information in Practice:

Lessons Learned

Summary of Existing Challenges: Use of Assessment Information in Practice

Access to trauma-focused

MH services

Resources• California Evidence-Based Clearinghouse for

Child Welfare = www.cebc4cw.org, includes information on assessment measures

• TAP Online Training = www.taptraining.net • CANS Resources and Training Information =

www.praedfoundation.org • National Child Traumatic Stress Network =

www.nctsn.org• NCTSN Measure Review Database =

http://www.nctsn.org/resources/online-research/measures-review

Contact InformationLisa Conradi, Psy.D.SAMHSA/ACYF Projects Co-DirectorChadwick Center for Children and FamiliesRady Children’s Hospital – San Diego3020 Children’s Way, MC 5131Ph: (858)576-1700 x6008E-mail: lconradi@rchsd.org