Each year between 200,000 and 270,000 children and youth enter foster care placements with child welfare services, and many more children receive child welfare services while remaining in their parent’s care, according to the U.S. Department of Health and Human Services. Although many of these children have a documented history of abuse or neglect, children may respond differently to incidents of maltreatment or other potentially traumatic events. Incorporating a trauma screening — which assesses how trauma and maltreatment affected each child — into the child welfare evaluation process provides information that could be used to connect children to the specific mental-health services they need, according to new research from the Penn State College of Health and Human Development and the Child Health and Development Institute.

Individuals react differently to traumatic events like stress or abuse. Some children develop signs of traumatic stress while other people in similar situations do not. For children who experience distress, some become hypervigilant, and others may become withdrawn.

Christian Connell, associate professor of human development and family studies and director of the Child Maltreatment Solutions Network, and collaborator, Jason Lang, chief program officer at the Child Health and Development Institute and a faculty member in the Yale School of Medicine and University of Connecticut, led a study on the value of screening for traumatic experiences during child welfare system intake evaluations. Their study demonstrated that asking a small number of questions about trauma during these evaluations led to better identification of trauma symptoms and more appropriate trauma-focused service recommendations for children. Results of the study were recently published in Journal of Traumatic Stress.

“The goal is to connect children who have experienced trauma to the services and supports they need.”

– Christian Connell, associate professor of human development and family studies and director of the Child Maltreatment Solutions Network

In 2014, Connell and Lang created the Child Trauma Screen, a 10-item screening questionnaire that measures trauma exposure and symptoms of post-traumatic stress disorder in children. The screen was designed for use with established child welfare service evaluations and is freely available to any government entity or child-serving service organization that wishes to use it. Since 2015, the state of Connecticut has included the Child Trauma Screen as part of evaluations for children placed in the child welfare system.

In this study, the researchers reviewed Connecticut child welfare records from July 2013 through October 2014, before the screening was implemented, and from October 2015 through March 2016, after the screening was integrated into evaluations across the state. The research team examined 70 records from the pre-screening time period and 100 records from the screening time period for children between the ages of six and 17.

“When a child encounters the child welfare system, he or she may have had a number of difficult life experiences. The Child Trauma Screen helps staff understand how the system might best respond to that child’s needs related to these experiences,” said Connell, who is also one of the principal investigators of the Translational Center for Child Maltreatment Studies, within the Penn State Center for Safe and Healthy Children. “While the child welfare investigation processes usually identifies the types of experiences the child may have had leading to child welfare involvement, staff also need a standard way to assess how the child is processing those experiences to better identify appropriate service referrals. This is why we created the Child Trauma Screen.”

By using the Child Trauma Screen when children entered formal involvement with the child welfare system, case workers were able to gather consistent information on the types of traumatic stress reactions experienced by children. Results from the study showed that using the screening led to better documentation of children’s reactions to traumatic events and increased service recommendations and referrals for specific, trauma-focused services.

“Screening is an effective strategy for identifying children who are suffering and providing support.”

– Jason Lang, chief program officer at the Child Health and Development Institute

One potential concern arises from the fact that — despite the heightened rates of referral for services prompted by the trauma screening — the results did not demonstrate a corresponding increase in children receiving trauma-related services. The data in this study do not explain why the recommendations did not lead to more services being documented in the child welfare record, but the researchers agreed that identifying that disconnect is critically important so that they can understand and rectify it. Potential explanations include challenges in accessing services within communities or a failure to document services that were provided.

“Ultimately, the goal is to connect children who have experienced trauma to the services and supports they need,” Connell said. “Our results show that screening can be an important part of that process, but that further work is required to make the connection. The next step is identifying the barriers to providing trauma-related services and then connecting each child with the specific help they need.”

The Child Trauma Screen has been translated into several languages and is used by juvenile courts and child welfare systems in multiple states and localities in the U.S. and internationally. Connell and Lang said that there are multiple valid tools that can be used for trauma screening, but the most important thing is that children should be screened for trauma experiences and trauma-related symptoms if there in an opportunity to connect them with necessary services.

“Most children who suffer from traumatic stress do not receive behavioral health services, and some suffer in silence alone without telling anybody what they experienced,” Lang said. “Screening is an effective strategy for identifying children who are suffering and providing support and connection with behavioral health or other services. Unfortunately, trauma screening is not commonly used in many settings where it can be helpful, so we are also creating trainings for adults who work with children.”

The Child Health and Development Institute is developing a web-based training program about trauma screening for social workers, health care providers, educators and other people who work with children. Trauma ScreenTIME is a five-module, web-based training on trauma screening developed with funding from the Substance Abuse and Mental Health Services Administration’s National Child Traumatic Stress Network. So far, over 1,600 people have enrolled and more than 500 have completed the training, according to Connell, who is evaluating the effects of the training among participants.

Modules for people who work in schools and pediatric medical care are available now, and modules for people who work in early childcare, child welfare and juvenile justice are in development. Like the Child Trauma Screen, the Trauma ScreenTime trainings are available for free online.

“Many child-serving professionals are reluctant or don’t feel equipped to talk with children and families about trauma,” Lang said. “Trauma ScreenTIME provides comprehensive courses in trauma-screening best practices. The trainings address common questions and concerns and provide simple strategies that can be used in virtually any child-serving setting.”

Ann Shun Swanson, graduate student at Penn State, and Maegan Genovese, research associate at The Consultation Center in the Yale School of Medicine, also contributed to this research.

The United States Department of Health and Human Services, Administration for Children and Families and the Children’s Bureau funded this project.