Trauma practice model: Building resilience for children
Larimer County (CO) Department of Human Services provides trauma screenings for children with open child welfare cases, conducts comprehensive neurodevelopmental trauma assessments, uses resiliency-based case plans, and provides intensive in-home, trauma-informed coaching programs.
Services range from helping parents learn child regulation techniques to intensive in-home services. The program has been expanded to seven counties in Colorado that are operating the program under the state’s Title IV-E child welfare funding waiver.
Publication date: 2020
All children and families in Larimer County with an open child welfare case (about 1,000 children per year) are provided with a trauma screening; of these, 20 percent (about 200 children) then qualify for a comprehensive trauma assessment and additional services.
Of the 1,000 children screened, 140 are in foster care with the Department of Human Services, including a small proportion in relative foster care. 150 children are in relative care and custody with Department of Human Services oversight, Temporary Aid to Needy Families (TANF) support, and case management.
Theory of change
Identification of past or current traumatic events and their impact on a child provides a starting point for understanding the dynamics and challenges that put a child at risk for out-of-home placement. Investing in upfront trauma-informed assessments, care plans, and indicated services will result in better outcomes for children and youth, including reduced placements in congregate care and improved child wellbeing and resilience.
The program is operated by the Larimer County Department of Human Services. The providers are the Child Trauma and Resilience Assessment Center (CTRAC) at Colorado State University and Summit Stone Health Partners, Larimer County’s community mental health center. Larimer County contracts with other community agencies to deliver assessments and services to families under the model.
Role of public agency
The Larimer County Department of Human Services has care and custody responsibility for children, provides case management, and makes all referrals for assessment and services. As a differential response community, Larimer County Department of Human Services also provides services through non-court involved cases.
Key service components
- Outcomes assessment—For all children age six and older, a Treatment Outcome Package (TOP) is completed by the caseworker, the child (if age appropriate), the parent or caregiver, and other key team members (e.g., therapist, school staff, mentor) at the time the case opens. This assessment is completed every 90 days until case closure to provide a measure for monitoring the child’s well-being across multiple areas over time. The TOP helps adults understand the child’s perspective and allows the child to voice their concerns, which, in turn, is influential in case planning and referrals to services. The TOP also gives the treatment team, parents, and child a clear understanding of whether the services provided are helping or not.
- Initial trauma screening—Each child’s caseworker completes the Child Trauma Assessment Center’s Trauma Screening Checklist. Children who score a certain level on the assessment (currently a 6) then receive the comprehensive trauma assessment (outlined below). For those who do not meet the threshold, the screening results still help families understand the impact of trauma on child development and behaviors.
- Comprehensive trauma assessment—Children who meet the screen-in threshold are referred for a comprehensive trauma assessment. These trauma assessments provide an understanding of the neurodevelopmental impact of the child’s exposure to trauma and become the foundation for the development of a trauma-informed, resiliency-based case plan. Recommendations focus on the resiliency needs of relatedness, mastery, and affect regulation for both the child and caregiver, aimed at preserving and strengthening the child’s placement.
- Services to address issues found in the assessment—Based on the assessment, Larimer County offers a variety of resiliency-based interventions for children and families. Services include in-home coaching/mentoring programs, psychoeducation and treatment coordination, and a 24-hour/7-day hotline for crisis intervention. They also provide additional creative services to help children with mastery, affect regulation, and relatedness. These services can be as varied as a glass-blowing class; karate, soccer, and other sports; support to help a child care for a treasured pet; and heart rate monitors so children can monitor their own level of excitement and begin to regulate it.
All children in the county with an open child welfare case are served so no specific outreach is necessary.
Staffing and training
Program coordination required 1.5 new full-time equivalent staff:
- 1 FTE program quality assurance coordinator carries the responsibility of service and referral coordination. The coordinator is also responsible for monitoring compliance with trauma screening and trauma assessment fidelity.
- .5 FTE Medicaid liaison works with providers to become certified/credentialed to provide Medicaid-funded mental health services and helps navigate the complex bureaucracy surrounding Medicaid behavioral health systems.
In addition, six Larimer County Department of Human Services staff (a combination of supervisors and caseworkers) pair with a contracted clinician from the community to facilitate Resilience Alliance (an intervention developed to reduce secondary traumatic stress and increase resilience of child welfare staff). County staff are paid a stipend to deliver Resilience Alliance twice per month within the organization. Resilience Alliance is a product of the National Child Traumatic Stress Network.
The project does not require additional caseworkers, but did require increased training about the model and the effects of trauma.
Contracted staff at the partner agencies include master’s-level social workers who conduct all the assessments. Service delivery is also provided by these staff at the contracted agencies, plus a small number of Larimer County Department of Human Services staff that provide some home-based skills services.
In Larimer County, caseworkers and supervisors are required to complete at least 20 hours of trauma-focused training per year.
Each of the agencies that conducts assessments must complete an endorsement process, which includes a two-day training, observation of a trained clinician conducting an assessment, site visits, and neurodevelopmental tools training. Each provider must then be observed by a trained clinician while conducting three to five assessments. The observation includes the assessment (neurodevelopmental tools and psychosocial interview) and debriefing sessions, review of the written report, and clinical consultation throughout the process.
Larimer County has also provided and funded training for service providers and other community members. The majority of training has focused on building a common language about trauma, increasing providers’ knowledge base, and enhancing existing service options.
Evaluation and outcomes
The current evaluation plan focuses on process fidelity and outcome evaluation. The following have been identified as fidelity measures:
- Fidelity of the trauma screening process (percentage of the children who met the target population who received the screening; percentage who were screened in or screened out; screening scores across program areas and age)
- Fidelity of the trauma assessment process (percentage of children who were screened in who received a trauma assessment; timeframes for completion; compliance with the assessment model)
- Fidelity of the TOP administration process (percentage of children who met the TOP criteria; percentage of the population who received an initial TOP and follow up; timeliness; multi-rater involvement)
- The outcome evaluation plan focuses on child welfare outcomes and child well-being outcomes as measured by the TOP. Larimer County has begun some preliminary analysis of well-being measures for children who received a trauma assessment. Overall, these findings, while early, demonstrate an improvement in well-being. Most significantly, children are reporting and identifying an improvement in their well-being.
Budget and funding
The seven counties—which included Larimer County—applied for and received Title IV-E waiver funding to operate the program. The budget for the waiver program is $1.9 million for state fiscal year (FY) 2016. Activities under the program included trauma assessments for children, caseworker and community training, the TOP well- being measure, and project evaluation. In addition to the funding for all seven counties, Larimer County also received $450,000 for FY 2016 for trauma assessments and trauma-focused services for children and families.
The project has been funded through a combination of federal and state/county child welfare funds, including:
- County child welfare block grant funds
- Family preservation funds through a state budget allocation
- Title IV-E waiver funds
- Limited Medicaid funding for trauma assessments
As noted above, with the addition of a half-time Medicaid staff member, the goal is to increase the portion of services that can be covered by Medicaid and to increase the number of providers who accept Medicaid to offer these services to children and families.
Partnerships required or recommended
Success of the project rests on partnership and collaboration across systems. Implementation of this project has required significant involvement from the local community mental health system, private providers, schools, probation staff, judicial partners, the behavioral health organization, foster parents, and the community at large. In addition to local engagement, long-term success and sustainability is dependent on partnership from the Colorado Department of Human Services (child welfare and behavioral health areas) and Health Care Policy and Finance.
In an effort to support the creation of a trauma-informed system, Larimer County created two key stakeholder groups—the Trauma Practice Group and the Trauma Leadership Group:
- The Trauma Practice Group, which meets monthly, is co-chaired by a Larimer County liaison and a community member. The group includes providers who deliver trauma-informed services, probation staff, local school district staff, family members, family advocates, foster parents, and county child welfare staff. The goals of the group are to create common language, engage community partners, identify barriers and brainstorm solutions, advertise training and the latest research, share experiences and successes, foster resiliency, and work to build and sustain capacity.
- The Leadership Group meets quarterly and includes executive staff from the agencies and organizations in the Trauma Practice Group. The Leadership Group identifies and removes system barriers and aligns policies.
- A key factor in the sustainability of this project will be to align Medicaid resources and state policy with the project. Representatives from each county department, their behavioral health organizations, community mental health centers, other providers, resiliency center staff, and state staff meet monthly to oversee project implementation and to share implementation concerns and successes.
Challenges and future direction
The largest challenge has been accessing Medicaid funding for assessments and treatment of children. The difficulties are demonstrated in the following:
- The lengthy and difficult process for providers to become Medicaid providers, including at least one provider who has been working on approval for more than 15 months.
- The misperception that addressing trauma from abuse and neglect is the primary responsibility of the child welfare agency and that such trauma is not mental health trauma eligible for funding through Medicaid.
- Building capacity for trauma-informed care in a system that is largely focused on behaviors has been time-consuming and at times met with resistance. Engagement of key stakeholders has proven to demonstrate the greatest success in overcoming this barrier, yet local jurisdictions are still facing challenges within systems driven by policy and funding allocation.
Another challenge is that child welfare staff having become the experts in screening, assessing, and treating traumatized children has created some tension between the behavioral health system and the child welfare system. In the past, determinations for services were made by the behavioral health system and the shift to having child welfare staff be responsible has created some tension.
In response to these challenges, the Larimer County Department of Human Services has taken on the role of advocating for policy and funding changes.