Implementation of a workforce initiative to build trauma-informed child welfare practice and services: Findings from the Massachusetts Child Trauma Project
Introduction
Child abuse and neglect are traumatic experiences that profoundly disrupt the developmental imperative of safe, predictable, and nurturing care (Cook et al., 2003). Children involved with Child Protective Services who are removed from the home potentially suffer the additional trauma of separation from the primary caregiver and the cumulative insult of repeated experiences of separation and loss due to placement changes in foster care (Greeson et al., 2011, Spinazzola et al., 2013). The chronic and cumulative experience of abuse, neglect, and parental loss prevalent among children involved with child welfare services is recognized as “complex trauma” because of its invasive interpersonal nature and deleterious impact on children's self-regulatory functioning and capacity to form healthy attachments and relationships (Courtois and Ford, 2009, Kisiel et al., 2009, Spinazzola et al., 2013). The effects of complex trauma on children's short- and long-term health and well-being are wide-ranging and include anxiety, depression, substance abuse, aggression, and sexual disorders in adolescence and adulthood (Cook et al., 2003, Spinazzola et al., 2005).
Despite the high level of need, addressing child trauma presents significant challenges to the child welfare system. At the organizational level, administrative and frontline workers need sufficient knowledge, skills, and tools to support new trauma-informed practices (e.g., awareness of trauma triggers; timely and sensitive identification; referral to trauma-specific evidence-based treatment) (Ko, 2007, Ko et al., 2008). Given the high rates of traumatic stress symptoms and/or compassion fatigue in child welfare workers which leads to job burnout, job withdrawal, and exit from child welfare positions (Bride, 2012, Conrad and Kellar-Guenther, 2006, Pryce et al., 2007, Sprang et al., 2011, Van Hook and Rothenberg, 2009), special attention must also be given to reducing the impact of work-related trauma (Hopkins, Cohen-Callow, Kim, & Hwang, 2010). Specific training materials are available to support these trauma-informed practice changes (Bride, 2012, Conrad and Kellar-Guenther, 2006, Layne et al., 2011, Pryce et al., 2007, Sprang et al., 2011, Van Hook and Rothenberg, 2009). However, as with any system-wide training initiative, building capacity for trauma sensitive care involves considerable long-term commitment of resources, planning, and oversight.
At the community level, dissemination of evidence-based trauma-focused mental health treatment is similarly resource-intensive, with recent research estimating costs as high as $500,000 to implement an EBT statewide (Sigel, Benton, Lynch, & Kramer, 2013). Training to support adoption of a new clinical practice is demanding under any circumstances and particularly when treating children and youth experiencing complex trauma (Aarons et al., 2011, Aarons et al., 2009, Chamberlain et al., 2012, Cohen and Mannarino, 2008). Further, uptake of an EBT requires intensive training and consultation, as well as a sufficient length of time to learn the new approach with clients, to support transferability of the desired outcomes from the research to practice setting (Ebert et al., 2008, Fixsen et al., 2005, Sigel, Kramer, et al., 2013).
In 2011, the Massachusetts Department of Children and Families (MA DCF) ranked 43rd out of 51 states in the Child and Family Services Review composite measure of placement stability, indicating a clear need for improved services for vulnerable children and youth. A closer look at placement data during the period of 2009 to 2011 showed adolescents and preschool age children generally had poorer placement stability than those who were latency-aged. Additionally, youth in kinship placements were more stable than those in other placements, including foster care and residential levels of service, consistent with other research on placement stability (Children and Families Research Center, 2004). Further exploration of state Child Welfare System (CWS) data found that 68.5% of children had home removal reasons consistent with complex trauma (e.g., abandonment, neglect, physical or sexual abuse). Eighty-five percent of these children had no prior home removal episodes, 15% had one prior removal, and 3% had two or more prior home removals. Reasons most commonly cited for home removal included neglect (77.6%), parental drug abuse (22.9%), and physical abuse (14.7%). After a home removal incidence, children had an average of 3.9 placements (range = 1–47) and the average number of placement days was 132 (range = 1–1066 days).
As part of its strategic planning efforts, and in response to these indicators, MA DCF designed and implemented a new casework practice model to transform the culture of the agency to reflect more progressive best practices in child welfare. Grounded in the nationally recognized Strengthening Families and Positive Youth Development frameworks (Center for the Study of Social Policy, n.d-a, Center for the Study of Social Policy, n.d-b), the design drew heavily on implementation science and adult learning. The new practice model builds on the experience of other states (including Minnesota, California, New Jersey and Missouri) implementing a Differential Response model and the Signs of Safety framework (Chapman & Field, 2007). A parallel effort was also initiated within DCF to address secondary traumatic stress (STS) and organizational stress inherent in the child welfare system. The work focused on STS had been initiated in 2008 in collaboration with an expert in organizational behavior at the Boston University School of Management (Kahn, 2003, Kahn, 2011). This effort included training managers and staff on the impact of STS, training DCF volunteer social workers and supervisors to facilitate debriefing groups, and instituting debriefing and “social work support groups” after critical incidents or home removals.
The cornerstones of the new practice model are positive engagement and empowerment of families, progressive understanding of families' needs and strengths, building capacity of parents to effectively parent their children, and consolidating and sustaining gains. The clinical approaches established in the new model emphasize safety-organized, trauma-informed and solution-focused casework. To support this effort, MA DCF instituted a significant training and coaching process to assist child welfare staff in adopting these new practices. The new casework practice model provided an important foundation for enhancing the capacity of child welfare staff to engage in trauma-informed practice.
MA DCF's work to transform casework practices was accompanied by efforts to strengthen collaboration with mental health providers providing services, with the focus on MA DCF's Support and Stabilization program, the state's Medicaid program comprehensive services for children with Serious Emotional Disturbance (known as the Children's Behavioral Health Initiative), and outpatient behavioral health. Towards this end, the Department became involved in a National Child Traumatic Stress Network (NCTSN) Breakthrough Series Collaborative focused on trauma-informed child welfare practice to improve foster care placement stability (Conradi et al., 2011). The Breakthrough Series Collaborative method was developed by the Institute for Healthcare Improvement nearly two decades ago and has since been used successfully in multiple health care settings and systems (Institute for Healthcare Improvement, 2003). It was designed to be a short-term learning system “to help organizations close [the gap between what we know and what we do] by creating a structure in which interested organizations can easily learn from each other and from recognized experts in topic area where they want to make improvements.”(Institute for Healthcare Improvement, 2003)
The trauma-informed child welfare practice Breakthrough Series Collaborative, which took place between 2010 and 2012, involved teams from nine states across the country, each comprising a partnership between a county- or State-level public child welfare agency and an organization that provided evidence-based intervention for child trauma. Provider organizations were part of the NCTSN consortium of grantees across the country funded by the Substance Abuse and Mental Health Services Administration to enhance the standard of care for traumatized children and their families (Conradi et al., 2011). In Massachusetts, the partnership was between DCF and the Central Massachusetts Child Trauma Center (which itself was a partnership between LUK, a community-based mental health provider agency, and the University of Massachusetts Medical School).
The Breakthrough Series Collaborative process identified a number of priorities for the MA DCF's work going forward in building trauma-informed casework practice: (a) improving identification and assessment of children exposed to complex trauma; (b) fostering trauma-sensitive and trauma-informed practices among child-serving agencies; (c) increasing trauma training and sensitivity of caregivers (e.g., biological, kin, and foster parents); (d) improving linkages and referral rates to evidence-based trauma treatments; and (3) building service provider capacity for trauma-focused EBTs in Massachusetts.
This history of public-private collaboration led next to an ambitious statewide initiative in Massachusetts to build capacity for trauma-informed care and trauma-specific services at the child welfare system and community provider levels, respectively. This initiative, which is called the Massachusetts Child Trauma Project (MCTP), is funded by the Administration for Children and Families Children's Bureau and is a partnership between DCF, LUK, the Child Witness to Violence Project at Boston Medical Center, the Justice Resource Institute, and the University of Massachusetts Medical School. The primary goal of MCTP is to improve placement stability and permanency outcomes for children with complex trauma in MA DCF's care. The overarching vision for the initiative is to build sustainable workforce capacity for trauma sensitive practice changes within MA DCF and to integrate evidence-based trauma treatments into the existing mental health service array in Massachusetts, as well as to foster greater communication between the two systems.
This article describes the major components of the MCTP since its inception in the fall of 2011. We present our approach, including activities that informed implementation, the evaluation plan, and preliminary implementation findings in the initial year (October 2012–September 2013). We then reflect on lessons learned about implementation and solutions forged in pursuing a parallel track of capacity building at both the agency and the community provider level.
Section snippets
Methods
As noted above, MCTP is a two-pronged capacity-building effort focused on coordinating dissemination of trauma-focused EBTs at community-based mental health agencies in parallel with training to support trauma-informed practice by child welfare staff. Each of these tracks is discussed below.
Results
In the section that follows we report the findings to date regarding organizational readiness, implementation of the TILT teams, and EBT implementation progress
Discussion
The goal of MCTP is to promote alignment across multiple service delivery systems to ensure that families are receiving appropriate trauma-informed services, with a particular focus on increasing placement stability and access to trauma-focused treatments. Fundamental to this system transformation is recognition that agency culture plays a significant role in determining the most effective strategies to implement change. Implementation of any significant change in practice requires sensitivity
Acknowledgements
The project described in this paper was funded by the Administration for Children and Families, Children's Bureau, through Grant No. 09C01057.
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