Children and Youth Services Review 84 (2018) 110–117
Contents lists available at ScienceDirect
Children and Youth Services Review
journal homepage: www.elsevier.com/locate/childyouth
The impact of a statewide trauma-informed care initiative in child welfare
on the well-being of children and youth with complex trauma☆
T
⁎
Jessica Dym Bartletta, , Jessica L. Griffinb, Joseph Spinazzolac, Jenifer Goldman Fraserd,
Carmen Rosa Noroñad, Ruth Bodiane, Marybeth Toddb, Crystaltina Montagnab, Beth Bartof
a
Child Trends, United States
University of Massachusetts Medical School, United States
c
Trauma Center at Justice Resource Institute, United States
d
Child Witness to Violence Project, Boston Medical Center, United States
e
Massachusetts Department of Children & Families, United States
f
LUK, Inc., United States
b
A R T I C L E I N F O
A B S T R A C T
Keywords:
Trauma
Complex trauma
Trauma-informed care
Child welfare
Child maltreatment
Evidence-based treatment
The current study examined the effectiveness of three trauma treatments in the context of a statewide, traumainformed child welfare initiative to improve outcomes for children with complex trauma. Clinicians enrolled 842
children (birth-18 years) involved in the child welfare system within the past year and administered measures at
up to three time points (baseline, 6 months, 12 months) to assess children's behavior problems, symptoms of
posttraumatic stress disorder (PTSD), and strengths and needs using parent/caregiver, youth, and clinician report measures. The results of four-level regression models specified to account for non-independence of observations within children, and among clinicians and within agencies, indicated that trauma treatment was
associated with significant improvements in child behavior problems, PTSD symptoms, strengths, and needs.
However, results differed by treatment model, with optimal outcomes for children receiving Attachment, SelfRegulation and Competency (ARC) and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Positive
findings across multiple child outcomes suggest that trauma treatment is an effective means of improving the
developmental trajectories of children with complex trauma, but that each model has specific strengths and
weaknesses that should be taken into account when selecting a treatment model for this population.
1. Introduction
Child abuse and neglect is a widespread societal problem that often
has devastating effects on children's development that persist into
adulthood (Widom, Czaja, Bentley, & Johnson, 2012). In 2015, an estimated 4 million referrals for maltreatment were made to child protective services involving 7.2 million children (U.S. Department of
Health & Human Services, n.d.). While individual child outcomes vary
depending on the age of the child, the nature of the maltreatment, the
relationship between the child and the perpetrator, and the balance of
risk and protective factors in the child's life, research shows that the
consequences of maltreatment can span multiple developmental domains and include negative alterations to brain structure and functioning, difficulties forming attachments, posttraumatic stress, internalizing and externalizing behaviors, and chronic health problems
(Institute of Medicine & National Research Council, 2014; Leenarts,
Diehle, Doreleijers, Jansma, & Lindauer, 2013). While in the child
welfare (CW) system, children may endure additional experiences of
separation and loss in foster care. These chronic, interpersonal adversities that begin early in life are often referred to as complex trauma,
and are associated with impairments in biology, attachment, affect
regulation, behavioral control, cognition, and self-concept (Kisiel,
Fehrenbach, Small, & Lyons, 2009; Spinazzola et al., 2013). Not surprisingly, children in the CW system are considerably more likely to
require mental health (MH) services compared to non-maltreated
children (Yanos, Czaja, & Widom, 2010).
Several therapeutic models have been developed to treat complex
trauma and to promote positive developmental trajectories among
maltreated children. Few have been rigorously evaluated, and they
have shown varying levels of effectiveness (Leenarts et al., 2013).
☆
Acknowledgements: Funding provided by the Administration for Children and Families, Children's Bureau, Grant No. 90C01057. The Massachusetts Department of Children and
Families served as the Principal Investigator.
⁎
Corresponding author at: 56 Robins Street, Acton, MA 01720, United States.
E-mail address: jbartlett@childtrends.org (J.D. Bartlett).
https://doi.org/10.1016/j.childyouth.2017.11.015
Received 31 July 2017; Received in revised form 11 November 2017; Accepted 12 November 2017
Available online 13 November 2017
0190-7409/ © 2017 Elsevier Ltd. All rights reserved.
Children and Youth Services Review 84 (2018) 110–117
J.D. Bartlett et al.
derived from the intended usage indications, empirical evidence-base,
and history of successful implementation of each model with children
and caregivers within and across three contextual parameters: developmental stage, caregiver involvement and primary clinical presentation (Fraser et al., 2014). Clinicians administered assessments at baseline (i.e., onset of treatment), 6, 12, and 18 months, or until treatment
was complete or treatment was terminated. The protocol took approximately 1 hour to administer, although the length of time varied
depending upon whether youth were old enough (≥ 8 years) to complete self-report measures and whether parents or other caregivers
opted to complete some of the measures while waiting for the session to
begin.
In the study sample, 44.89% (n = 378) children and youth received
ARC, 35.99% (n = 303) received TF-CBT, and 18.76% (n = 158) received CPP. Children averaged 9.14 years at enrollment (SD = 4.66;
Range = 0–18 years); ARC M(SD) = 10.25 (4.13), Range = 2–18 years;
CPP M(SD) = 3.38 (1.53), Range = 0–7 years; and TF-CBT M(SD)
= 10.69 (4.06), Range = 3–18. Over half of children (53.92%) were
female. Approximately 4.35% were Hispanic, 70.31% were White,
18.65% were African-American, 1.7% were American Indian or Alaskan
Native, 1.31% were Asian (others unknown); respondents were given
the option to select as many categories and combinations of race/ethnicity as applied. Over one third (38.24%) were using psychotropic
medication at baseline. Approximately 43.59% of children were in the
legal guardianship of their parent and 38.12% were in state custody.
Almost one quarter resided in foster homes (23.63%). The most
common types of trauma they experienced were within the caregiving
system (e.g., physical abuse, neglect, caregiver impairment; M = 5.2
out
of
20
types)
(http://www.nctsn.org/nctsn_assets/dcri/
NCTSN_CCDS_Trauma_DetailVersion_4Final%20.pdf, n.d.).
Moreover, little is known about how they compare to one another in
producing their intended outcomes. To our knowledge, only one study
has been conducted previously comparing outcomes of different trauma
treatments for children involved in the child welfare system. Weiner,
Schneider, & Lyons (2009) compared three treatment models (ChildParent Psychotherapy [CPP], Trauma-Focused Cognitive Behavioral
Therapy [TF-CBT], and Structured Psychotherapy for Adolescents Responding to Chronic Stress [SPARCS]), two of which are included in the
current study (CPP and TF-CBT), and found they were equally effective
in reducing symptoms and improving child functioning. However, this
study was limited to children in out-of-home care, which represents less
than one-quarter of children reported to child protective services (U.S.
Department of Health & Human Services, n.d.). We examined the effects
of three widely disseminated trauma treatments—Attachment, SelfRegulation, and Competency (ARC) (Kinniburgh, Blaustein, Spinazzola,
& van der Kolk, 2005), Child-Parent Psychotherapy (Lieberman & Van
Horn, 2004), and Trauma-Focused Cognitive Behavioral Therapy
(Cohen, Mannarino, & Deblinger, 2006)—on children's functioning
(PTSD symptoms; behavior problems; needs and strengths). Treatment
models were selected based on promising research of their effectiveness
with complexly traumatized children, the projects' commitment to
providing treatment to children from birth to age 18, and the availability of trainers to provide technical assistance and training in each
model. Treatment was provided through a statewide trauma-informed
care initiative implemented in CW, the Massachusetts Child Trauma
Project (MCTP). See Bartlett et al. (2016) and Fraser et al. (2014) for
additional information on implementation and first-year outcomes.
1.1. The Massachusetts Child Trauma Project
Multipronged, systemic efforts are essential to creating a traumainformed CW system that effectively addresses complex trauma, yet
there are few statewide initiatives such as MCTP. Central to the MCTP
approach is trauma-informed care (TIC) infused throughout the service
delivery system. MCTP's goals were to: (a) improve identification and
assessment of children exposed to complex trauma; (b) build MH services to deliver trauma-specific, evidence-based treatments and practices in community agencies serving CW involved children; (c) increase
referrals of children to trauma treatment; and (d) increase caregivers'
awareness and knowledge of child trauma.
2.2. Trauma treatment models
Three cohorts of clinicians, each in different regions of the state,
were trained from 2012 to 2014 (one cohort per year) to provide one or
more of the trauma treatment models through Learning Collaboratives,
which included face-to-face learning sessions, monthly telephone
coaching calls, supervisor coaching calls, and senior leader sustainability calls. Clinicians began to offer treatment to children and youth
following the basic training for each model and continued to provide
treatment throughout the four-year implementation period
(2012–2016), as clinically indicated. Additional details on the implementation of each model are provided below.
1.2. Current study
The current study examined the effectiveness of three communitybased trauma treatments with CW involved children and youth. We
assessed whether participation in treatment predicted positive child
outcomes and compared outcomes by treatment model. We hypothesized that children and youth would exhibit more positive functioning,
including reductions in PTSD symptoms, problem behaviors, and needs,
and improvement in strengths following treatment. We also conducted
an exploratory investigation of differential effects on child outcomes by
treatment model.
2.3. Attachment, self-regulation, and competency (ARC)
ARC is a comprehensive, clinical objectives-driven intervention
framework for children and youth who have experienced complex
trauma. It is grounded in attachment theory, the effects of childhood
traumatic stress on development, and resilience building. ARC is guided
by three integrative strategies, eight primary clinical targets or building
blocks, and one overarching goal of trauma experience integration
(Blaustein & Kinniburgh, 2010; Kinniburgh et al., 2005). It was designed for children and youth age 2–21 years; in MCTP it was offered to
children 3–18 years of age. Clinicians were trained through a 12-month
Learning Collaborative (LC). A randomized controlled trial (RCT) of
ARC is underway, and several observational studies derived from program evaluation have shown that it is a promising, evidence-informed
clinical intervention (Achenbach & Rescorla, 2001; Arvidson et al.,
2011; Hodgdon, Kinniburgh, Gabowitz, Blaustein, & Spinazzola, 2013;
Pynoos, Rodriguez, Steinberg, Stuber, & Frederick, 1998).
2. Method
2.1. Sample and procedures
A total of 842 children in one of three trauma treatments participated in the evaluation. The study utilized a convenience sample.
Clinicians (n = 323) were trained in one or more trauma treatment
model and provided guidance on how to recruit eligible children: birth18 years, English or Spanish speaking who had families involved in the
CW system within a year of referral to MH agencies. MH agencies with
clinicians that offered more than one treatment model were trained to
pair children and youth with a treatment model based on their age and
individual needs. Guidelines for treatment model selection were
2.4. Child-Parent Psychotherapy (CPP)
CPP is a long-term dyadic attachment-based treatment model developed for children from birth to five years old that address trauma as
111
Children and Youth Services Review 84 (2018) 110–117
J.D. Bartlett et al.
Table 1
Regression models examining change in posttraumatic stress symptoms (UCLA PTSD Index), by treatment model.
Parent version
Re-experiencing
ARC
TF-CBT
Both
Avoidance/numbing
ARC
TF-CBT
Both
Arousal
ARC
TF-CBT
Both
Severity
ARC
TF-CBT
Both
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
Child version
B
SE
−0.669
−1.818⁎
−0.966 ~
−2.417⁎⁎
−0.799⁎
−2.188⁎⁎⁎
−0.848 ~
−1.697 ~
−1.983⁎⁎⁎
−0.239
−1.340⁎⁎⁎
−0.954
−0.829⁎
−2.077⁎⁎⁎
−1.260⁎⁎
−0.733
−1.044⁎⁎⁎
−1.484⁎⁎
−2.402⁎
−5.553⁎⁎
−4.200⁎⁎
−3.626 ~
−3.201⁎⁎⁎
−4.719⁎⁎⁎
0.456
0.819
0.554
0.916
0.358
0.616
0.511
0.915
0.595
0.986
0.391
0.671
0.360
0.634
0.418
0.693
0.279
0.475
1.041
1.860
1.326
2.190
0.841
1.443
p
n
ES
B
SE
p
n
ES
–
0.684
0.203
0.507
0.165
0.452
0.159
0.321
0.388
–
0.257
− 2.527⁎⁎⁎
− 3.584⁎⁎⁎
− 2.918⁎⁎⁎
− 2.817⁎⁎⁎
− 2.677⁎⁎⁎
− 3.266⁎⁎⁎
− 1.297⁎
− 2.931⁎⁎
− 2.928⁎⁎⁎
− 2.285⁎
− 2.068⁎⁎⁎
− 2.668⁎⁎⁎
− 1.700⁎⁎⁎
− 2.701⁎⁎⁎
− 1.843⁎⁎⁎
− 1.591⁎
− 1.726⁎⁎⁎
− 2.103⁎⁎⁎
− 5.359⁎⁎⁎
− 9.406⁎⁎⁎
− 8.279⁎⁎⁎
− 7.128⁎⁎⁎
− 6.725⁎⁎⁎
− 8.294⁎⁎⁎
0.403
0.742
0.500
0.789
0.321
0.538
0.563
1.008
0.599
0.944
0.422
0.699
0.401
0.724
0.423
0.671
0.299
0.498
1.148
2.035
1.246
1.962
0.865
1.425
< 0.001
0.000
< 0.001
< 0.001
< 0.001
< 0.001
0.029
0.004
< 0.001
0.016
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
0.018
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
249
0.081
0.008
0.026
< 0.001
0.098
0.062
0.001
0.808
0.001
0.155
0.024
0.001
0.003
0.291
< 0.001
0.002
0.021
0.003
0.002
0.098
< 0.001
0.001
237
–
205
–
442
–
236
–
205
–
440
–
237
–
205
–
442
–
236
–
205
–
440
–
0.453
0.669
0.569
0.549
0.511
0.624
0.204
0.476
0.494
0.386
0.343
0.443
0.401
0.645
0.413
0.357
0.401
0.489
0.380
0.684
0.619
0.533
0.497
0.614
0.202
0.512
0.317
–
0.259
0.368
0.200
0.463
0.351
0.303
0.266
0.393
215
456
236
208
436
241
211
444
234
207
433
Note. B = unstandardized regression coefficient, SE = standard error, n = sample size, ES = effect size (Cohen's d). T2 = 6 months; T3 = 12 months. The symbol “–” indicates the
sample size was too small to analyze.
⁎⁎⁎
p < 0.001.
⁎⁎
p < 0.01
⁎
p < 0.05.
~
p < 0.01.
in PTSD symptoms, depression, and behavior problems in youth, and
reduced caregiver depression and increased competencies (Cary &
Mcmillen, 2012). In MCTP, clinicians were trained through a 12-month
LC and delivered treatment to children ages 3–18 years.
it affects the parent-child relationship with explicit sensitivity to contextual factors that may affect that relationship. The goal of CPP is to
support and strengthen the caregiver-child relationship as a vehicle for
restoring and protecting the child's MH and development. Therapeutic
sessions involve the child and parent or primary caregiver together
(Lieberman & Van Horn, 2004). In MCTP, CPP was delivered to young
children 0–6 years of age and initially (first two of three cohorts) disseminated through a 12-month LC. In the third cohort, the training
period increased to 18 months to accommodate new requirements from
model developers for acquiring core knowledge and clinical competencies (assessment, reflective practice, bimonthly consultation). CPP
has five RCTs showing reductions in behavior problems, PTSD symptoms, lower avoidance, resistance, and anger, as well as improvements
in attachment security and maternal PTSD symptoms (http://
www.nctsnet.org/nctsn_assets/pdfs/promising_practices/cpp_general.pdf, n.d.; Lieberman, Ghosh Ippen, & Van Horn, 2006; Lieberman,
Horn, & Ippen, 2005; Lieberman, Weston, & Pawl, 1991; Toth, Rogosch,
Manly, & Cicchetti, 2006).
3. Measures
3.1. Child and family demographics
We used project-developed survey questions to assess child age, sex,
race, ethnicity, legal guardian, residence, referral source, and psychotropic medication use.
3.2. Childhood trauma exposure
We assessed children's exposure to trauma using the General
Trauma Information Form of the clinician-administered Core Clinical
Characteristics (CCC) developed by the National Child Traumatic Stress
Network (NCTSN) (Blaustein & Kinniburgh, 2010). Items on this form
ask whether the child has experienced 20 different types of trauma (19
specified types and “other”): sexual maltreatment/abuse; sexual assault/rape; physical maltreatment/abuse; physical assault; emotional
abuse; neglect; domestic violence; war/terrorism/political violence
(inside U.S.); war/terrorism/political violence (outside U.S.); medical
illness/trauma; serious injury/accident; natural disaster; kidnapping;
traumatic loss/bereavement; forced displacement; impaired caregiver;
extreme interpersonal violence; community violence; school violence;
and other. Endorsements were summed to determine total number of
trauma types experienced. No psychometric properties are available for
this checklist.
2.5. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
TF-CBT is a components-based, phase-oriented, evidence-based
treatment that incorporates elements of cognitive-behavioral, attachment, exposure therapy, and family therapy models to address the
unique needs of trauma-affected children.11(p32) TF-CBT has been used
successfully to treat children with a variety of trauma experiences, including complex trauma (Cohen, Mannarino, Kliethermes, & Murray,
2012). TF-CBT components are summarized by the acronym PRACTICE:
Psychoeducation and Parenting skills, Relaxation, Affective regulation,
Cognitive coping skills, Trauma Narration, In vivo mastery, Conjoint
child-parent sessions, and Enhancing Safety and Future Development.11(p33) TF-CBT is the most rigorously tested trauma treatment
for children, with over 21 RCTs to date, showing significant reductions
112
Children and Youth Services Review 84 (2018) 110–117
J.D. Bartlett et al.
Table 2
Regression models examining change in trauma symptomology (YCPC), by treatment
model.
Re-experiencing
ARC
CPP
TF-CBT
All
Avoidance/
numbing
ARC
CPP
TF-CBT
All
Arousal
ARC
CPP
TF-CBT
All
Functional
impairment
ARC
CPP
TF-CBT
All
Severity
ARC
CPP
TF-CBT
All
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
B
SE
p
n
ES
− 1.820⁎
− 0.537
− 0.138
− 1.218
− 0.099
− 4.102⁎⁎
− 0.730~
− 1.897⁎
− 2.363⁎⁎
− 1.710
− 0.215
1.088
− 1.687⁎
− 3.301⁎
− 1.357⁎⁎
− 1.845⁎
− 1.493⁎
1.305
− 1.272~
− 2.728~
− 3.164⁎⁎⁎
− 4.578⁎⁎⁎
− 1.792⁎⁎⁎
− 1.631~
− 3.549⁎⁎⁎
1.040
− 2.264⁎⁎
− 1.236
− 3.010⁎
− 4.344⁎
− 2.879⁎⁎⁎
− 1.571
− 5.625⁎⁎
− 1.475
− 1.606
− 2.347
− 4.905⁎
− 11.913⁎⁎⁎
− 3.775⁎⁎⁎
− 5.355⁎
0.797
1.445
0.547
1.316
0.902
1.464
0.435
0.854
0.867
1.558
0.645
1.571
0.844
1.335
0.488
0.942
0.702
1.322
0.667
1.634
0.734
1.191
0.431
0.854
0.979
1.839
0.770
1.981
1.280
1.993
0.572
1.140
2.026
3.586
1.641
3.953
2.141
3.394
1.159
2.231
0.022
0.710
0.801
0.354
0.912
0.005
0.094
0.026
0.006
0.272
0.738
0.489
0.046
0.013
0.005
0.050
0.033
0.324
0.057
0.095
< 0.001
< 0.001
< 0.001
0.056
< 0.001
0.572
0.003
0.533
0.019
0.029
< 0.001
0.168
0.006
0.681
0.328
0.553
0.022
< 0.001
0.001
0.016
118
0.353
–
–
–
–
0.689
0.134
0.349
0.471
–
–
–
0.315
0.617
0.276
0.376
0.320
–
0.251
0.538
0.614
0.889
0.361
0.328
0.539
–
0.347
–
0.448
0.647
0.433
–
0.456
–
–
–
0.332
0.808
0.283
0.402
142
76
336
117
136
75
328
117
141
76
334
117
144
76
335
115
132
74
321
Table 3
Regression models examining changes in child behavior (Child Behavior Checklist), by
treatment model.
Internalizing
ARC
CPP
TF-CBT
All models
Externalizing
ARC
CPP
TF-CBT
All models
Total
Problems
ARC
CPP
TF-CBT
All models
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
T2
T3
B
SE
p
n
ES
− 4.806⁎⁎⁎
− 8.150⁎⁎⁎
− 4.280⁎
− 2.293
− 4.489⁎⁎⁎
− 4.171⁎⁎⁎
− 4.675⁎⁎⁎
− 5.817⁎⁎⁎
− 3.319⁎⁎⁎
− 4.620⁎⁎⁎
− 3.502 ~
− 2.108
− 3.608⁎⁎⁎
− 4.654⁎⁎⁎
− 3.553⁎⁎⁎
− 4.328⁎⁎⁎
− 4.409⁎⁎⁎
− 6.370⁎⁎⁎
− 3.941⁎
− 3.966
− 4.276⁎⁎⁎
− 4.782⁎⁎⁎
− 4.428⁎⁎⁎
− 5.482⁎⁎⁎
0.828
1.502
0.000
0.000
0.787
1.294
0.566
1.016
0.760
1.393
1.933
4.617
0.872
1.432
0.575
1.038
0.769
1.402
1.803
4.310
0.825
1.355
0.560
1.007
< 0.001
< 0.001
0.013
0.579
< 0.001
0.001
< 0.001
< 0.001
< 0.001
0.001
0.070
0.648
< 0.001
0.001
< 0.001
< 0.001
< 0.001
< 0.001
0.029
0.357
< 0.001
< 0.001
< 0.001
< 0.001
353
0.452
0.766
0.377
–
0.498
0.463
0.453
0.563
0.297
0.413
0.263
–
0.343
0.442
0.311
0.379
0.422
0.611
0.319
–
0.471
0.526
0.424
0.525
138
279
770
353
138
279
770
353
138
279
770
Note. B = unstandardized regression coefficient, SE = standard error, n = sample size,
ES = effect size (Cohen's d). T2 = 6 months; T3 = 12 months.
⁎⁎⁎
p < 0.001.
⁎
p < 0.05.
~
p < 0.01.
Symptom frequency in the past two weeks is rated on a 4-point Likert
scale; for Functional Impairment symptoms, caregivers indicate the
extent to which each symptom “gets in the way.” Suggested cutoff
scores are ≥ 26 (“probable diagnosis”) and ≥ 4 (“functional impairment”). The YCPC symptom items have demonstrated good test-retest
reliability and predictive validity in a clinical interview format
(Scheeringa, n.d.). Several items have questionable applicability for
children under the age of three; accordingly, findings for children in the
lower age limit are considered exploratory (Scheeringa, 2017).
Note. B = unstandardized regression coefficient, SE = standard error, n = sample size,
ES = effect size (Cohen's d); T2 = 6 months; T3 = 12 months.
⁎⁎⁎
p < 0.001.
⁎⁎
p < 0.01.
⁎
p < 0.05.
~
p < 0.10.
3.5. Child behavior problems
To assess behavioral problems, we used the parent/caregiver report
on the Child Behavior Checklist (CBCL), including the preschool version
for children 1.5–5 years (Achenbach & Rescorla, 2001) and the schoolage version for children aged 6–18 years (Achenbach & Edelbrock,
1983). The CBCL is a standardized measure of children's behavioral
problems with good psychometric properties (e.g., reliability, convergent and discriminative validity of scales; Chronbach's alpha = 0.71
for somatic problem items and 0.89 for conduct problem items)
(Nakamura, Ebesutani, Bernstein, & Chorpita, 2009) consisting of 113
items scored on a 3-point scale. Subscales include Internalizing, Externalizing, and Total Problem Behaviors (cutoff = 63).
3.3. PTSD symptoms in older children
To assess trauma among older children (aged 7–18), we used the
University of California, Los Angeles Posttraumatic Stress Disorder
Reaction Index (UCLA PTSD-RI) (Pynoos et al., 1998). The measure is a
48-item semi-structured interview assessing child exposure to 26 types
of trauma and DSM-IV PTSD diagnostic criteria. The Parent Version was
used for children < 8 years; both the Child and Parent Versions were
used for children 8–18 years. The PTSD-RI has good psychometric
properties (e.g., Chronbach's alpha = 0.90; test-retest inter-item
agreement = 94%;
intra-class
correlation
coefficient = 0.93)
(Steinberg, Brymer, Decker, & Pynoos, 2004).
3.6. Child/youth needs and strengths
Type and severity of clinical and psychosocial factors impacting
treatment decisions and outcomes were assessed via provider report on
the Child and Adolescent Needs and Strengths–Mental Health (CANSMental Health) (Lyons, 1999). Needs and strengths are rated on a 3point scale. Subscales include: Life Domain Functioning, Better Behavior and Fewer Emotional needs, Fewer Risk Behaviors, Greater Child
Strengths/Resources, and Greater Caregiver Strengths/Resources.
Clinicians also completed two modules of the CANS-Trauma Comprehensive (CANS-Trauma)(Kisiel et al., 2011): Characteristics of Trauma
3.4. PTSD symptoms in young children
The 42-item Young Child PTSD Checklist (YCPC) (Scheeringa, n.d.),
a caregiver report questionnaire, assessed PTSD stress symptoms and
functional impairment in children ages 1–6 years (trauma exposure was
assessed separately, as described above). The YCPC comprises items
from the Diagnostic and Statistical Manual of Mental Disorders (DSMV) and from empirical studies of traumatic stress in young children.
113
Children and Youth Services Review 84 (2018) 110–117
J.D. Bartlett et al.
Table 4
Regression models examining change in children's strengths and needs (CANS), by treatment model.
Time Point
Life domain functioning
ARC
CPP
TF-CBT
All
Child behavior and emotional needs
ARC
CPP
TF-CBT
All
Child risk behaviors
ARC
CPP
TF-CBT
All
Child strengths
ARC
CPP
TF-CBT
All
Caregiver resources & needs
ARC
CPP
TF-CBT
All
Trauma characteristics
ARC
CPP
TF-CBT
All
Trauma adjustment
ARC
CPP
TF-CBT
All
T2
T3
T2
T2
T3
T2
T3
T2
T3
T2
T2
T3
T2
T3
T2
T3
T2
T2
T3
T2
T3
T2
T3
T2
T2
T3
T2
T3
T2
T3
T2
T2
T3
T2
T3
T2
T3
T2
T2
T3
T2
T3
T2
T3
T2
T2
T3
T2
T3
Young children
Youth
B
SE
p
n
ES
B
SE
p
n
ES
−2.588⁎
–
−2.523⁎⁎
−2.956⁎
–
−2.489⁎⁎⁎
–
−3.268⁎⁎⁎
–
−2.021⁎⁎⁎
−2.762⁎
–
−2.137⁎⁎⁎
–
−1.845⁎⁎⁎
–
−0.706⁎
−1.995⁎⁎
–
−0.899⁎⁎
–
−0.193
–
−0.933~
−0.760⁎
–
−0.763⁎
–
0.482⁎
–
−0.737~
0.437
–
−0.573
–
3.071⁎
–
0.120
−0.455
–
0.567
–
−2.117⁎
–
−0.648~
−1.931⁎
–
−0.995⁎⁎
–
1.190
–
0.726
1.181
–
0.573
–
0.713
–
0.525
1.127
–
0.439
–
0.434
0.030
–
0.001
0.012
–
< 0.001
–
< 0.001
–
< 0.001
0.014
–
< 0.001
–
< 0.001
0.030
0.002
–
0.001
–
0.833
–
0.060
0.030
–
0.040
–
0.017
–
0.077
0.552
–
0.101
–
0.020
–
0.865
0.815
–
0.379
–
0.015
–
0.057
0.012
–
0.002
–
0.465
–
0.397
0.504
–
0.406
–
0.742
–
0.455
0.511
–
0.465
–
0.677
–
0.329
0.640
–
0.376
–
–
–
0.208
0.224
–
0.184
–
–
–
0.257
–
–
0.200
–
0.874
–
–
–
–
–
–
0.912
–
0.300
0.633
–
0.424
–
− 0.634⁎⁎
− 1.047⁎
0.177
− 1.321⁎⁎⁎
− 2.374⁎⁎⁎
− 0.909⁎⁎⁎
− 1.556⁎⁎⁎
− 0.664⁎⁎
− 0.792⁎
− 1.470⁎
− 1.933⁎⁎⁎
− 2.533⁎⁎⁎
− 1.202⁎⁎⁎
− 1.507⁎⁎⁎
− 0.613⁎⁎
− 0.842⁎
− 1.346⁎
− 0.802⁎⁎
− 1.176⁎
− 0.679⁎⁎⁎
− 0.911⁎⁎
− 0.846⁎⁎
− 0.765
0.804
− 1.156⁎⁎
− 2.242⁎⁎⁎
− 0.913⁎⁎⁎
− 1.324⁎⁎
− 0.104
0.111
0.640
− 0.310
− 0.457
− 0.147
− 0.024
− 1.550⁎⁎⁎
− 1.579⁎⁎
− 1.354⁎
− 1.707⁎⁎⁎
− 2.362⁎⁎
− 1.596⁎⁎⁎
− 1.907⁎⁎⁎
− 0.785⁎⁎⁎
− 1.427⁎⁎⁎
− 0.705
− 0.875⁎⁎⁎
− 1.519⁎⁎⁎
− 0.814⁎⁎⁎
− 1.435⁎⁎⁎
0.241
0.430
0.928
0.302
0.548
0.187
0.337
0.215
0.375
0.623
0.295
0.532
0.173
0.308
0.199
0.347
0.604
0.266
0.478
0.157
0.278
0.292
0.517
1.192
0.356
0.643
0.223
0.401
0.197
0.352
0.508
0.275
0.512
0.159
0.290
0.326
0.589
0.588
0.373
0.686
0.238
0.435
0.146
0.263
0.480
0.169
0.316
0.108
0.198
0.009
0.015
0.862
< 0.001
< 0.001
< 0.001
< 0.001
0.002
0.035
0.014
< 0.001
< 0.001
< 0.001
< 0.001
0.002
0.015
0.025
0.003
0.014
< 0.001
0.001
0.004
0.139
0.593
0.001
< 0.001
< 0.001
0.001
0.599
0.750
0.648
0.261
0.371
0.355
0.934
< 0.001
0.007
0.014
< 0.001
0.001
< 0.001
< 0.001
< 0.001
< 0.001
0.131
< 0.001
< 0.001
< 0.001
< 0.001
349
0.325
0.631
–
0.274
–
0.915
–
0.496
0.350
–
0.372
–
0.202
–
0.416
0.734
–
0.349
–
1.317
–
0.713
1.942
–
0.644
–
0.867
–
0.340
0.766
–
0.319
–
27
–
97
16
–
140
–
26
–
97
16
–
139
–
26
–
96
16
–
138
–
26
–
95
16
–
137
–
26
–
96
16
–
138
–
26
–
92
16
–
134
–
26
–
94
16
–
136
–
0.152
0.250
–
0.318
0.570
0.220
0.376
0.182
0.217
0.500
0.513
0.672
0.327
0.410
0.166
0.228
0.521
0.222
0.326
0.187
0.251
0.191
–
–
0.238
0.461
0.197
0.286
–
–
–
–
–
–
–
0.260
0.265
0.268
0.288
0.399
0.269
0.322
0.351
0.640
–
0.418
0.726
0.376
0.662
34
278
662
348
34
278
661
348
34
278
661
349
34
278
662
344
33
278
651
347
30
274
652
345
31
271
648
Note. B = unstandardized regression coefficient, SE = standard error, n = sample size, ES = effect size (Cohen's d). T2 = 6 months; T3 = 12 months; “–” indicates the sample size was
too small to analyze; T3 CPP outcomes were not analyzed due to small sample size.
⁎⁎⁎
p < 0.001.
⁎⁎
p < 0.01.
⁎
p < 0.05.
~
p < 0.10.
assessments; fewer completed 12-month assessments (e.g., 438 caregivers completed the baseline measure of older children's trauma
symptoms, and 49 caregivers completed a 12-month assessment; 343
caregivers completed the baseline measure of young children's trauma
symptoms, and 23 caregivers completed the 12-month assessment).
Given that both ARC and TF-CBT are typically shorter-term interventions, this type of missingness was expected for these models, though
not for CPP, a considerably longer intervention. We fit models for each
outcome, by treatment model and across treatment models. We did not
analyze 12-month outcomes on the CANS for CPP, as the sample size
was too small. Covariates included child age and sex, total trauma
types, psychotropic medication use (yes/no), and custody status
(parent, other adult, state, other). Effect sizes (ES) represent the effect
Experience (type, closeness to perpetrator, frequency, duration, force)
and Adjustment to Trauma (reaction to potentially traumatic/adverse
experiences). The manual states that items represent targets of intervention, and traditional psychometrics may not apply. However, at
least one study found support for validity of the subscales as outcomes
(Alamdari & Kelber, 2016).
4. Analytic plan
For each outcome, four-level regression models were specified to
account for non-independence of observations within children (repeated assessments), and among clinicians and within agencies. Few
children completed 6-month assessments compared to baseline
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Children and Youth Services Review 84 (2018) 110–117
J.D. Bartlett et al.
5.5. Child and adolescent needs and strengths
of a one unit standard deviation change in the outcome for a unit
change in time.
Given a high rate of clinician turnover and non-response (40% of
discharge assessments were missing), we used maximum likelihood
estimation (ML) to address missing data. To ensure that selection of ML
was a reasonable approach, we conducted sensitivity analyses comparing ML results to complete-case analysis on a selection of outcomes;
the effects were similar in direction and magnitude, but ML offered
more power to detect significant effects, reducing Type II error.
Results from the CANS (YCANS, OCANS, CANS-Trauma) are presented in Table 4. Clinicians reported that young children exhibited
significant improvements in Life Domain Functioning, Behavior/Emotional Needs, and Child Strengths at 6 months. ARC and TF-CBT clinicians reported improvements in Life Domain Functioning, Behavior/
Emotional Needs, Child Risk Behaviors, and Caregiver Strengths/Resources at 6 months. On the OCANS, clinicians indicated improvements
in children's Life Domain Functioning, Behavior/Emotional Needs,
Child Risk Behaviors, and Child Strengths/Resources at 6 and
12 months. Findings were comparable for TF-CBT. Results for ARC were
significant for Life Domain Functioning, Behavior/Emotional Needs,
and Child Risk Behaviors at both time points, and for Child Strengths/
Resources at 6 months. Children in CPP showed improvements in Behavior/Emotional Needs and Child Risk Behaviors at 6 months.
Across models, young children showed improved Trauma
Adjustment and Trauma Characteristics at both time points. However,
those in ARC had fewer Trauma Characteristics at 6 months compared
to baseline. Children in ARC and TF-CBT had better Trauma Adjustment
at 6 months and fewer Trauma Characteristics and better Trauma
Adjustment at both time points. Children in CPP showed fewer Trauma
Characteristics at 6 months.
5. Results
5.1. Participation in treatment
The average number of sessions for all models combined was approximately 27 sessions (n = 354; M = 26.83; SD = 24.60;
Range = 1–185). Children in CPP averaged 16 sessions (n = 49;
M = 16.00; SD = 20.33; Range = 2–123), children in TF-CBT averaged
21 sessions (n = 132; M = 21.14; SD = 15.82; Range = 1–91), and
children in ARC averaged 29 sessions (n = 173; M = 33.31;
SD = 29.20; Range = 2–185).
5.2. PTSD symptoms–youth
6. Discussion
Results for the UCLA PTSD Index are presented in Table 1. Parents
reported that children had less severe PTSD symptoms, arousal, and reexperiencing symptoms from baseline to 6 and 12 months, regardless of
model. They reported less severe avoidance/numbing symptoms at
6 months. ARC parents reported less severe symptoms at both follow-up
time points; TF-CBT parents reported less severe symptoms among
children and youth at 6 months. Engagement in each treatment predicted fewer re-experiencing symptoms at 12 months.
Parents/caregivers with children in TF-CBT reported significantly
fewer avoidance/numbing symptoms at 6 months. Those with children
in ARC and TF-CBT indicated reductions in arousal symptoms at
6 months; children in ARC had reduced symptoms at 12 months (see
Table 1).
Youth (8–18 years) reported a decrease in symptom severity, reexperiencing, avoidance/Numbing, and arousal symptoms from baseline to both follow-up time points. ARC and TF-CBT youth reported
reductions in re-experiencing, avoidance/numbing, and arousal symptoms at 6 and 12 months.
In the current study, we hypothesized that trauma treatment would
have substantial benefits for children and youth in the CW system, including improvements in posttraumatic stress, behavior problems,
needs, and strengths. Trauma treatment predicted positive child/youth
outcomes across multiple domains, as reported by multiple sources:
youth, parents/caregivers, and clinicians. By 6 months, we found reductions in parent/caregiver and youth reported symptoms of PTSD,
improvements in parent/caregiver reported child behavior problems
and improvements in strengths and needs of children/youth for both
younger and older children.
At 12 months, the association between trauma treatment and
symptomatology were less consistent, with positive findings only for
avoidance/numbing symptoms. This may be explained in part by high
clinician turnover and/or family attrition, resulting in small sample
sizes. Alternatively, children who remained in treatment 12 months
may have experienced challenges (e.g., less successful therapy; complex/severe clinical issues). Family members also may not have revealed symptoms until they established trust with clinicians and understood experiences as symptoms of trauma. It is also possible that the
positive effects of treatment diminish over time.
5.3. PTSD symptoms–young children
6.1. Differences by treatment model
Parent/caregiver report on the YCPC overall indicated improvements in young children's symptom severity and avoidance/numbing at
6 and 12 months, and in arousal and functional impairment at
6 months. Children in ARC had less severe symptoms at 6 and
12 months for re-experiencing, avoidance/numbing, arousal symptoms,
and functional impairment at 6 months. Children in TF-CBT had significantly reduced avoidance/numbing symptoms, arousal symptoms,
and functional impairment.
Functional Impairment at both time points, and for re-experiencing
symptoms at 12 months. Children in CPP had less Functional
Impairment at 6 months (Table 2).
A unique feature of this study is that we examined findings across
three trauma treatments: ARC, CPP, and TF-CBT. Results demonstrated
that ARC and TF-CBT predicted significant reductions in child behavior
problems across all domains at both time points. Positive findings for
CPP were found for Internalizing and Total Problem Behaviors at
6 months.
We also found differential effects on symptoms of PTSD. At 6 and
12 months, youth in ARC and TF-CBT had better outcomes for re-experiencing, arousal, and severity. Only TF-CBT was associated with
improvements in avoidance/numbing. Parents/caregivers of older
children reported fewer improvements than youth. Perhaps their positive internal experiences were not easily detectable, or adults may have
had a lower threshold for their symptoms.
Results for younger children were mixed. Children in ARC and TFCBT exhibited less avoidance/numbing, arousal, and functional impairment at 6 months, and those in ARC had fewer re-experiencing
symptoms, but CPP treatment predicted only reduced Functional
5.4. Child behavior problems
Across models, children had fewer Total Problem, Internalizing, and
Externalizing Behaviors from baseline to both follow-up time points, as
did children ARC and TF-CBT separately. Children in CPP experienced
fewer Total Problem and Internalizing Behaviors by 6 months (Table 3).
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J.D. Bartlett et al.
behaviors, and functioning, and used multiple informants (http://
www.nctsn.org/trauma-types/complex-trauma/assessment, n.d.). Positive findings across multiple child outcomes suggest that trauma
treatment is an effective means of improving the developmental trajectories of children in the CW system with complex trauma, but that
each model may have strengths and weaknesses. More rigorous examination utilizing a control group would be useful for verifying these
differences and further specifying variation in outcomes among the
treatment models. The results of this study suggest that both ARC and
TF-CBT are worthy of federal, state, and local investments to improve
the adjustment of children exposed to trauma and to decrease the
likelihood of poor functioning later in life—moving beyond a focus on
child safety and permanency to include an emphasis on child wellbeing. Despite our findings, CPP has undergone rigorous study and
found to be effective in reducing behavior problems, PTSD symptoms,
and attachment security (http://www.nctsnet.org/nctsn_assets/pdfs/
promising_practices/cpp_general.pdf, n.d.; Lieberman et al., 1991;
Lieberman et al., 2005; Lieberman et al., 2006; Toth et al., 2006).
Additional research is needed to inform treatment with young children,
particularly infants and toddlers, and to identify the most salient outcome measures during this developmental period (Jones Harden, n.d.).
Furthermore, a cost-benefit analysis by treatment model and developmental stage would be important to determining how best to allocate
funding for treatment among children and youth in the child welfare
system. Finally, future research on the mechanisms that underlie successful treatment (moderators and mediators) would be useful for understanding key characteristics of treatment (e.g., dosage, fidelity), families, and their environments (e.g., risk and protective factors) that
promote resilience among children with complex trauma. Nevertheless,
the current study findings add to a growing body of literature that
strongly suggests the need for trauma-focused policies and practices,
such as trauma screening upon entry into CW, and funding to support a
trauma-informed child welfare and mental health services.6(p14) Such
steps will be essential to building responsive service systems that promote healing and recovery in this highly vulnerable population.
Impairment. At 12 months, only TF-CBT was associated with decreased
symptoms of PTSD.
Findings on children's strengths and needs similarly varied by
model. Clinicians reported that young children improved in Life
Domain Functioning, Behavior/Emotional Needs, and Risk Behavior at
6 months. Children's Adjustment to Trauma improved for those in ARC
and TF-CBT, but only children in TF-CBT had improvements in strength
and resources. Results for older children were similar, except that
clinicians across models reported significantly fewer trauma characteristics, and children in both ARC and TF-CBT had greater Strengths/
Resources. Only children in TF-CBT had greater Child Strengths/
Resources. None of the treatments had significant findings for Caregiver
Strengths/Resources Trauma Characteristics at 12 months. It is possible
that treatment did not influence such outcomes, yet positive findings on
other measures completed by caregivers and youth suggest this is not
the case. Perhaps clinicians continued to identify trauma symptoms and
family problems to justify continued service provision. Overall, the
most pronounced improvements were among children in ARC and TFCBT.
6.2. Study limitations
There are several study limitations that warrant consideration when
interpreting our findings. First, the study did not use an experimental
design or a comparison group, and we cannot attribute causality. A
second challenge was the high level of turnover in MH agencies. While
turnover is common in the field (Morse, Salyers, Rollins, MonroeDeVita, & Pfahler, 2012), the fact that many clinicians did not complete
discharge assessments with families is problematic. We used appropriate statistical methods to account for missing data, yet findings still
may over-represent children served by clinicians who remained with
their agencies while underrepresenting children who terminated when
clinicians left their agencies. Third, because only CPP was appropriate
for children under age three, some sample sizes were too small for
analysis. The absence of significant findings for CPP also may have
other explanations, such as insufficient dosage. Most families participated in fewer than the 20–32 sessions recommended by model developers (M = 16 sessions) (Lieberman & Van Horn, 2004). In addition,
over half (56%) of children in CPP were age three or younger (versus
3% and 1% in ARC and TF-CBT, respectively). Perhaps the YCPC captured symptom expression in children 3–6 years but overlooked
symptom expression in younger children. A study is currently underway
to investigate these issues further. Cost and feasibility issues also precluded the use of caregiver-child relationship measures (Crowell &
Feldman, 1988), which may have been more appropriate for assessing
CPP outcomes. Implementation changes in CPP training during the
project also may have affected the results. Therefore, we recommend
caution when interpreting results that include children ages birth to
three. Another limitation is that we were not able to assess inter-rater
reliability among clinicians, who may have differed in their approach to
administering study measures. Evaluators did, however, take steps to
address this issue, including: conducting a two-hour training for clinicians on the measures prior to the study, offering guidance on monthly
consultation calls, and providing ongoing support through a dedicated
email address. Finally, the fact that MH clinicians administered the
measures during treatment rather than researchers reduced the study
burden for families, but introduces potential reporter bias. In addition,
as we did not utilize a measure of fidelity, we cannot be certain that the
models were consistently implemented as intended.
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117
Answer all the questions fully based on the other reading attached. This assignment for
a research class, you really need to be familiar with the concepts in order to answer the
questions and find the answers from the article.
The format of the paper should be double-spaced, times new roman 12 font, 1 margin.
1)
Indicate which article you chose to work with
2) Research Purpose (1 point):
What was the primary goal or purpose of this study? Please describe this using your own words.
3) Research Hypothesis (1 point):
What is/are the researchers’ hypothesis(s)?
4) Variables (4 points):
a) What are the primary independent variable(s) of interest in the study and how are they
operationalized?
b) What are the dependent variable(s) and how are they operationalized?
5) Sampling (3 points):
Describe the sampling procedures and the study sample. Your description should include:
a) What is the sample size?
b) What type of sampling was used – probability or non-probability? Describe the process they
used to establish their sample.
c) Provide a general description of the study sample. (ie. important demographic characteristics)
6) Threats to validity (4 points):
a) Given the sampling procedures and research design, how generalizable are the findings (or
too whom are the findings generalizable)? Does the author mention this in the conclusion? If so
what do they say? Do you agree? If the authors do not mention this in the conclusion what do
you think about the external validity of the findings?
b) What is one threat to internal validity that was controlled for and how was it controlled for?
7)
Results (2 points):
a) What are the main results of the study? (Note: Please address the results for all the primary
IVs and DVs)
8) Conclusions (3 points):
a) What do the authors state as the conclusions and implications of the study? Do you agree
with the authors? Explain your reason for agreeing or disagree with the authors.
9)
Limitations (2 Points)
a) What is one limitation of this study other than generalizability?
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