Considerations for Implementation
Clinicians should consider the following when selecting trauma screening or assessment tools to implement in a given system:
- Considering the number of items/length of administration—The shorter the tool, the more likely you will use it.
- Cost—Systems are more likely to use free or low-cost tools.
- Child age range targeted with the instrument—Many prefer tools that apply to a range of ages or have age-defined versions.
- Method of administration—Tools that you can administer quickly and easily in a paper and pencil or interview format gather more comprehensive and accurate information.
- Respondent—What is the feasibility of having a particular respondent (child, caregiver or caseworker) complete a specific tool (e.g., availability)?
- Translations and available languages—For tools to be relevant and accurate, they should be available in the family’s language.
- Accessibility & Mobility—As tools are developed that include on-line administration, real-time scoring and reporting features, and mobile access, you will need to consider feasibility, organizational readiness, costs, and security of these products.
Empirical support—You should use tools that have empirical support. Here are some key empirical concepts to consider:
1. Reliability: The extent to which a measurement instrument yields consistent, stable, and uniform results over repeated observations or measurements when administered under the same testing conditions.
2. Validity: The degree to which a measure actually measures what is intended, rather than something else. An IQ test has validity if it measures IQ and not IQ plus achievement in reading. A measure of depression has validity if it measures depression and not both depression and anxiety.
3. Standardization of Norms: Standardization is the process of testing a group of people to ascertain their typical scores on a construct. For example, the presence of specific trauma symptoms within a population of children who have experienced physical abuse. With a standardized test, the participant can compare where his or her score falls compared to the standardization group's performance.
4. Specificity and sensitivity: These metrics/statistics are important when trying to determine if a characteristic or diagnosis is truly present or absent. A measure is specific when it accurately identifies a construct that is present. A measure is sensitive when it accurately identifies the construct as absent. For example, many researchers have tried to use existing measures to screen for PTSD symptoms and their efforts illustrate the difficulty in achieving both specificity and sensitivity. Specific items on the Child Behavior Checklist identify children likely to have the diagnosis of PTSD. However, because certain items assessing some aspects of PTSD were not included in the original version of the CBCL, the existing items are not sensitive which may lead to false positives, and thus do not accurately identify those who should not be considered to have PTSD (i.e., those where PTSD is truly absent).
Implementing a Trauma Screening Process or Tool
Prior to implementing a trauma screening or assessment process into a child serving system, take these important steps to facilitate seamless implementation and to support the workforce throughout the process. The Chadwick Trauma-Informed Systems Dissemination and Implementation Project (CTISP-DI; www.ctisp.org) makes the following suggestions:
1. Pull together an “Implementation Team” that includes an expert in research and psychometrics.
2. Become familiar with some of the common concerns that may arise prior to the implementation of a screening process.
a. Professionals or paraprofessionals may express concern that the process of asking questions about a child’s trauma history or symptoms may potentially distress the child. Multiple research studies have explored this topic and none has found any evidence that asking questions regarding trauma exposure and symptoms increases a child’s level of distress (Finkelhor, Turner, Shattuck, and Hamby, 2013).
b. Professionals often question whether the screening or assessment tool or process will provide additional information not previously collected in the interview process. Numerous research studies have explored this issue over the last half century and have consistently found that the use of measures outperforms clinical judgment, suggesting that both forms of information gathering are essential (Grove & Lloyd, 2006).
c. A further concern of professionals is the time it may take to implement, evaluate, and re-assess the selected processes and protocols over the period working with the child and family. While this concern is valid, the amount of information gathered through the process can help clinicians provide the best care to the child and family.
3. Child-serving systems should provide broad training on child traumatic stress to the entire workforce, including training on different trauma types (e.g., sexual abuse, physical abuse, neglect, exposure to domestic violence) and various traumatic stress reactions that children may exhibit, including internalizing and externalizing problems. Through training, the workforce should acquire a core knowledge base of how child traumatic stress reactions may manifest, the trauma reminders typical in their populations, and concrete strategies to address child traumatic stress reactions. The NCTSN has developed resources that provide broad training on child traumatic stress, including the Child Welfare Trauma Training Toolkit (for child welfare), Think Trauma (for juvenile justice), and the Core Curriculum on Childhood Trauma (for clinicians and other professionals).
4. Child-serving systems should establish an ongoing relationship with a mental health provider so that if a screening process determines that a child would benefit from a trauma-focused mental health assessment, there is a clear linkage to a provider trained in providing such an assessment.
5. Identify the informants for the screening or assessment tool. Determine during initial contacts if it is more appropriate to administer the assessment tool to the child or to ask the caregiver to answer the questions about the child. Determine this by considering the age of the child, the caregiver’s knowledge of the child’s symptoms, and the willingness of either to give the information. Screening and assessment tools are not interchangeable, meaning that you cannot administer a tool intended for a child to an adult and vice-versa.
6. Pilot test the screening or assessment process within the system prior to implementation. Asking questions about trauma exposure and symptoms may be uncomfortable, and providers who practice with a colleague become more comfortable with the language and managing various responses.
7. Initiate a system for addressing secondary traumatic stress. Service providers should have an organizational policy in place to address secondary/vicarious trauma. Find more information on addressing this here.