Please find the attached files for instructions and questions and the assigned article. Based on the article you are going to answer the research questions in details. IT IS BETTER AND IMPORTANT TO BE FAMILIAR WITH THE RESEARCH TERMS AN HOW TO FIND THEM FROM THE ARTICLE. READ THE QUESTIONS AND SEE IF YOU CAN DO IT BEFORE YOU MAKE A BID.
Unformatted Attachment Preview
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
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
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
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.
Limitations (2 Points)
a) What is one limitation of this study other than generalizability?
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☆
Jessica Dym Bartletta, , Jessica L. Griﬃnb, Joseph Spinazzolac, Jenifer Goldman Fraserd,
Carmen Rosa Noroñad, Ruth Bodiane, Marybeth Toddb, Crystaltina Montagnab, Beth Bartof
Child Trends, United States
University of Massachusetts Medical School, United States
Trauma Center at Justice Resource Institute, United States
Child Witness to Violence Project, Boston Medical Center, United States
Massachusetts Department of Children & Families, United States
LUK, Inc., United States
A R T I C L E I N F O
A B S T R A C T
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.
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: [email protected] (J.D. Bartlett).
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
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
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
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).
2.1. 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
Children and Youth Services Review 84 (2018) 110–117
J.D. Bartlett et al.
Regression models examining change in posttraumatic stress symptoms (UCLA PTSD Index), by treatment model.
< 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, & ... Purchase answer to see full attachment