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Questions
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?
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: [email protected] (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, & ... Purchase answer to see full attachment