Dealing With Trauma in the Child Welfare System

May 30, 2013 | Charles Wilson, Senior Director, Chadwick Center for Children and Families

Charles Wilson, MSSW, is the Senior Director of the Chadwick Center for Children and Families and the Sam and Rose Stein Endowed Chair in Child Protection at Rady Children’s Hospital‒San Diego, where he oversees a large multi-service child and family maltreatment organization providing prevention, intervention, medical assessment, and trauma treatment services along with professional education and research.

Charles Wilson, MSSW, is the Senior Director of the Chadwick Center for Children and Families and the Sam and Rose Stein Endowed Chair in Child Protection at Rady Children’s Hospital‒San Diego, where he oversees a large multi-service child and family maltreatment organization providing prevention, intervention, medical assessment, and trauma treatment services along with professional education and research. Wilson also serves as the director of the California Evidence-Based Clearinghouse for Child Welfare, under contract with the California Department of Social Services; the Chadwick Trauma-Informed Systems Project for SAMHSA; the Safe Kids California Project, funded by the ACYF/Children’s Bureau and California Department of Social Services; and the California Screening, Assessment, and Treatment Initiative supported by the ACYF/Children’s Bureau. He co-chairs the Child Welfare Committee of the SAMHSA-funded National Child Traumatic Stress Center, and chairs the San Diego County Child Protection Team Management Committee. Within Rady Children’s Hospital, Wilson is the Co-Director of the Centers of Developmental and Behavioral Sciences and administratively oversees the hospital’s inpatient and outpatient psychiatry programs and medical social work department.

I started in the child welfare field in 1972. For the first 20 years my focus was primarily on helping to stop abuse, making children safe, and moving them as quickly as possible to permanence. As young workers my colleagues and I saw mental health as a service to which we referred parents. It was not until sexual abuse emerged as a major national issue in the 1980s that we thought much about referring children for therapy. Even then, it only seemed to occur to us that children needed therapy if they were victims of sexual abuse or their behavior was so disruptive in the foster home that their placement was threatened. Thankfully, all that has changed in the current world of child welfare.

Today we recognize that children coming to the attention of child welfare arrive with a host of developmental and mental health needs. Their rates of mental health and developmental challenges far exceed those of the general population. In fact, drawing on the work of the National Survey of Child and Adolescent Well-being (NSCAW), we know that post-traumatic stress disorder (PTSD); depression; and cognitive, developmental, behavioral, and relational problems occur at a rate 2 to 6 times higher than in the general population.

Buried in the etiology of these disorders and problems is often a common denominator: trauma and traumatic stress, which causes or amplifies a wide range of emotional distress. As the scientific evidence of the short- and long term effects of trauma have come to light, child welfare increasingly has recognized this reality.  

Child welfare has also come to recognize the importance of research and evidence in delivery of mental health services. With the support of resources like the California Evidence-Based Clearinghouse for Child Welfare (CEBC) and the National Registry of Effective Programs, child welfare administrators and caseworkers have easy access to the best science and reviews of common mental health interventions that their clients might benefit from. Driving child welfare further and faster across the nation has been the emphasis that the federal government and the Administration of Children, Youth, and Families at the US Department of Health and Human Services has placed on the importance of “social and emotional well-being.”

So what is the role of child welfare in meeting the social and emotional needs of the children they serve, especially their mental health needs? No one expects child welfare to address the mental health issues alone. Rather, they act as part of a team composed of the caseworker, caregivers, trained mental health professionals, ancillary support services, and often the child or youth.

The key is determining which children need mental health services and connecting those who do with providers who can provide treatment uniquely suited for the individual child and family. That is no easy task, especially when it comes to children with strong trauma histories and complex mental health presentations. In fact, trauma symptoms often masquerade as behavior problems or serious mental illness, which increases the risk that some foster children may be misdiagnosed and unnecessarily treated with psycho-pharmaceuticals. Conversely, children with trauma histories may also suffer from naturally occurring biologically based mental health disorders that may be overlooked if the providers exclusively focus on trauma. The trick is figuring out which child needs what.

In today’s world, child welfare administrators should work with their counterparts in public and private mental health and social services to ensure that the community has access to a wide mix of evidence-based and evidence-informed mental health services designed to treat the most common forms of mental health issues faced by children served by child welfare in their community. This typically would involve a mix of caregiver-mediated behavioral interventions, from parenting programs to more intense interventions like Parent Child Interaction Therapy, to intensive parent management programs such as Multi-Dimensional Treatment Foster Care.

While these types of programs address many of the symptoms children face, these symptoms often have their origins in traumatic stress and it is important to have specialized trauma treatment programs for children who need them such as TF-CBT, CPP, CBITS, and others that can be found on the CEBC and on the National Child Traumatic Stress Network website. Of course the mental health continuum must also be able to address substance abuse issues and general mental health needs and supported by proper use of medication, when needed. In building a service continuum within the system, child welfare leaders also need non-clinical supports that can tap into the natural resiliency of children and youth with everything from faith-based supports to sports, arts, and mentoring.

Such a service continuum, however, is of little value unless child welfare is adept at identifying which child needs which service and connecting them with the right provider. That is where screening and assessment come in. Child welfare should have a standard means to screen every child who enters services to assess mental health needs. Screening here refers to a short process, often performed by the child welfare worker, with the primary purpose of deciding who needs a more in-depth mental health assessment and who does not. Those who do not screen positive for an assessment should periodically be rescreened as the child’s life and development progress. Children who do exhibit symptoms of mental health disorders or significant traumatic stress during the screening should be referred to a properly trained and supervised mental health professional for a more comprehensive trauma-informed mental health assessment to identify their strengths and needs and determine what, if any, mental health intervention is needed.

Those doing assessments for child welfare should be well versed in the use of standardized measures as well as outstanding clinical interviewing, traumatic stress, and critical thinking skills. An assessment should not be a simple, perfunctory process that leads to a “one size fits all” intervention by the same therapist, but rather a thoughtful examination of the child’s unique experience and selection of a mental health intervention and provider that is tailored to address what the child needs and not just what the assigned provider likes to do.

This approach requires a change in thinking in many communities. This process represents a unique window of opportunity to alter the life trajectory of a child, and often a family, and should not be squandered by ill-considered or undirected service by a professional who is not trained and not skilled in trauma-informed mental health. If we do this right we can achieve outcomes that can help shape a life for the better.