Running the Numbers

In 2011, the North Carolina Department of Health and Human Services, Division of Social Services (DSS), in partnership with the Center for Child and Family Health (CCFH) and the University of North Carolina at Chapel Hill School of Social Work Jordan Institute, launched Project Broadcast, a 5-year initiative to develop a trauma-informed child welfare system with funding from the Administration of Children and Families.

To help meet the requirements of the Child and Family Services Improvement and Innovation Act of 2011, North Carolina set out to complete emotional trauma screenings for children involved in child welfare. It was determined the project would combine features from several tools to create the Project Broadcast Screening Tool [1]. CCFH and DSS selected the format of the Henry, Black-Pond and Richardson (2010) tool [2], and added 4 direct questions about potentially traumatic exposures for children aged 6–18 years. A comprehensive list of trauma-related symptoms was developed from a number of other measures, most importantly the Child Welfare Trauma Training Toolkit Screening Tool and the clinical knowledge of the CCFH/DSS team.

Through March 2017, more than 20,000 trauma screenings have been completed on more than 14,000 unique children. Domestic violence has consistently been one of the most prevalent adverse childhood experiences (second only to exposure to drug/substance abuse or a related activity). This edition of Running the Numbers is a summary of those children who have been exposed to domestic violence, as captured by data from 13 participating county departments of social services through March 2017.

Trauma screening is considered an essential component of efforts to promote trauma-informed care and to ameliorate the effects of childhood trauma for children involved in child welfare. It can promote engagement between child welfare workers and the children and families they serve through a dialogue about “what happened” to the child and family, rather than “what's wrong” with the child or family. Trauma screening can prevent misdiagnosis, which is especially common among children suffering from exposure to trauma [3]. Screening can help social workers make better placement decisions and promotes early identification and rapid access to trauma-focused, evidence-based services. North Carolina intends to spread trauma screening to all 100 county departments of social services, using implementation science principles to ensure it is sustainable and executed with care.

There were 3,245 children whose completed trauma screens indicated exposure to domestic violence. The large majority of screens were completed in the assessment/investigation phase of the child welfare case (66%) or in the out-of-home placement/foster care phase (26%). These children were evenly split between male (49%) and female (51%). Forty-two percent were white, 35% were African American, and 13% were Hispanic.

Our screening indicates that children exposed to domestic violence are often exposed to additional types of traumatic events. As shown in Figure 1, 66% of children were exposed to 2 or more adverse childhood experiences. The types of additional exposure to abuse varied from exposure to drug/substance abuse, school bullying, and human trafficking, as outlined in Table 1.

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FIGURE 1.

Number of Traumatic Events for Children Exposed to Domestic Violence

Research indicates that children exposed to adverse childhood experiences are at greater risk for many chronic health and mental health problems through adulthood, including depression, suicide, heart disease, substance abuse, and premature death [4]. Therefore, it is incumbent upon child-serving agencies to identify trauma early and intervene with effective services to mitigate the effects.

It is not surprising that children exposed to domestic violence, combined with other trauma exposure, would also exhibit behavioral and emotional concerns. In fact, almost 40% of the trauma screens indicated behavioral concerns such as sleeping problems (21%), hyperactivity/distractibility/inattention (48%), negative/hostile/defiant behavior (45%), or excessive aggression (22%). Some children exhibit emotional concerns, such as excessive worry (35%), difficulty expressing feelings (39%), or being withdrawn (16%). Others cope with their trauma through self-harm (9%), suicidal ideation (13%), or use of drugs or alcohol (10%).

By conducting screening in the child welfare setting and specifically asking 4 questions of children directly, there were 86 screens that yielded new information previously unknown to the screener. This required 15 new CPS reports. Regardless of whether new information is identified, the Project Broadcast Trauma Screening Tool allows the screener and others in that child's life to begin to see the connection between adverse childhood exposure and emotional and behavioral health issues.

• ©2018 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.