5/16/2016

1

Family Assessment Scale for Trauma and Well‐Being

Lisa Lipka, Director of Family Preservation Services, New Jersey

Priscilla Martens,  Executive Director, National Family Preservation Network

Patricia Mowry, VP Operations Georgia, Turning Point/Health Connect America

Kimberly M. Horton, Assistant Clinical Director, Mississippi Children’s Home Services

Kayla Erickson, Research/Outcomes Coordinator, Mississippi Children’s Home Services

Overview

• Trauma informed care as a philosophy

• Our story and process

• Our successes and outcomes

5/16/2016

2

Trauma Informed Care‐A Better Way of Doing Business

• What does it mean?

• Where do you begin?

5/16/2016

3

The Beginning

• TIC Committee formed

• Kick off event

• Agency wide survey 

• Review data

• Devise a plan and goals

5/16/2016

4

Training a Large Agency

• Spread trainings out

• Plan for problems up front

• Toolkits/ trainings available online‐ E‐Learning

• Continuous presentations/trainings in different forums

• Online library of resources ‐ TIC corner

• Continual support via email to all staff– tic@oaksintcare.org

• Partnership with internal departments for agency wide messaging

5/16/2016

5

TIC TIP of the month EMAIL example:

August message of the month from our Trauma Committee-As we wrap up Toolkit 2 and open enrollment, now is a great time to remind everyone about the importance of taking care of your own health and wellness! It's easy to forget to take care of yourself when you're busy being the caretaker of others. To continue to offer our consumers the best care possible and prevent burnout, you must make time to take care of yourself. Read a book, take a walk, see a movie or, if you need to, seek professional help.

Remember- Oaks Integrated Care’s Employee Assistance Program (EAP)gives all employees and your household members 24/7 access to professional, confidential services and referrals FREE of charge. Call for advice or a referral for service on topics such as relationship difficulties, emotional/psychological concerns, work or family stress and anxiety, grief issues, legal/financial services and much more. View the attached flyer for more details.

If you have comments or questions for the Trauma Informed Committee, please email TIC@oaksintcare.org.

5/16/2016

6

Training/Toolkit Topics

• Toolkit 1‐ Establishing a Supportive Environment

• Toolkit 2‐ Establishing a Safe Environment

• Toolkit 3‐ Supporting Staff Development: Training and Education

• Toolkit 4‐Moving Training into Practice

• Toolkit 5‐ Trauma Informed Supervision

5/16/2016

7

5/16/2016

8

Survey Feedback & Outcomes

• “Staff have been using trauma‐informed conversations and more readily ask about trauma related issues with clients and family/collaterals”.

• “I hear staff using trauma informed language and giving observations regarding consumers that reflects their learning of the impact & symptoms of trauma as well as recognizing the importance of providing an emotionally & physically safe environment.”

• “the video is powerful in representing both the pervasive impact of trauma and the resiliency possible through hope & healing… the symptoms sheets by developmental phases will be very useful for staff in increasing their awareness of consumers w/ trauma history… the information regarding early childhood trauma's long term impact on someone… I loved the question for discussion: "How can we portray hopefulness to consumers at Oaks Integrated Care?" So important!!”

5/16/2016

9

5/16/2016

10

Trauma Informed Care‐Closing Remarks

5/16/2016

11

Domain Scales NCFAS NCFAS-R NCFAS-G NCFAS-G+R

A. Environment X X X X

B. Parental Capabilities X X X X

C. Family Interactions X X X X

D. Family Safety X X X X

E. Child Well-Being X X X X

F. Caregiver/Child Ambivalence X X

G. Readiness for Reunification X X

F. Social/Community Life X X

G. Self-Sufficiency X X

H. Family Health X X

NCFAS, NCFAS‐R, NCFAS‐G, NCFAS‐G+RDomains Matrix

All Domains and Subscales Employ the Same Scaling Strategy

• 6‐point scale

• Scale ranges from Clear Strength to Serious Problem• No mid‐point

ClearStrength

MildStrength

Baseline/Adequate

MildProblem

ModerateProblem

SeriousProblem

#. Domain/Subscale titleIntake (I)Closure (C)

+2+2

+1+1

00

–1–1

–2–2

–3–3

5/16/2016

12

Scale Point Definitions

• Of the 6 points on each scale, 3 levels of functioning are defined by guiding language to assist workers to assign ratings:

• +2  = >  Clear Strength

• 0 = >  Baseline/Adequate

• –3 = >  Serious Problem

• Intermediate levels of functioning (+1, ‐1, ‐2) are left undefined in order to encourage worker inquiry and judgment when assigning ratings. The NCFAS‐G+R is designed to encourage worker judgment.

Scale Point Definitions, cont.

• Definition of Baseline/Adequate

• The Baseline/Adequate level of functioning is the threshold above which there is no legal, moral, or ethical reason for public intervention.

• The level of functioning described by this definition reflects the community standards in which the scale is applied in practice. This definition does not preclude the offer or acceptance of voluntary services, regardless of assigned rating.

5/16/2016

13

Definitions: An Example from the NCFAS‐G+R F. Social/Community Life

3. Relationships with Child Care, Schools, and Extracurricular Services

+ 2 Clear Strength Caregivers’ relationship with schools, child care providers, and other child serving organizations (e.g., sports, youth groups) is open, respectful, frequent, and honest. Caregivers and teacher or service provider communicate clearly and encourage each other’s success. Interactions focus on best interest of children, and each advocates for children’s best interest.

0 Baseline/Adequate Relationship between caregivers and school, child care, or other youth service provider is adequate to insure children’s safety and is respectful. Minor difficulties in communications or advocacy may occur but do not significantly impair relationship.

– 3 Serious Problem Relationship between caregivers and schools, child care or youth service providers is unsupportive, critical, disrespectful, hostile, dishonest, or nonexistent. Communication does not focus on best interest of children but may focus on caregivers’ convenience or caregivers’ interest at expense of children’s participation and success.

Definitions

• Definitions listed in the Scale Definitions for the NCFAS‐G+R are derived from the literature, the experience of the scale authors and other scale authors, conceptual or actual legal thresholds, and practice wisdom of social workers using the scales.

• The definitions comprise guiding language and may require local contextual adjustments, based on worker/supervisor judgment or legal/policy requirements.

5/16/2016

14

Assigning Ratings

• Assess and Rate at Intake and Closure• Rate all subscales prior to making Overall Domain rating

• Domain ratings not the average of the subscale ratings; they are the worker's overall perspective of the subscales in each domain.

• Intake ratings completed when sufficient information has been obtained (sufficient family or collateral contact)

• Closure ratings within a few days of closure

Uses of NCFAS‐G+R Ratings (Intake)

Intake Ratings

• Provide a framework for team meetings/case reviews

• Focus resources to alleviate problems

• Prioritize issues for intervention

• Permit incorporation of strengths in case plan

• Focus periodic reassessments on key issues and components of case plan

5/16/2016

15

Uses of NCFAS‐G+R Ratings (Closure)

Closure Ratings

• Provide outcome measures of services

• Provide indication of unresolved issues

• Inform the case decisions made at Closure 

• Inform step‐down service planning or referral needs

• Permit computation of change scores which reflect progress made or not made

• Goal setting is continuation of the assessment process. 

• The goal setting process includes identifying strengths and needs, goal development, as well as the actual goal writing. 

Goal Setting

5/16/2016

16

• Tells us where to focus

• Help you assess/track where families are in their plan

• Help us and the family evaluate where they are

Goals Guide Change

Definition of Goals and Tasks/Activities

• Goals—an object or end that one tries to obtain, aim

• Tasks/Activities—an undertaking involving labor or difficulty

5/16/2016

17

Goals Should Be…

• Clearly phrased in understandable manner

• Written in behavioral terms which identifies what the family will be doing differently when change occurs

• Measurable and time‐limited

• Relevant to the reducing or eliminating the risk of the children

• Realistic and attainable

• Agreed upon

• Should identify the task that each party is responsible for, to achieve the identified goals.

• Consistent with families values

Domain Scales NCFAS NCFAS-R NCFAS-G NCFAS-G+R T/WB

A. Environment X X X X

B. Parental Capabilities X X X X

C. Family Interactions X X X X

D. Family Safety X X X X

E. Child Well-Being X X X XF. Caregiver/Child Ambivalence X X

G. Readiness for Reunification X X

F. Social/Community Life X X

G. Self-Sufficiency X X

H. Family Health X X

Trauma X

Post-Trauma Well-Being X

NCFAS and T/WB Domains Matrix

5/16/2016

18

T/WB (2 Domains)A closer look at the domains and subscales.

Trauma

• Traumatic Sexual Abuse of Child(ren)

• Traumatic Physical Abuse of Child(ren)

• Traumatic Neglect of Child(ren)

• Traumatic Emotional/Psychological Abuse of Child(ren)

• Parent/Caregiver Trauma 

• Overall Trauma

T/WB (2 Domains), cont.A closer look at the domains and subscales.

Post‐Trauma Well‐Being

• Post‐Traumatic Cognitive/Physical Well‐Being of Child(ren)

• Post‐Traumatic Emotional/Psychological Well‐Being of Child(ren)

• Post‐Traumatic Social Functioning of Child(ren)

• Post‐Trauma Parent/Caregiver Support of Child(ren)

• Post‐Trauma Parent/Caregiver Well‐Being

• Overall Post‐Trauma Well‐Being

5/16/2016

19

Assigning Ratings

Unlike the other NCFAS domains, where the same subscales are rated at both Intake and Closure, in the T/WB:

• Trauma is rated ONLY at Intake

• Post‐Trauma Well‐Being is rated ONLY:

• If the Trauma assessment at intake shows a “problem” rating (–1, –2, –3)

• At Interim, if the case is open more than 90 days

• At case Closure

(Note: The next 6 slides will illustrate these points.)

No INTAKE Ratings for Post-Trauma Well-Being

NotApplic.

ClearStrength

MildStrength

Baseline/Adequate

MildProblem

ModerateProblem

SeriousProblem Unknown

1. Post-Trauma Cognitive/Physical Well-Being of Child(ren) Intake N/A +2 +1 0 –1 –2 –3 UK

2. Post-Trauma Emotional/Psychological Well-Being of Child(ren)Intake N/A +2 +1 0 –1 –2 –3 UK

3. Post-Trauma Social Functioning of Child(ren)Intake N/A +2 +1 0 –1 –2 –3 UK

4. Post-Trauma Parent/Caregiver Support of Child(ren) Intake N/A +2 +1 0 –1 –2 –3 UK

5. Post-Trauma Parent/Caregiver Well-BeingIntake N/A +2 +1 0 –1 –2 –3 UK

6. Overall Post-Trauma Well-BeingIntake N/A +2 +1 0 –1 –2 –3 UK

5/16/2016

20

No INTERIM or CLOSURE Ratings for Trauma

NotApplic.

ClearStrength

MildStrength

Baseline/Adequate

MildProblem

ModerateProblem

SeriousProblem Unknown

1. Traumatic Sexual Abuse of Child(ren)InterimClosure

N/AN/A

+2+2

+1+1

00

–1–1

–2–2

–3–3

UKUK

2. Traumatic Physical Abuse of Child(ren)InterimClosure

N/AN/A

+2+2

+1+1

00

–1–1

–2–2

–3–3

UKUK

3. Traumatic Neglect of Child(ren)InterimClosure

N/AN/A

+2+2

+1+1

00

–1–1

–2–2

–3–3

UKUK

4. Traumatic Emotional/Psychological Abuse of Child(ren)InterimClosure

N/AN/A

+2+2

+1+1

00

–1–1

–2–2

–3–3

UKUK

5. Parent/Caregiver TraumaInterimClosure

N/AN/A

+2+2

+1+1

00

–1–1

–2–2

–3–3

UKUK

6. Overall TraumaInterimClosure

N/AN/A

+2+2

+1+1

00

–1–1

–2–2

–3–3

UKUK

When Trauma ratings at Intake are at or above Baseline (0, +1, +2) . . .

NotApplic.

ClearStrength

MildStrength

Baseline/Adequate

MildProblem

ModerateProblem

SeriousProblem Unknown

1. Traumatic Sexual Abuse of Child(ren)Intake N/A +2 +1 0 –1 –2 –3 UK

2. Traumatic Physical Abuse of Child(ren)Intake N/A +2 +1 0 –1 –2 –3 UK

3. Traumatic Neglect of Child(ren)Intake N/A +2 +1 0 –1 –2 –3 UK

4. Traumatic Emotional/Psychological Abuse of Child(ren)Intake N/A +2 +1 0 –1 –2 –3 UK

5. Parent/Caregiver TraumaIntake N/A +2 +1 0 –1 –2 –3 UK

6. Overall TraumaIntake N/A +2 +1 0 –1 –2 –3 UK

5/16/2016

21

. . . NO Post-Trauma Well-Being ratingsare entered at case Closure.

NotApplic.

ClearStrength

MildStrength

Baseline/Adequate

MildProblem

ModerateProblem

SeriousProblem Unknown

1. Post-Trauma Cognitive/Physical Well-Being of Child(ren) InterimClosure

N/AN/A

+2+2

+1+1

00

–1–1

–2–2

–3–3

UKUK

2. Post-Trauma Emotional/Psychological Well-Being of Child(ren)InterimClosure

N/AN/A

+2+2

+1+1

00

–1–1

–2–2

–3–3

UKUK

3. Post-Trauma Social Functioning of Child(ren)InterimClosure

N/AN/A

+2+2

+1+1

00

–1–1

–2–2

–3–3

UKUK

4. Post-Trauma Parent/Caregiver Support of Child(ren) InterimClosure

N/AN/A

+2+2

+1+1

00

–1–1

–2–2

–3–3

UKUK

5. Post-Trauma Parent/Caregiver Well-BeingInterimClosure

N/AN/A

+2+2

+1+1

00

–1–1

–2–2

–3–3

UKUK

6. Overall Post-Trauma Well-BeingInterimClosure

N/AN/A

+2+2

+1+1

00

–1–1

–2–2

–3–3

UKUK

When Trauma ratings at Intake identify at least one Problem area (–1, –2, –3) . . .

NotApplic.

ClearStrength

MildStrength

Baseline/Adequate

MildProblem

ModerateProblem

SeriousProblem Unknown

1. Traumatic Sexual Abuse of Child(ren)Intake N/A +2 +1 0 –1 –2 –3 UK

2. Traumatic Physical Abuse of Child(ren)Intake N/A +2 +1 0 –1 –2 –3 UK

3. Traumatic Neglect of Child(ren)Intake N/A +2 +1 0 –1 –2 –3 UK

4. Traumatic Emotional/Psychological Abuse of Child(ren)Intake N/A +2 +1 0 –1 –2 –3 UK

5. Parent/Caregiver TraumaIntake N/A +2 +1 0 –1 –2 –3 UK

6. Overall TraumaIntake N/A +2 +1 0 –1 –2 –3 UK

5/16/2016

22

. . . complete Post-Trauma Well-Being ratingsat case Closure.

NotApplic.

ClearStrength

MildStrength

Baseline/Adequate

MildProblem

ModerateProblem

SeriousProblem Unknown

1. Post-Trauma Cognitive/Physical Well-Being of Child(ren) InterimClosure

N/AN/A

+2+2

+1+1

0

0–1–1

–2–2

–3–3

UKUK

2. Post-Trauma Emotional/Psychological Well-Being of Child(ren)InterimClosure

N/AN/A

+2+2

+1+1

0

0–1–1

–2–2

–3–3

UKUK

3. Post-Trauma Social Functioning of Child(ren)InterimClosure

N/AN/A

+2+2

+1+1

00

–1

–1–2–2

–3–3

UKUK

4. Post-Trauma Parent/Caregiver Support of Child(ren) InterimClosure

N/AN/A

+2+2

+1+1

00

–1

–1–2–2

–3–3

UKUK

5. Post-Trauma Parent/Caregiver Well-BeingInterimClosure

N/AN/A

+2+2

+1+1

0

0–1–1

–2–2

–3–3

UKUK

6. Overall Post-Trauma Well-BeingInterimClosure

N/AN/A

+2+2

+1+1

00

–1

–1–2–2

–3–3

UKUK

What is it?• Comprehensive Family Support Services Program (CFSSP) is a Division of Family and Children’s Services contract with MCHS which provides:

• Family Preservation: Designed to keep families together

• Family Reunification: Reunification for children and adolescents who have been removed from their homes and placed in MDHS custody

Who do we serve?• Families are referred by DHS Families may voluntarily agree to actively participate

• Families may be court ordered for services

Background of Program

5/16/2016

23

Background Cont.

Feature of Services:

• Crisis intervention services available 24 hours a day, 7 days a week

• Child and Family Team Meetings

• Therapeutic Services

• Case management and service coordination

• Flex funds available to assist with immediate needs

• Parenting Education

• Behavior management planning

Implementing Pilot

• MCHS has been using the NCFAS evidence based assessment tool since 2007. 

• The National Family Preservation Network posted a request for partners to create 

a trauma domain for the NCFAS. 

• The initial phase of the pilot required several conference calls.

• The next phase consisted of the creation of the trauma and post trauma domain 

scale. 

• The final phase was the implementation of the 6 month pilot.

5/16/2016

24

Trauma Field Test Protocol

• MCHS would provide data on 100 cases to the NFPN by July 31, 2014. 

• MCHS would begin collecting NCFAS G+R and T/WB data on April 1, 2014.

• MCHS would identify a point of contact for CFSSP Supervisors regarding questions or clarification on clinical ratings of the NCFAS G+R and/or the trauma domain.

• MCHS would identify a field test coordinator and individual to be the point of contact for CFSSP Supervisors regarding data entry and completion and accuracy. 

Procedures

Supervisor’s Role

•Ensure the clinicians were properly trained on the use of the scale

•Work closely with field test coordinator

•Enter data from the electronic record into 

the trauma template provided by NFPN.

•Ensure clinicians incorporated any ratings below baseline into the families case plan/treatment plan and/or treatment process.

Clinicians Role

•Administer the NCFAS G+R with the trauma 

domains on every child/family that entered 

CFSSP within 10 days of admission.

•Administer the NCFAS G+R with the trauma 

domains at closure on every child/family that 

discharged within 24 hours of case closure.

•Identify primary caregiver.

•Identify primary child.

5/16/2016

25

Wrap Up

• The data was compiled and submitted to field coordinator monthly

• Data was reviewed at least monthly by field coordinator to ensure that all fields in 

the Trauma Template were complete and accurate, per chart review.

• Data was collected until research was complete.

• Data was submitted to NFNP for the creation of the NCFAS Trauma and well‐being 

domains.

• Staff reactions to using the new domains 

Trauma and Post‐Trauma Well Being Field Test

Purpose‐ Examine the Trauma and Post‐Trauma Well‐Being Domains 

• In practice

• In relation to the other domains of the NCFAS G+R

5/16/2016

26

Composition of Field Study Data

62%25%

13%

Mississippi was the Anchor Site for the Field Study, providing 2/3 of the data.

Mississippi Iowa North Carolina

Demographics

• Primary Caregivers:

• Predominately female (89%) and mostly Caucasian (66%).

• Children:

• Even distribution of age groups

• Gender was split equally

• Race distributed more evenly than PC

• Most biological children to PC (90%)

N= 170 Family Cases (352 Children)79% 82%

Intake Closure

Slightly More Children were Living with Birth or Adoptive Parents at Case Closure.

Reliability of the NCFAS G+R

• NCFAS G+R has already demonstrated reliability for use in child welfare settings.

• Reassessed in this Field Study

• Statistically demonstrated very high reliability and internal consistency on Intake and Closure

• Instrument was used appropriately and good clinical judgment was used when rating scales.

5/16/2016

27

Analysis of T/WB Scales and Domains

• Good internal consistency and reliability

• Similar to other NCFAS G+R domains

• Post‐Trauma Well‐Being Scale‐ suggests trauma symptoms can be reduced with appropriate services

Trauma Ratings

81%

19%

A Majority of the Families in the Field Test Disclosed at Least One Problematic Area Related to Trauma

Disclosed Trauma at Intake No Trauma Disclosed

13% 19%

44% 48%57%

Of the 81% of Families that Disclosed Trauma, Parental/Caregiver Trauma was most Frequently Reported

5/16/2016

28

Trauma Ratings

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Sexual Abuse PhyscialAbuse

Neglect Cog/Phys WB Emot/PsychAbuse

Emot/PsychWB

SocialFunctioning

P/C TraumaHx

P/C WB P/C Supportof Child

OverallTrauma

OverallTrauma WB

Data Suggests that Families who Disclosed Trauma at Intake, Improved Due to Trauma Services Provided

Intake Closure

Mean Item

 Rating

T/WB Scales Related to Service Provision  

Strong Trends

•Traumatic sexual abuse  victims referred to mental health service providers

•Emotional/Psychological Abuse referred to mental health service providers and general workers

No Trends

•Overall trauma indicated as problematic no trends related to who provided 

services. 

5/16/2016

29

T/WB Scales Related to Service Provision 

Implications

• Who provides services aren’t necessarily associated with overall levels of trauma history or symptomology.

• However, having an elevated overall trauma domain rating was likely to result in referral to services associated with trauma.

• Within specific types or trauma, workers appear to be using the information on trauma items to make treatment decisions.

T/WB Scales Related to Service Provision

• Post‐Service Ratings data (NCFAS G+R & T/WB Scales) suggest workers had trauma informed skills.

• Those skills provided by those workers appeared to be effective.

5/16/2016

30

11

89

Foster Care

Biological orAdoptiveParent

A Small Percentage of Families (only included in the Trauma and Post‐Trauma Domains) were living in Foster Care at Case Closure

• No placement trends related to some trauma well‐being domains.

• Being in foster care at case closure was significantly related to being below baseline on overall trauma well‐being (as well as some other specific domains).

• Being below baseline increased risk of being in or remaining in foster care.

N=99

T/WB Scales Related to Placement

Take Home on T/WB Domains

• Reliable & valid

• Fit well with the rest of the NCFAS G+R

• Easy to use

• Related to other NCFAS G+R Scales, but captures unique information

• Beneficial to families (identifies trauma problems so treatment can be 

tailored to include trauma services)