The successful implementation of a screening process for trauma and victimization has multiple different elements and considerations that need to be taken into account. The current resource is designed to serve as an implementation support tool for the selection and implementation of trauma and/or victimization screening processes within a selected agency and/or system. Using the Exploration, Preparation, Implementation, and Sustainability (EPIS Framework defined by Aarons et al., (2011), this resource is designed to guide leadership in the selection and implementation of a trauma screening process in their agency and/or system. This resource is intended for Agency Administrators and Project Coordinators.
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Exploration Phase
During the exploration phase of implementing a trauma screening process, agency leadership is considering the implementation of a screening process within their agency and/or system and thinking through the potential ways in which a screening process may be helpful to their clientele, but also potential challenges.
Consider which individuals within the agency will be responsible for supporting the implementation of the screening process. It is recommended that the implementation team include agency leadership, supervisors, and front-line staff members who will be responsible for the implementation itself. Including individuals with “lived experience” (e.g., former clients) on the implementation team will provide critical information regarding the process that may not be considered if only staff members sit on the implementation team. Ensure that the implementation team members are prepared to be “trauma champions” for this work and will serve as leaders for these efforts (whether or not they have an official “leadership” title).
- Who will be the members of the Implementation Team?
- Does it include agency leadership, supervisors, and front-line staff members?
- Are there individuals with “lived experience” who can help support the process?
Consider your reasons for implementing the trauma screening process. Some potential reasons why you may want to screen for trauma in your system (adapted from Kerig, Ford, & Olafson, 2014):
- Document youths’ trauma history
- Provide information requested from collaborative partners
- Inform case and/or service planning decisions
- Identify youth in need of referral for trauma-specific mental health assessment or treatment
- Identify youth at risk for adverse reactions to procedures
- Inform a trauma-informed safety plan to reduce harm to self or others while youth are in care
- Increase staff’s ability to work effectively with youth
- Identify, monitor and/or track trauma-related needs for agency, community or state planning
- What is the problem that you are trying to solve through the implementation of a trauma screening process?
- Are you trying to document a youth’s trauma history?
- Use the information to direct referrals and treatment/case planning?
- Share with collaborative partners?
Be specific.
There are a number of different tools that exist for trauma screening. Some tools focus primarily on gathering information on an individual’s exposure to trauma by indicating what types of trauma they have experienced. Other tools focus on gathering information on trauma symptoms that an individual may experience following trauma exposure. A number of tools gather information on both trauma exposure and trauma symptoms.
- Trauma History/exposure – The number and types of trauma an individual has experienced or been exposed to within a certain period of time. These include events such as physical or sexual abuse, exposure to domestic violence, exposure to war/refugee trauma and/or exposure to natural disasters, among others.
- Trauma Symptoms – These are symptoms that an individual may be experiencing following exposure to traumatic event and is closely tied to the symptoms for posttraumatic stress disorder. Trauma symptoms include hypervigilance, reexperiencing of the event, avoidance of reminders of the event, and other symptoms such as depression, anxiety and dissociation.
- What type of screening would specifically meet the needs that you identified in question #2?
- Do you only need to know a youth’s history of trauma exposure?
- Or would it be helpful to also gather information on their trauma symptoms?
Consider the organization’s and system’s need and readiness to implement a trauma screening approach.
- What is the purpose of the screening process?
- Is it being used to facilitate case decision-making, inform clinical practice, or evaluate intervention outcomes?
- Have your clients identified areas of concern that would be improved by the implementation of a screening process?
- If you are uncertain, it may be helpful to solicit their feedback through consumer surveys, interviews, and/or focus groups.
- Have your community partners and other stakeholders identified areas of concern that would be improved by the implementation of a screening process?
- If you are uncertain, it may be helpful to solicit their feedback through surveys, interviews, and/or focus groups.
- Who will be screened?
- Will you screen all of the children and families we serve, or a subset in a particular program?
- Will you start small and then get broader over time?
- What is your budget and what is the cost of the tool and/or process?
- What staff do you have available to complete the trauma screening?
- What is their level of education and experience in mental health and trauma?
- Is there training available to equip staff to respond sensitively and effectively to youth disclosures and protect staff from vicarious traumatization?
Utilize the information gathered from the Needs Assessment to (1) determine if the implementation of a screening process would be helpful and informative; and, if so (2) potential ways in which the screening process may work. Conduct a review of existing trauma screening tools and consider the pros and cons of each, including the following elements:
- Are your clients old enough to answer questions about their own trauma history and symptoms?
- Do you have access to caregivers in our agency?
- Are they reliable informants?
- If not, is there another trusted and informed adult?
- Do the case files provide enough information?
- With whom will the information be shared?
- What happens if the child does not meet the identified threshold?
- Is there a process to re-screen at regular intervals?
- What research has been conducted on the identified tool or process?
- Has this tool or process been used in similar populations (race, ethnicity, gender, sexual orientation, gender identity, socio-economic, etc.)?
- While not necessary, it is helpful to use a tool that has some research behind it if possible.
- What is the youth’s state of mind and understanding of the purpose of trauma screening, and how might this affect her/his ability and willingness to respond accurately and completely?
- How will disclosures be handled in keeping with mandated reporting laws?
- Will youths’ privacy and rights to avoid self-incrimination be protected?
- How will the results inform case and/or treatment planning?
- Are resources available to refer youth in need to trauma-informed behavioral health assessments?
- Are trauma-informed behavioral health services available and accessible to the youth and family?
- How will the agency/organization’s and staff’s practices be adapted in ways that are trauma-informed?
- Based on the information gathered above, is the trauma screening a good fit for the agency? Why or why not?
Determine if trauma screening is a good fit for the agency based on the information gathered above.
Additional Resources to Consider during the Exploration Phase:
- Measure Reviews – a database of reviews of trauma screening and assessment screening compiled by the National Child Traumatic Stress Network
- Screening and Assessment: Considerations for Implementation
- Recommended Screening Tools for CACs
Screening and Assessment for Trauma in Child Welfare Settings, Webinar Series
- Screening Measures for Parent-Child Dyads
- The Application of Trauma Screening/Assessment in Child Welfare Settings: Direct Service Level
- The Application of Trauma Screening/Assessment in Child Welfare Settings: Systems Level
- Trauma Screening and Assessment Measures for Child Welfare Settings
- An Overview of Screening and Assessment for Child Trauma
Screening and Assessment in the Juvenile Justice System, Webinar Series
- The Use of Web-Based Screening for Trauma and Associated Disorders with Justice Involved Youth
- Utilizing Trauma Screening and Assessments in Court Decisions: Perspectives from the Bench and Mental Health
- PTSD and Risk Assessment for Juvenile Court Evaluations
- Trauma-Informed Screening and Assessment in Juvenile Justice Settings: Strengths and Limitations of Commonly Used Instruments
Preparation Phase
Leadership plays a critical role in a successful implementation of a screening process, particularly during the Exploration and Preparation phases. Leadership needs to display a true commitment to this work by attending early planning meetings, providing resources, and creating a broader communication message to the agency supporting these implementation efforts.
- What is the level of leadership buy-in for the trauma screening process?
- Do they appear to be truly committed to this work by attending early planning meetings, providing resources, and creating a broader communication message to the agency supporting this process?
While it may appear simple to implement screening, it is often far more complex. Creating a system to support the implementation that includes members of the implementation team as well as other key stakeholders, will ensure that challenges are identified early and that there are strategies to overcome them.
- Who will be the members of the implementation support system?
- Does it include members of the implementation team as well as other key stakeholders? Who are they and what do they bring to the process?
Be specific
A screening process extends far beyond the initial agency that is leading the implementation efforts. It involves multiple stakeholders who may have varying roles in the results from the screening. For example, a screening may be used to determine if a child/youth should be referred for a mental health assessment and therefore, mental health partners should be included in the process. Similarly, the screener agency may be central to multidisciplinary team efforts (such as a Child Advocacy Center), and the information from the screening may be used to support case/service planning. Identifying and integrating relevant stakeholders will decrease duplication efforts and maximize coordination and collaboration across all systems that interact with this child/youth and family. Utilize this process to identify any potential challenges to effectively implementing the screening process and using the information gathered in a helpful way.
- Who are your key stakeholders for the screening process?
- What role will they play?
- Will the results of the screening be shared with them, or will it inform referrals to them only?
Be specific.
Once an initial screening process has been identified, it is critical to bring this information to a diverse advisory group that includes youth and families who have received services for their input on the process, including when the screening is occurring, how information regarding the screening is shared with the youth and family, and how it informs case/treatment planning efforts.
- Does the selected trauma screening process successfully address the concerns that were identified during the Exploration phase by those with lived experience?
The implementation of a screening process requires multiple resources and supports. These include funding to pay for the tools themselves (if there is a cost associated with them), staff time in creating the screening process, staff time for training on the process, staff time in conducting the screenings, and re-training as needed. Investigate potential funding streams to support both the initial implementation efforts, and also ongoing support for the process. If the potential funding streams are time-limited (grants, etc.), begin thinking about potential ways to continue this work after the initial funding ends.
- How will this process be financially supported?
- How will the cost (if any) of the tools be covered?
- How will staff time be covered to create the screening process itself?
- To train other staff members on the process? To conduct the screening?
- Re-training as needed?
- If the funding is time-limited, how will the process be supported after that funding ends?
- What barriers can you identify at this time that may get in the way of successfully implementing the screening process, or at least make it more difficult?
- How might you overcome these barriers?
Be specific.
Create an implementation plan and timeline that includes all of the aforementioned activities, such as working with stakeholders, training staff, and fully implementing the new screening process. Consider implementing the screening process in one small unit to gather feedback prior to expanding to the larger organization. Think realistically about timelines, allowing additional time to course correct as needed.
Create a realistic timetable of the implementation process. Make sure to include activities such as working with stakeholders, training staff, refining the process per client feedback, etc.
Implementation Phase
The screening practice is implemented. This is where the rubber meets the road and the implementers will find out if their work during the Preparation Phase addressed the major issues.
Work with staff and stakeholders to ensure that they buy-in to the process. As with all implementation efforts, some staff members will be “early adopters” who are excited and willing to do this work and will be trauma champions. However, there will also likely be others who are less engaged and somewhat resistant to this change. It is recommended that time and energy for implementation is spent with the “early adopters” and “middle adopters” (individuals who are hesitant but will eventually buy-in). The momentum of the effort will eventually motivate “late adopters” to join the implementation effort or seek out other opportunities elsewhere.
- Are staff and stakeholders truly bought into the process?
- Are there “early adopters” who are truly bought into the process and serve as trauma champions?
- Are there others who are less engaged and somewhat resistant to the change?
Training should include the following: (1) Overview of trauma and its effects; (2) How to conduct the screening (including role plays); (3) How to use the information gathered from the screening; and (4) Managing secondary traumatic stress that may emerge when hearing about a child/youth’s trauma history during the screening process. Training should also include specific support for supervisors who will be overseeing front-line staff in their screening efforts.
- Describe the training that will be conducted to support the screening process. Who is conducting the training?
- When will it be held?
- Does it include background information on trauma and its effects? Does it provide concrete information on how to conduct the screening?
- Does it provide information on how to use the information gathered from the screening to direct referrals and case/treatment planning?
- Is there a piece focused on managing secondary traumatic stress from both an individual and organizational level?
Ensure that there are materials for staff to use to support the implementation of the screening process. These may include handouts and tip sheets, frequently asked questions, central filing (electronic or otherwise) of the tools and resources in one place.
- What materials are needed to successfully support the implementation efforts?
- Would it be helpful to create handouts, tip sheets, frequently asked questions, etc?
- What other resources are needed? Where will the information be stored (electronic or otherwise)?
Ensure that the system is in place to screen all children/youth in the identified group.
- What will be the referral process for the screening?
- Is the system in place to ensure that those who need to get screened receive it?
Work with supervisors to create a process to ensure that the screenings are being conducted in a timely manner, to support staff in using the information gathered from the screening process to make appropriate referrals, and providing a support environment for staff to process any distressing information that they might hear during the screening.
- Who is responsible for monitoring fidelity to the screening process?
- Are screenings being conducted in a timely manner?
- Are staff making the correct referrals based on the screening results?
- Does the environment successfully support staff in managing some of the difficult information that they might hear during the screening process?
Potential outcomes to collect include: (1) Number of screenings completed; (2) How many children/youth screened meet a threshold for services; (3) How many children/youth who meet that threshold are referred; and (4) feedback from the children/youth on the screening process itself. This information can be used evaluate implementation efforts and made modifications to the process as needed. Outcomes can also be helpful in securing ongoing funding.
- What outcomes are you collecting?
Some ideas include: (1) Number of screenings completed; (2) How many children/youth screened meet a threshold for services; (3) How many children/youth who meet that threshold are referred; and (4) feedback from the children/youth on the screening process itself.
- Do you have any results from the outcomes that you have been collecting?
- Should the screening process be modified in any way based on the information that you have gathered?
The initial implementation of the screening process may only occur in one unit or office. Consider using lessons learned from the initial implementation to scale up the training more broadly in the organization or system.
- Is the screening process ready to be scaled up/expanded more broadly from the initial unit or office?
- What lessons have you learned from the initial implementation that should be applied as the process is scaled up?
Additional Resources to Consider during the Implementation Phase:
- Best Practices in Screening and Assessment of Refugee Youth – an NCTSN Webinar (must long into learn.nctsn.org and obtain free account to view):
Sustainment
- How will the screening continue to be funded once the initial funding has ended or if the current funding stream changes?
- funding stream changes?
Consider how you will train new staff on the screening process or offer booster training for existing staff to sharpen their skills.
- How will new staff be trained on the screening process?
- How will booster training be offered to existing staff to sharpen their skills?
Continuous monitoring of the screening process and correcting as needed.
- How is the screening process being monitored for fidelity? Consider checking in on this process at ongoing intervals.
Continue monitoring outcomes over time
- Are we learning anything from the outcomes that we identified during the Implementation Phase?
- Are there new outcomes we should start monitoring?
- What do these outcomes tell us about our process and our broader services?
Course correct as needed to ensure that the process is sustainable over time
- Does anything need to be adjusted to ensure that the screening process is sustainable over time?
Once the initial implementation is completed and embedded into the culture of the agency or system, consider whether it would be helpful to include other units, offices or systems in this process.
- Now that the screening process has been implemented at your agency and embedded into the culture of the system, would it be helpful to include other units, offices or systems in the process?
- How will the energy and enthusiasm for this initiative be sustained over time?
- Who will be involved?
- What individual or group will be responsible for continuing to review and update the process as needed?