Social-Emotional Screening Protocol Implementation: A Trauma-Informed Response for Young Children in Child Welfare

Introduction: Adverse childhood experiences in children less than three years of age have been shown to result in negative outcomes including damaged learning processes, decreased coping skills, and diminished social-emotional regulation, as trauma and resulting toxic stress affects the child’s brain growth and development (Centers for Disease Control and Prevention [CDC], 2016; SAMHSA, 2014; The National Child Trauma Stress Network, 2018). Children within the child welfare system are more likely to have experienced trauma and are at higher risk for social-emotional delays (Szilagyi, et al., 2015). Without intervention, trauma-based behavioral problems in children may be prolonged and intensified, which in turn, may lead to caregiver frustration, increased transitions among foster care placements, and issues with emotional attachment (Szilagyi, et al., 2015; Burns, et al., 2004). Within the child welfare setting, early recognition of delayed social-emotional skills and collaboration with caregivers in application of treatment strategies is essential in building positive relationships and diminishing the effects of trauma for young children. The purpose of this quality improvement project is to improve identification of social-emotional impairments among young children at risk for childhood trauma/toxic stress and to refer these children to trauma-informed mental health services. This project will implement an evidence-based, social-emotional screening protocol for young children between the ages of 1 month to 3 years old placed in out-of-home care through the Wisconsin child welfare system. The project will evaluate if the process change increases identification and referral of young children with social-emotional impairments that may be trauma related. In cases of positive screenings, the protocol will indicate child referral for further diagnostic mental health assessments and trauma-informed treatment therapies if needed.

Background: This project will be implemented in the ongoing case management department at a non-for-profit child welfare agency. This agency serves around 900 families including around 1200 children in ongoing Child Protective Services (CPS) cases in a large Midwestern urban city. The ASQ:SE-2 was originally chosen as the potential screening tool of choice as it was readily available to the child welfare agency, developmentally appropriate, and able to screen young children 1 month to three years old. While the ASQ:SE 2 does not specifically diagnose or directly identify past traumatic experiences in children, the test does identify delays in social-emotional behaviors which are common in children who have experienced trauma.

The child welfare agency currently attempts to ensure case managers are accounting for child mental health by utilizing the Child and Adolescent Needs and Strengths- Wisconsin Comprehensive (CANS) Child/Youth Mental Health Algorithm. This algorithm, run through an online documentation system by completing the CANS screening, is supposed to be completed within 30 days of entry to out-of-home care, and is intended to inform decisions relating to seeking immediate mental health services for children in out-of-home care (Wisconsin Department of Children and Families, 2018). While the CANS-Comprehensive tool itself has been tested and proven valid and reliable to determine a child’s needs and strengths, the Child/Youth Mental Health Algorithm utilized by the organization to determine a child’s need to be seen by a mental health provider based on CANS data is not evidenced based and has not been tested for young children (Lyons, 2009). This algorithm is not specific to the child’s developmental age and screens all children from newborns to teens. The screening is completed by case managers rather than in conjunction with the child’s caregivers, and there is no questionnaire or structured interview to obtain necessary information regarding specific behaviors. It is difficult for case managers to properly determine if an infant or young child is having moderate or severe problems in these areas without further guiding questions about the young child’s mental health (Hoffman, Bunger, Robertson, Cao, & West, 2016). Nurses within the child welfare agency have noted that the CANS algorithm does not sufficiently catch all children with social-emotional health needs, even those noted by caregivers to have severe and concerning behaviors.

Literature Review: An integrative literature review was conducted using multiple data sources to determine current best evidence. The literature review intended to address the PICO question “In children, less than three years of age, how does utilization of the ASQ:SE screening tool affect early identification of social emotional concerns and rates of child referral to mental health therapies?”. A total of 15 articles were found to be included in the comprehensive literature search. Current AAP guidelines recommend that all children entering the foster care system, ideally, should have a comprehensive mental health evaluation within 30 days of placement, but that priority should be given to children identified with social-emotional needs identified through screening when resources are limited (AAP, 2015). Literature synthesis indicated that for very young children, the ASQ:SE 2 is an evidenced-based screening in identifying social-emotional impairments and improving referral rates (Jee & Szilagyi, 2017; Banger, Rodriguez, Blake, Linares, & Carter’s, 2012; McCrae & Brown, 2017; Velikonja et al., 2016). Among children in foster care, one study found that use of the ASQ:SE led to a six-fold increase in identification of social-emotional problems (Jee et al., 2010). The ASQ:SE was found to significantly increase rates of social-emotional problem identification compared to baseline provider identification or caregiver identification alone (Jee et al., 2010; Williams, Zamora, Akinsilo, Chen, & Poulsen, 2018). A systematic review of social-emotional tools noted that the ASQ:SE specifically demonstrates qualities appropriate for use in child welfare compared to other tools as these tools demonstrate above-average psychometric properties, assess psychological domains that are concerning for maltreated children, assess the child’s strengths and have proven validity for use among disadvantaged families (McCrae & Brown, 2017). Currently, the ASQ:SE-2 is the only tool available to screen for social-emotional problems in children less than one year old (Banger, Rodriguez, Blake, Linares, & Carter, 2012).

Methods. The project will be implemented as an observational, single systems design. Prior to initiating the project, the author/project manager completed a Human Subjects Research Assessment form which designation the project as quality improvement and not in need of, further IRB review. The new screening protocol will be implemented for all children entering out of home care less than 3 years of age. As part of the protocol, the ASQ:SE-2 will be completed by kinship caregivers or foster parents during the initial nurse home visit which occurs for all children less than 3 years old, typically around 15-30 days after placement. In cases of positive screening, a process will be implemented to refer the child for further mental health evaluation through the organization’s mental health clinic, notify HMO health care coordinators and primary care providers of screening results in order to collaborate care, and link the child to potential therapy or services if indicated by mental health evaluation. Data will be tracked by the project manager/child welfare nurse to assess if early identification of social emotional impairments and referrals to trauma focused mental health therapy is affected by a standardized screening process implemented for children less than 3 years old. Data analysis will be completed retroactively utilizing CANS data 3 months’ pre-protocol implementation and project data 3 months’ post-implementation. All data will be de-identified prior to analysis.

Results Pending

Discussion Pending

Conclusion Pending