Table 3 The inter-related decision set for trauma screening, assessment, and treatment

 Target population: Whether to screen the entire population or a sub-population with a specific screening tool

Who to screen, specifically whether to implement:

 1. Universal population-level screening for all children entering foster care

 2. Universal screening for a subsample of children entering foster care

 3. No universal screening administered

“We had one county partner in our area that said any kid that comes in, right, any kid who we accept a child welfare referral on we will do a trauma screen on, and then if needed that trauma screen will get sent over to a mental health provider for a trauma assessment and treatment as needed. That was great and that's not something that all of our county partners were able to do just based on capacity, and frankly, around – some of our partners at mental health don't – I don't want to say they don't have trauma-informed providers – but don't have the capacity to treat all of our kids that come in Child Welfare's door with trauma-informed resources.”—Child Welfare

 Timing of initial screening: When should the screener be initially administered?

The timeframe within which the screening is required, specifically whether the screening must be complete within:

 1. 7 days of entry into foster care

 2. 30 days of entry into foster care

 3. 45 days of entry into foster care

“Not – we had to move our goal of the time when we were going to – so the time limit or – what's the – timeline for having the screeners done used to be 30 days. And we had to move it out to 45 days. So that's more on the pessimistic side, I guess, because I'd rather us be able to do quality work of what we can do, rather than try to overstretch and then it just be shoddy work that doesn't mean anything to anybody.”—Child Welfare

 Ongoing screening: Determine whether to and the frequency for when to rescreen for trauma

The frequency within which a screening must be re-administered; options included:

 1. Screening completed only at entry

 2. Screening completed every 30 days

 3. Screening completed every 90 days

 4. Screening completed every 180 days

 5. Screening completed at provider’s discretion when significant life events occur

“Interviewee: Well, we had to make the determination of frequency of the measure that was being implemented and what really seems the most practical and logical. Some of the considerations that we were looking at first and foremost was, like what level of frequency would give us the most beneficial data that we could really act upon to make informed decisions about children's behavioral health needs? And recognizing that this is not static, it's dynamic.”—Other State Partner

 Collaterals: Who should be a collateral consulted in the screening process (e.g., caregiver of origin, foster parent, etc.)?

The collaterals who might inform the screening process; options include:

 1. Caregivers of origin and foster parents

 2. Caregivers of origin only

 3. Foster parents only

“Another difficulty we’ve had is always including birth families at these assessments. We feel that’s integral, especially for a temporary court ward, to get that parent’s perspective, to help this parent understand the trauma.”—Child Welfare

 Construct: Whether screen would assess adequately for trauma exposure and/or symptoms as defined by the agency

The content of the screening tool; options include screening of:

 1. Both trauma symptomology and exposure

 2. Trauma symptomology

 3. Broad trauma exposure

 4. Specific trauma exposure (e.g., war, sexual abuse)

“But I think that we're interested more in – and when I talk to the Care for Kids, they do not have, beyond that CANS screen, a specific trauma screen. But I think what we're most interested in is not a screening for trauma overall but screenings specifically for trauma symptomatology ‘cause I think almost by definition, foster care children are going to have high trauma scores.”—Medicaid

 Discretion: Whether to mandate a single tool for screening trauma or provide a list of recommended screening tools

The extent of discretion provided to the clinician in assessing trauma; options include:

 1. State mandated screening tool

 2. County mandated screening tool

 3. List of potential screeners required by state

 4. Provider discretion

“Yeah. You know how we have endorsed screening tools is we believe there are psychologists, psychiatrists out there that actually they’re doing the screening and physicians. And as long as it is like a reputable tool, like you said, if they have a preference, and I don’t know the exact numbers but there might be let’s say five tools that are really good for picking up trauma in children. And we say to the practitioner if there's on that you like better over the other we’re giving you the freedom to choose as long as it's a validated tool.”—Mental Health

 Threshold-level: Identify whether to adjust the screening threshold (i.e., “cut-score”) and if so, what threshold would be used for further “referral”

The “cut-score” or threshold used for referring to additional services; options included:

 1. Set threshold at developer recommendation

 2. Set threshold above developer recommendation

“And so we did consider things like that. Maybe the discussion was we really would like to go with a six and above, but you know what, we're gonna go with an eight and above because capacity probably, across the state, is not gonna allow us to do six and above.”—Mental Health

 Mandated “Cut-Score:” Identify whether implement a statewide or county-specific “cut-score”?

Option include:

 1. Statewide “cut-score” required

 2. Statewide minimal standard set with county-level discretion provided

 3. Complete county discretion

“What their threshold is in terms of what is an appropriate screen in referral, that can also vary county to county. And the reason for those business decisions was the service array varies hugely between the counties in Colorado, available service array, and they didn't want to be overwhelming their local community mental health centers with a whole bunch of referrals that all come at once as child welfare gets involved. So the idea was to let the counties be more discriminating on how they targeted this intervention.”—Child Welfare

 Additional criteria for referral: Identify whether referrals are advanced based on scores alone, concerns alone, or both

Options for materials supplemental to the cut-score, alone, included:

 1. Referrals advanced based on scores alone

 2. Referrals based on provider/caseworker concern alone

 3. Referrals based on either scores or provider/caseworker concern

“Really what we decided, or what we’ve kind of discussed as far as thresholds is not necessarily focusing so much on the number. We do have kind of a guide for folks to look at on when they should refer for further assessment. But we really focused heavily on convening a team on behalf of the child. I know that you’ll talk with [Colleague II] who is our My Team manager. So [state] has a case practice model called My Team. It’s teaming, engagement, assessment, and mentoring. So those are kind of the four main constancies of that model.”—Child Welfare

 Administrator credentials: Who can administer the screening?

Options for required credentials to administer the screening included:

 1. Physician

 2. Physician with trauma training/ certification

 3. Masters-level clinicians

 4. Masters-level clinician with trauma training/certification

 5. Caseworkers

 6. Caseworkers with trauma training/certification

“Yes. So we have, like I said, a draft trauma protocol that we have spent a lot of time putting together. So some of the areas on that are the administration of the checklist. That was kind of based on the instructions that we received from CTAC since they developed the tool. That it’s really staff that administer the tool, they do not need to have a clinical, necessarily, background to be able to administer that tool since it’s just a screening.”—Child Welfare

 Administrator training: What training is required to implement the screening tool and what are the associated fiscal and human resources required for implementation?

Options for the training resources required included:

 1. Training for all child welfare staff on screening

 2. Training for new child welfare staff

 3. Training for specialized sub-population of child welfare staff

“Several of our counties had already been trained by [CTAC Developer] to use the screening tool, but it wasn’t something that we were requiring. So this will, it’s now going to be a mandatory training for all public and private child welfare staff to administer that screening to all kids in care.”—Child Welfare

 Development of trauma-specific service array: Are trauma treatments mandated or is a list of recommended treatments provided?

Options for the development of a trauma-specific service array included:

 1. Selection of trauma treatments to accommodate available workforce capacity

 2. Increase of the threshold for screening treatment to decrease required workforce capacity

“So we don't require any particular instrument, we just require that they address the trauma and that if they are doing – if they say that they are doing trauma therapy or working with a trauma for a kid, that therapist has to be trauma certified. We have put that requirement. So it's kind of hitting it from both ends.”—Other State Partner

 Development of new capacity: How to build new capacity in the workforce to address anticipated trauma treatment needs?

Options to build the capacity of trauma-specific services included:

 1. Single mandated tool required

 2. List of new psychosocial services to address trauma

 3. Requirement that therapist must be trauma certified

“And so those were some of the drivers around thinking about TARGET as a potential intervention that – because it doesn't require licensed clinicians to provide the intervention because it is focused on educating youth around the impact of exposure to trauma, the concept of triggers, recognizing being triggered and enhancing their skills around managing those responses.”—Child Welfare