Volume 21, Number 3
June 2016
This publication for child
welfare professionals is
produced by the North
Carolina Division of Social
Services and the Family
and Children’s Resource
Program, part of the Jordan
Institute for Families within
the School of Social Work
at the University of North
Carolina at Chapel Hill.
In summarizing research, we
try to give you new ideas for
refining your practice. How-ever,
this publication is not
intended to replace child
welfare training, regular su-pervision,
or peer consulta-tion—
only to enhance them.
Let us hear from you!
To comment about some-thing
that appears in Prac-tice
Notes, please contact:
John McMahon
Jordan Institute for Families
School of Social Work
UNC–Chapel Hill
Chapel Hill, NC 27599-3550
jdmcmaho@unc.edu
Newsletter Staff
Sarah Marsh
John McMahon
Laura Phipps
Special Contributors
to this issue:
Mellicent Blythe
Chrystal Coble
Jenny Cooper
Jeanne Preisler
Visit Our Website
www.practicenotes.org
Partnering with NC’s Mental Health System
Partnering with the mental health system is
a key part of achieving positive outcomes
in child welfare. Because of their expertise
and desire to help children and families
heal and thrive, those working in the men-tal
health system are natural partners for
child welfare professionals.
But even in natural partnerships, things
aren’t always easy. Child welfare profes-sionals
sometimes find it difficult to obtain
appropriate, evidence-based services for
clients. Poor communication and lack of
clarity about each other’s roles, mandates,
and procedures can trip up even the most
sincere attempts to work together.
Yet despite the occasional frustrations,
these barriers can be overcome. If the
recently released final report from the Gov-ernor’s
Task Force on Mental Health and
Substance Use (available here: http://bit.
ly/1TsryJN) is any indication, in the future
our two systems will almost certainly be
working together more, not less.
This issue of Practice Notes demonstrates
that to some extent this future is already
here. Through Project Broadcast and many
other efforts, child welfare and mental health
agencies are searching for new ways to col-laborate
so they can be stronger, more effi-cient,
and more successful.
We hope this issue of Practice Notes will
provide you with inspiration and ideas to
make your partnerships with mental health
deeper and more fruitful for the kids and
families you both serve. 
“You just can’t do child
welfare without mental
health partnering.”
— Child welfare system
stakeholder
The NC Division of Social Services is pleased
to announce the launch of Advocating for
Child and Adolescent Mental Health Ser-vices,
a self-paced, on-demand, online
course that provides basic information to our
state’s child welfare workers and supervisors
on working with local management entities/
managed care organizations (LME/MCOs)
to connect children and families to services.
This 2-hour training teaches child welfare
staff how to monitor services and build col-laborative
relationships with LME/MCOs
so youth and families can be connected
to needed behavioral health services. The
course explains how LME/MCOs determine
eligibility, outlines the functions of the LME/
MCO, describes what to expect from behav-ioral
health providers, and teaches strategies
that can be used
to advocate for
appropriate ser-vices
for clients.
This course was developed with fund-ing
from the NC Division of Mental Health,
Developmental Disability, and Substance
Abuse by the Behavioral Healthcare Resource
Program, part of the Jordan Institute for
Families at the UNC School of Social Work.
To Take This Course
Visit ncswLearn.org for a full course descrip-tion
or to take this course. No registration
is required. Simply log in to your account
and navigate to the “Personalized Learning
Portfolio (PLP) / Online Courses” section at
http://ncswLearn.org. 
New Course for Child Welfare Professionals on
Advocating for Mental Health Services
2
Building a Trauma-Responsive Child Serving System in NC
Project Broadcast was launched in
October 2011 with a five-year grant
from the U.S. Administration for Chil-dren
and Families (#90CO1058) to
help our child welfare system become
more trauma-informed. Almost five
years later, even though funding is
coming to an end, the project’s mission
will remain a key component to child
welfare services in North Carolina.
Why Focus on Trauma?
National studies have shown that
adverse childhood experiences (ACEs)
lead to increased use of health and
human services, poor health out-comes,
and early death. In fact, with
an ACE score of three (out of ten),
at some point in your life you are 2x
more likely to become a smoker and
6x more likely to attempt suicide. With
an ACE score of four, you are 7x more
likely to become an alcoholic and 12x
more likely to try suicide at some point.
In fact, there is a “dose-effect” for
childhood trauma. As Figure 1 shows,
the more ACEs you have, the more
likely you are to experience mental
health disorders. As Figure 2 shows,
ACEs have a dose-effect for physi-cal
health outcomes as well. (Figures
reprinted from Putnam, et al. 2015,
which is available at www.canarra-tives.
org.)
Trauma can have a huge impact,
but fortunately its effects can be miti-gated
if we identify trauma early and
intervene effectively.
Screening for Trauma
Project Broadcast developed two
trauma screening tools for use by
child welfare professionals: one for
children under age six and one for
children age six and older.
These one-page tools help identify
potential trauma exposure and func-tional
impairments often associated
with trauma, and they help workers
decide whether to refer youth for a
comprehensive, trauma-informed clin-ical
assessment. The screening form
for children age six and older includes
four questions the social worker spe-cifically
asks the child about physical
abuse, sexual abuse, domestic vio-lence
and other traumatic events.
These tools have been used widely
in Project Broadcast counties. Over
the course of 36 months (Jan. 2013 to
Dec. 2015), child welfare workers in 12
NC counties completed 9,714 trauma
screenings. Because some children
were screened more than once, the
total number of children screened was
6,651. On average, children screened
were 8.39 years old. Slightly more than
half (51%) were male. Thirty-nine per-cent
were white, 39% were black, and
13% were Hispanic.
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Figure 1
Figure 2
Cumulative ACEs and Mental Health
Cumulative ACEs and Chronic Disease
Figures reprinted from Putnam, Harris, Lieberman, Putnam, & Amaya-Jackson, 2015
continued next page
Twenty percent of the children
screened were found to have had
three or more adverse childhood
experiences. That’s more than 1,300
children who are 6x more likely to
attempt suicide in their lifetime. This
is why the work we do is so important.
After we ensure children are safe, we
must tend to their well-being so they
can become productive, success-ful
adults. We want them to live long
enough to know their grandchildren
some day.
Among the children screened by
Project Broadcast the most common
trauma experience was exposure to
domestic violence (48%), followed by
exposure to drug/substance abuse or
related activity (42%).
Children’s trauma varied by case
type. For example, 54% of CPS in-home
and 48% of foster care cases
had experienced trauma, compared
to 23% for children involved in CPS
assessments/investigations. Overall,
30% of children screened had experi-enced
some type of trauma. Of these,
56% were referred for further assess-ment.
(Most of the remaining 44%
were already in treatment.)
When children older than six were
asked directly about their history, 15%
indicated they had experienced physi-cal
abuse, 22% had been exposed
to domestic violence, 10% had
been sexually abused, and 2% had
another traumatic event occur. The
trauma screening revealed previously
unknown information about 113 chil-dren.
Thanks to trauma screening, we
can provide them with services and
psychoeducation to help them heal.
The Future of Project Broadcast
The NC Division of Social Services and
its partners want to expand Project
Broadcast to all NC counties. We want
to ensure our entire child welfare work-force
has the knowledge and skills they
need to identify and respond to child
trauma. We also want to make sure
all child welfare agencies attend to the
secondary traumatic stress needs of
employees and have effective working
relationships with the mental health
community. We want to provide the
support needed to make every agen-cy’s
culture trauma-informed.
We are using learning communi-ties
to spread Project Broadcast. The
current learning community is train-ing
representatives from 12 counties
to lead efforts to make their agencies
more trauma-informed. This learn-ing
community, though it is a year-long
process, is only the beginning:
becoming trauma-informed is a cul-ture
shift for all agencies.
Using learning communities is an
exciting new step for the Division of
Social Services as well. This is a prom-ising
approach to rolling out training
and implementing new initiatives. We
hope to offer another trauma-focused
learning community in spring 2017.
Other Child-Serving Systems
When it comes to our state’s vision for
making other child-serving systems
more trauma-informed, the word
“synergy” comes to mind. Synergy is
the interaction or cooperation of two or
more organizations to produce a com-bined
effect greater than the sum of
their separate effects (Oxford, 2016).
Today many entities in our state are
focused on trauma:
• The Division of Medical Assistance
is embedding trauma-informed
information into the mental health
service definitions;
• The Division of Mental Health,
Developmental Disabilities, and
Substance Abuse Services is fund-ing
the NC Child Treatment Pro-gram,
which is training hundreds
of new clinicians each year (visit
www.ncchildtreatmentprogram.org
often; new clinicians are added
monthly);
• The Department of Public Instruc-tion
is leading a School Mental
Health Initiative;
• The Department of Public Safety/
Division of Juvenile Justice have
implemented trauma-informed
assessments, treatment, practices,
and policies in their Youth Develop-ment
and Youth Detention Centers;
• The Department of Health and
Human Services is investing in
Mental Health First Aid (www.
mentalhealthfirstaid.org) which
could have a tremendous impact
on our entire system; and
• The Governor’s Task Force for
Mental Health and Substance Use
issued many trauma-informed rec-ommendations
in May 2016.
Conclusion
It’s an exciting time in our state. If we
can realize how prevalent trauma is,
recognize the signs and symptoms,
respond with trauma-informed skills
and practices, and avoid re-trauma-tizing
children and families, we will
be well on our way to mitigating trau-ma’s
negative effects. We can build
resilience in children and families,
promote protective factors, and heal
those who have experienced trauma.
You are part of this exciting time.
You can be part of the healing process.
For more information about Project
Broadcast or trauma-informed ser-vices
in North Carolina, please con-tact
Jeanne.Preisler@dhhs.nc.gov. 
continued from previous page
After we ensure children are safe,
we must tend to their well-being
so they can become productive,
successful adults. We want them
to live long enough to know their
grandchildren some day.
3
Trauma-Responsive System
Trauma-Informed Practice and NC Child Welfare Policy
The increasing emphasis on being trauma-informed can feel like pressure to add another complex dimension to child
welfare practice. However, child welfare policy in North Carolina already emphasizes a number of practices that are in
line with research recommendations about minimizing the effect of trauma. With the introduction of Multiple Response
System (MRS), and with federal laws passed in recent years, child welfare practice has increasingly emphasized partner-ing
with families, listening to the voices of children and youth, and building and maintaining healthy connections. These
are all trauma-informed activities and approaches. They’re also already part of your everyday practice with families. The
table below highlights North Carolina policies that align with key trauma-informed child welfare activities. 
Activity Related NC Policies* Trauma-Informed Implementation
Maximize
child’s
sense of
safety
Safety Planning
Coordinate
services
with other
agencies
Child and Family
Team Meetings
Permanency
Planning
Action Teams
Use
comprehensive
assessment of
child’s trauma
history to guide
services
CME/CFE
Strengths/Needs
Assessment
Individualized case
planning
Support
and promote
positive,
stable
relationships
Provide support
and guidance to
child’s family/
caregiver
Involving family in
case planning
Individualized foster
parent training and
development
Child welfare staff are strongly encouraged to involve parents and their chil-dren
in safety planning, and to ask questions that help the child describe their
concerns and fears as well as the things that help them feel safe. “Seeking first
to understand” and taking the “not knowing stance” are also part of under-standing
the safety needs and protective factors in families.
CFTs are one of the most important techniques we have for coordinating ser-vices.
Time spent preparing families, community partners, and others for CFTs
is essential. Talk early and often about CFTs; have conversations about who
will be helpful to have on the team. DSS agencies should be proactive about
educating community partners about CFTs on an ongoing basis. This can help
spread System of Care (SOC) values, which in turn ensure communities know
what the needs are and so take action to get them met.
NC policy requires us to engage children as part of assessments during the
provision of CPS services and throughout their involvement with DSS. Particu-larly
in family assessments, the focus should be on getting the big picture,
which includes the child’s history. Some county DSS agencies find it helpful to
consistently ask children a few simple questions to ensure that their trauma
histories are fully explored and appropriate services are provided. Child Medi-cal
and Child/Family Evaluations also gather trauma history information to
guide supportive interventions for children and families.
Placement priorities
Visitation plans
Sibling placement and
visits
Family notification
Reunification efforts
Shared Parenting
LINKS goal
Use of Life Books
Identifying and supporting positive, stable relationships for children is a theme
that runs throughout NC policy, from looking diligently for absent parents, to
prioritizing placements and frequent visitation with siblings and other kin, to
the LINKS goal of ensuring young people leaving foster care have a personal
support system of at least five caring adults in addition to professional rela-tionships.
It is possible to do the Safety Assessment in the family’s presence without
doing it “with” them. The “to, for, and with” frame taught in courses such as
CPS Assessments effectively engages and empowers all family members to
take part in planning for their own safety and well-being.
Involvement of foster parents and other substitute caregivers in CFTs and
shared parenting is an excellent way to ensure they have the information they
need to meet the needs of children in their care. Creating and actively sup-porting
individualized foster parent training and development plans is another
way to ensure they see children’s behaviors through a “trauma lens” and have
the skills they need to respond appropriately.
*This is not a comprehensive list. NC’s full child welfare policy can be found at <http://info.dhhs.state.nc.us/olm/manuals/>.
4
Collaborating to Improve Mental Health Services for Children Involved
with CPS: One DSS Director’s Perspective
A Conversation with Richmond County’s Robby Hall
Robby Hall, social services director in
Richmond County, NC, and his staff
have been working closely with men-tal
health providers, Sandhills Center
(their managed care organization,
or MCO), and community partners
to improve mental health access and
treatment for the children they serve.
Practice Notes recently spoke with
him about what this effort has accom-plished.
What is your approach or process to
partnering with mental health?
As a system we really need to focus
on the mental health treatment type
or intervention level that children
involved with child welfare receive. To
make a difference, we want to do this
for all children, especially those who
have been screened in by CPS but are
still in the home.
By providing targeted, front-loaded
services early on, we’re trying to meet
families’ needs so we can avoid fos-ter
care placement and reduce the
chance they’ll come to the attention of
CPS in the future.
How did your agency manage to
increase access to mental health
assessments and treatment for the
children you serve?
We began by holding a provider
meeting where we explained our
needs related to community mental
health access to our providers.
Eventually this led us to offer to
host two of our providers on-site at
our agency (i.e., co-locate). Under
our agreements with them we provide
office space, equipment, and take
care of their scheduling. It’s a great
arrangement: we now have on-site
therapists who do screening, assess-ments,
and treatment.
We’ve also heard you’re using
something called TOP . . .
Yes. Through funding from The Duke
Endowment, we have a project with
the nonprofit Kids Insight. With them
we’re using the Treatment Outcome
Package, a web-based assessment
tool that allows us to track child well-being
from the perspective of the
child, foster parent, biological parent,
GAL, and therapist. The information
can then be used in child and family
team meetings and for permanency
and treatment planning.
In the second phase of this project
we can look at all the children’s well-being
outcomes and see which treat-ments
or providers they had so that
we can match future children, based
on need, to the provider or treatment
that will serve them best. For example,
I might have one provider who does
great with teenagers and another who
does better with young children.
With the kind of data we get from
TOP, where a child receives treatment
can be tailored to the child’s needs
and the provider’s strengths.
How have providers reacted?
At first I was nervous about how they’d
respond. But I’ve done performance-based
contracting before, and provid-ers
left the meeting excited about the
possibilities of serving children better
and excelling within their sphere of
greatest ability.
We also showed them how com-pleting
the TOP assessment would
only take them a few minutes per
child. Plus, our agency is footing the
bill for it. This helps incentivize evi-dence-
based programming, which we
all want to see offered.
How will you continue using TOP?
We’re looking for other counties to
partner with so we can contract with
providers on a larger scale. Larger
contracts allow for cost savings that
will enable long-term sustainability.
How are you partnering with your
MCO?
When I first started as director in Rich-mond
County I met with Sandhills
Center directly, and I continue to meet
with them. They’re open and respon-sive.
I try to meet face-to-face with
their director as needed.
Have you engaged other players?
Absolutely. We’ve held collabora-tive
meetings with other community
stakeholders such as law enforcement
and school administrators. By having
directors or leaders of these organi-zations
at the table we can stream-line
decision making. This is better
than having lots of different front line
staff from the different organizations
contacting each other and trying to
address issues case by case. Since
county commissioners are on the
boards of the MCO, they sometimes
help arrange meetings.
We’ve also partnered with Commu-nity
Care of the Sandhills—the health
network that connects Richmond
County to Community Care of North
Carolina (CCNC)—to implement tele-psychiatry.
We’re using this approach
for screening and diagnostics in rural
areas to reduce wait times and bring
down costs. The main focus is on
screening children and starting treat-ment
sooner so we can reduce hos-pitalizations
for acute needs. We have
funding for telepsychiatry through
October 2016. Sandhills MCO has
begun talks with Richmond County
DSS around TOP, on-site mental health
services, and telepsychiatry. 
5
Learn More
Treatment Outcome Package (TOP)
is a patented behavioral health
assessment tool children for ages
3 and up that measures social and
emotional well-being over time.
TOP is available through Kids
Insight, a child welfare-focused
nonprofit supported by the Annie
E. Casey Foundation and The Duke
Endowment. To learn
more about TOP and
Kids Insight, visit
http://kidsinsight.org
The North Carolina Child Treatment Program
Helping Child Welfare Professionals Find the Right Mental Health Treatment for Every Child
Child welfare professionals spend
a lot of time trying to navigate the
mental health system on behalf of
families. Most of us have heard the
phrase “evidence-based treatment
models,” or EBTs. We realize there are
mental health treatments out there
that could make significant improve-ments
in children’s lives, but there are
challenges in accessing EBTs: how do
you know which treatments are likely
to help a particular child? And how
do you find the right kind of provider
when you need one?
The North Carolina Child Treat-ment
Program (NC CTP) is a tool that
can help you connect with EBT provid-ers
in your county. Founded in 2006,
the NC CTP is focused on dissemina-tion
of evidence-based mental health
treatments for infants, children, and
adolescents coping with attachment
difficulties, psychological trauma,
traumatic bereavement, and behav-ioral
challenges. This focus makes NC
CTP a useful partner for county DSS
agencies. And conversely, DSS child
welfare social workers are critical to
NC CTP realizing its mission.
Fidelity Matters
When looking for a specific evidence-based
treatment model, it’s important
to find a clinician who provides the
model with fidelity, meaning as the
model was designed and tested.
For example, one of the most well-studied
and effective interventions
for children who have experienced
trauma is Trauma-Focused Cognitive
Behavioral Therapy (TF-CBT). There
have been at least 12 randomized
controlled trials that have shown bet-ter
outcomes for children and youth
who receive TF-CBT compared to
other types of treatment or to no treat-ment
(NCTSN, 2012). To have the
best chance of improved outcomes,
you want to be sure the clinician is
providing TF-CBT with fidelity—that
is, in the same way it was provided in
those studies.
To ensure clinicians provide EBTs
with full fidelity, NC CTP provides
learning collaboratives that last from
one to two years, depending on the
model. Clinicians participate in mul-tiple
day-long trainings and also
receive intensive case consultation.
Those who successfully complete a
collaborative are included on a ros-ter
that can be searched by county at
http://ncchildtreatmentprogram.org/
TF-CBT in North Carolina
TF-CBT learning collaboratives have
been taking place since 2006. There
are currently 373 rostered TF-CBT
clinicians practicing across the state.
Each month new clinicians complete
the learning collaborative require-ments
and become rostered, so be
sure to check the site
What Is Evidence-Based Treatment?
The Society of Clinical Child and Adolescent Psychology
(2016) uses a concise definition of evidence-based treat-ments:
“treatments with scientific evidence supporting
them.” Other organizations and sites use different crite-ria
to determine when there is enough evidence to consider a treatment evidence-based,
or to rank treatments based on the amount of evidence available. You
can find the criteria used by California Evidence-Based Clearinghouse for Child
Welfare here: http://www.cebc4cw.org/ratings/scientific-rating-scale/
continued next page
6
Number of Rostered TF-CBT Clinicians in May 2016, by NC County
Source: NC Child Treatment Program, 2016
7
regularly. The map on the previous
page shows the number of rostered
TF-CBT clinicians in each county as of
May 2016.
Children age 3-21 who have expe-rienced
traumatic grief or other forms
of trauma may benefit from TF-CBT.
This therapeutic model helps clients
develop the skills to tolerate their
trauma memories and manage their
symptoms. It also helps clients change
how they view themselves, their his-tory,
and the world, allowing them
to reduce symptoms, heal, and build
resilience.
What about Younger Kids?
To participate in TF-CBT, children and
teens need to be able to remember
and verbally describe their experi-ences.
A common challenge for the
child welfare system is that the largest
category of children served is those
from birth to age 5 (Duncan, et al.,
2016). Many of these children are too
young or don’t yet have the verbal or
cognitive skills needed for TF-CBT.
In the past, many people believed
infants and young children were too
young to be affected by traumatic
experiences or exposure to chronic
stress. However, we now know young
children experience the effects of
trauma well before they are able to
describe what’s happening to them.
And of even greater concern, we know
that early childhood trauma has a sig-nificant
impact on children’s ability to
securely attach to their primary care-givers,
which in turn can significantly
affect their emotional and cognitive
development (NCSTN, 2010).
One of the most exciting develop-ments
in North Carolina’s mental
health system is the spread of an evi-dence-
based treatment model specifi-cally
for children from birth to age 5.
Child-Parent Psychotherapy (CPP)
was developed by psychologists Ali-cia
Lieberman and Patricia Van Horn.
The treatment is designed for infants
and children who have experienced
trauma or significant stress, or whose
parents have significant stress or his-tories
of trauma. In other words, it is
a model with the potential to meet the
needs of many families served by the
child welfare system.
CPP recognizes that the parent-child
relationship is the most impor-tant
factor in a young child’s life,
as well as the greatest source of
long-term healing and support. As
a result, CPP focuses on the parent-child
dyad, seeking to create a secure
attachment and a caregiver who can
remain attuned to and be protective
of the child even in the face of adver-sity.
Studies of CPP show that it has
been successful in reducing symptoms
NC CTP Treatment Models: The Basics
Trauma-Focused Cognitive Behavioral Therapy
• Rated as “1-well-supported by research evidence” and highly
relevant to child welfare by the California Evidence-Based
Clearinghouse for Child Welfare (CEBC, 2016)
• For children ages 3-21 who have experienced traumatic grief or other
forms of trauma
• Up to 24 weekly, 60-90-minute sessions; caregiver and child seen sepa-rately
and together
• Outcomes:
– Improvement in PTSD symptoms, depression, anxiety symptoms,
externalizing behavioral problems, sexualized behavior problems,
shame, trauma-related cognitions, interpersonal trust, and social
competence (NCTSN, 2012)
Child-Parent Psychotherapy (CPP)
• Rated as “2-supported by research evidence” and highly
relevant to child welfare by the California Evidence-Based
Clearinghouse for Child Welfare (CEBC, 2016)
• For children 0-5 years with symptoms resulting from:
– Trauma or significant stressors, OR
– Parents with trauma histories or significant stressors
• Up to 50 weekly, 1-hour sessions; caregiver and child generally seen
together but parent seen individually on occasion
• Outcomes:
– Children: reductions in behavior problems, traumatic stress symp-toms,
PTSD and depression diagnoses, and co-occurring diagno-ses;
improvement in sense of self and feelings about caregiver
– Parents: reductions in PTSD and depression symptoms
– Parent-child relationship: improved attachment
Sources: Lieberman, Van Horn, & Ghosh Ippen, 2005; Lieberman, Ghosh Ippen, & Van
Horn, 2006; Ghosh Ippen, Harris, Van Horn, & Lieberman, 2011
in both parents and children, and in
strengthening attachment (see above).
A new CPP learning collaborative
will begin in fall 2016. This means
clinicians may be able to accept refer-rals
from county DSS agencies before
the end of 2016. Keep your eyes
on the NC CTP website (www.ncchi-ldtreatmentprogram.
org) for more
information.
Child welfare and mental health
professionals often find each other’s
systems challenging to understand
and navigate. Working together, DSS
and NC CTP can serve as a bridge,
helping to find the right treatment and
the right provider for each child. 
TF-CBT
CPP
NC CTP continued from previous page
Evidence-Based Practices in Children’s Mental Health
The chart below, reprinted from a guide from the National Alliance for Mental Illness (2007), provides a quick
reference for evidence-based psychosocial interventions by diagnosis for children and adolescents. It also lists the
medications commonly prescribed for children and adolescents with mental illness by diagnosis.
Information in the chart is based on reviews by Burns, Chorpita, Chambless and Halloran, Hoagwood, Jensen, Weisz, and the authors
of the NAMI Guide (2007).
* Generally, there is limited research on children’s medication use, but more research exists on the utilization of ADHD medication.
** The Food and Drug Administration (FDA) has issued a “black box” warning about the increased risk of suicidal thoughts and behav-iors
in youth being treated with antidepressant medications.
8
Partnering for Excellence
Working to Improve Services and Outcomes for Children and Families Affected by Trauma
As this issue shows, a lot of energy
is being put into trying to improve
outcomes for children and families
involved with the child welfare system
in North Carolina, especially those
who have experienced trauma. Part-nering
for Excellence (PFE), a Duke
Endowment-funded effort in Rowan
County, is another great example.
History and Goals
Partnering for Excellence began in
2012 when The Duke Endowment
provided funding to Benchmarks,
an alliance of nationally-accredited
human service agencies in North Car-olina,
to redesign the way the child
welfare and mental health systems
interact to:
• Provide trauma-informed services
to support improved child and
family outcomes;
• Reduce costs by helping both sys-tems
avoid unnecessary use of
high-end services; and
• Reduce the need for future CPS
involvement in families currently
receiving child welfare services.
The pilot of PFE got off the ground in
July 2013 in Rowan County, where the
department of social services (DSS);
Cardinal Innovations, the county’s
mental health managed care orga-nization
(MCO); and private men-tal
health providers have been col-laborating
to increase their focus
on trauma and the use of evidence-based
practices. The Center for Child
and Family Policy at Duke University is
evaluating the PFE pilot.
The Model
PFE is a different way of doing busi-ness
for agencies serving child wel-fare-
involved children ages 5-17 and
their families. Key elements of the PFE
approach include the following.
Initial Trauma Screens. In Rowan
County, DSS workers screen all chil-dren
entering CPS in-home and
permanency planning services for
trauma exposure. Capitalizing on
the good work being done elsewhere
in the state, they do this using the
trauma screening tool developed by
Project Broadcast. This is a one-page
questionnaire completed by the DSS
child welfare worker after talking with
the child, birth parents, foster parents,
and any other relevant sources of
information about the child.
To date, 90% of young people
screened by Rowan DSS as part of
PFE have experienced some kind of
trauma. Among children in DSS cus-tody,
every single one (100%) has
screened positive for trauma (Bench-marks,
2016).
Trauma-Intensive Comprehensive
Clinical Assessments (TiCCAs). After
screening, DSS refers all children with
trauma histories for a TiCCA. These
in-depth evaluations are done by spe-cially
trained private mental health
providers. The goal of a TiCCA is to
fully understand what the child has
experienced and how those experi-ences
have affected and are continu-ing
to affect the child and family.
To conduct a TiCCA, a provider
must be trained to deliver Trauma-
Focused Cognitive Behavioral Therapy
(TF-CBT) and have an additional day
of training in case conceptualization.
PFE clinicians include in the TiCCA
holistic recommendations that discuss
not only the child’s needs for men-tal
health treatment but also school,
parenting, pro-social behaviors, and
anything else that may be needed.
Integrated Child Plan. The TiCCA
helps DSS and its partners start out on
the same page. DSS can incorporate
information from this assessment into
the family services agreement. Just as
importantly, it uses this information to
make referrals to (and advocate for)
the right services and an appropriate
model of care for each child. Guided
by TiCCA results, the MCO can
authorize needed services right from
the start. Appropriate services help
children heal from trauma and learn
coping skills, which have the potential
to help them stay in their own homes,
stabilize placements, continued next page
• TiCCA is
integrated into
the Family
Services
Agreement
through the
child and
family team
• DSS
strengthens
focus on:
– Youth
well-being
– Coaching
CFT
facilitators
– Referrals to
evidence-based
treatment
whenever
available
DSS
Screening
• DSS social
workers screen
for trauma in
youth ages 5 to
17 in In-Home,
Permanency
Planning, and
cases of abuse
• Children who
screen positive
for trauma
or enter DSS
custody are
referred for a
TiCCA
• Children
age 0 to 5
are referred
to CC4C
through the
Public Health
Department
for trauma and
developmental
screenings
Mental
Health
Assessment
• Specially
trained TF-CBT
clinicians use
a protocol and
template for
assessment
• Focus on
primary and
secondary
trauma
• Use of
collaterals
• Holistic,
trauma-informed
rec-ommendations
with a focus on
model and not
just level
• Enhanced rate
and privileging
through the
LME/MCO
Integrated
Child
Plan
Quality
Service
Array
• PFE team
works to
ensure
families
access quality,
evidence-informed
or
evidence-based
front
end services
in their
community
• Collabora-tive
vision of
a front end
service array
• Focus on
trauma
training and
increased
clinical
support for
those who
care for
children
Effective
Care
Management
• DSS, resource
parents, the
LME/MCO,
and private
providers
engage in
activities
to improve
communication,
coordination,
and monitoring
of child and
family
treatment
The Partnering for Excellence Model
9
or expedite permanency.
Quality Service Array. PFE has
Rowan DSS, Cardinal, and mental
health providers talking about what
else the community needs to serve
families better. In addition to expand-ing
the number of local TF-CBT pro-viders,
since PFE began Rowan has
added new parenting courses. The
idea is to create a community that is
trauma-informed, trauma-aware, and
trauma-responsive.
Effective Care Management. A
very important dimension of PFE is
the model’s emphasis on the need for
those serving DSS-involved families
to work together to improve commu-nication,
coordination, and monitor-ing
of child and family treatment. This
requires a lot from all parties, includ-ing
building a strong foundation by
attending training together, more for-mal
agreements (such as memoran-dums
of understanding), and com-mitting
to participation in ongoing
collaborative meetings.
Many of those involved have con-cluded
the added effort is worth it
because it helps the mental health
and child welfare systems under-stand
each other and their interde-pendence.
As one stakeholder put it,
“From a systematic view, you can’t do
child welfare without mental health
partnering” (Benchmarks, 2016).
PFE Outcomes
It’s too early in the evaluation of the
PFE pilot to talk about the extent to
which this effort can help communities
achieve the project’s long-term goals
of improving child and family out-comes,
avoiding unnecessary high-end
services, and reducing repeat
child maltreatment. That said, pre-liminary
evaluation results comparing
children before and after PFE came to
Rowan County seem promising.
For example, as Figure 1 shows,
since the start of PFE there has been a
decrease in the percentage of young
people diagnosed with ADHD and
conduct disorder, while the number
diagnosed with PTSD has increased.
One explanation for this change is
that because providers now have
more information about trauma histo-ries,
they see children’s symptoms and
behaviors in a new light.
PFE also seems to be having an
effect on the mental health services
DSS-involved children receive. As
Figure 2 shows, since PFE, more chil-dren
are being assessed and, perhaps
because TiCCAs are so thorough,
more are receiving outpatient thera-pies
such as TF-CBT.
What’s Next
Evaluators will continue to collect infor-
30%
Figure 1 Diagnoses for
Rowan County Children Eligible for PFE
25%
20%
15%
10%
5%
0%
ADHD Conduct Disorder PTSD
Figure 2
Mental Health Service Types for
Rowan County Children Eligible for PFE
50%
40%
30%
20%
10%
0%
Assessment Outpatient Therapy
mation to better understand whether
PFE ultimately has the desired impact.
In the meantime, Benchmarks and its
partners, with the continued support
of The Duke Endowment, are begin-ning
to work with additional coun-ties.
Cleveland County Department of
Social Services and its MCO, Partners
Behavioral Healthcare, started imple-menting
the PFE model earlier this
year, and the project will likely add at
least one more county in the next year.
To Learn More about PFE
For more information, contact Jenny
Cooper, the Partnering for Excellence
Project Director, at jcooper@bench-marksnc.
org. 
PFE continued from previous page
10
NC’s Five-County Project: Strategies for Successful Collaboration
between Child Welfare and Mental Health
Ensuring the safety, permanence, and
well-being of children is too big a job
for one agency or one service system
alone. Success depends on our ability
to collaborate across multiple sectors.
Fortunately, there are many groups
in North Carolina working to better
coordinate services to children and
families involved with child welfare.
The Five-County Project, which is
active in Franklin, Granville, Halifax,
Vance, and Warren counties, is one
such effort.
The Five-County Project
The Five-County Project seeks to
strengthen the system of services and
supports for children with behavioral
health care needs. The team for this
project is made up of representatives
from the five county DSS agencies,
Cardinal Innovations Healthcare (the
area’s MCO), schools, juvenile justice,
and mental health providers.
After it began in 2013, this mul-tidisciplinary
team went through a
process of reviewing data, identifying
problem areas, and prioritizing strat-egies
to increase placement stability
for children in care. In the hope of
supporting other cross-organizational
efforts, here are some strategies this
team has found useful on its journey.
Strategy 1
Identify and focus on a goal with
mutual importance
Most parties working with children in
child welfare are involved because
they care deeply about the well-being
of children. It is important to remem-ber
that, although we have different
roles across organizations, everyone
is here for similar reasons.
EXAMPLE: After reviewing relevant
data, DSS agencies from the five
counties and their managed care
organization (MCO) agreed reducing
placement disruptions was an impor-tant
shared concern. They reached
this conclusion because they all under-stood
the harmful impact disruptions
can have on children. Additionally,
everyone had other “pain points” that
placement disruptions contributed to,
including:
• Missed state permanency goals
• Long evenings or working on
weekends
• Foster parent turnover
• Strained relationships with other
parties (DSS, MCO, providers)
over finding a new placement
• Financial costs of moving a child
• Delays in payment approval, etc.
Although it is necessary and helpful
to acknowledge these very real chal-lenges,
the group found that frequent
reminders about their primary goal
kept them from getting sidetracked by
struggles with these “pain points.”
Strategy 2
Develop an understanding of each
organization’s role
DSS, MCOs, and providers all serve
the same children, but they each have
different legal and policy drivers, and
may use different terms to discuss the
same issues. Understanding every-one’s
legal and policy constraints
helps collaborative groups brainstorm
viable solutions instead of blaming
each other for the dysfunction.
EXAMPLE: One of the first things
the Five-County team did was map
each organization’s process for refer-ring
children to receive mental health
assessments and services. This “pro-cess
mapping” revealed differences in
language, documentation, and child
and family team (CFT) requirements.
This, in turn, helped the team zero in
on gaps and identify ways to improve
processes.
Strategy 3
Play to your strengths using small
groups
Everyone involved in a cross-system,
collaborative project needs a deep
understanding of the problem, the
desired outcomes, and the “big” action
items needed to achieve those out-comes.
For this you need a big group.
Once a solution is identified, how-ever,
you need small groups focused
on specific tasks. The composition of
these small groups matters. So do the
parameters of their work: the larger
group must always have an opportu-nity
to provide feedback and input on
small group efforts. Communication
must be two-way.
EXAMPLE: At the beginning of the
project the team collected, analyzed,
and discussed data related to place-ment
stability to help it decide about
goals, outcomes, and action steps.
However, it did not use a small group
to assist with this. As a result, the pro-cess
took an unnecessary amount of
time and frustrated group members,
who were ready to move forward with
action planning. A lesson learned here
was that the process of data mining
would have been better delegated to
a small group while the larger group
focused on other tasks. 
The Five-County Project
Launched: 2013
Goal: Strengthen services and supports for chil-dren
with behavioral health care needs in Franklin,
Granville, Halifax, Vance, and Warren counties
Facilitator: Jordan Institute for Families at UNC
School of Social Work
Participants: DSS agencies in the five counties, Cardinal Innovations
Healthcare, schools, juvenile justice, and mental health providers
Status: The strengthening of relationships across organizations has
allowed for action planning in focus areas targeted at impacting place-ment
stability
To Learn More: Contact Sarah Marsh, MSW (marshs@email.unc.edu)
11
12
References for this Issue
(Children’s Services Practice Notes, v. 21, n. 3 • www.practicenotes.org)
Benchmarks. (2016). Partnering for excellence: An innovative model for child and family well-being
[monograph]. Raleigh, NC: Author.
California Evidence-Based Clearinghouse for Child Welfare. (2016). Retrieved 5/18/16 from
http://www.cebc4cw.org
Duncan, D. F., Kum, H. C., Flair, K. A., Stewart, C. J., Vaughn, J. S., Guest, S., Rose, R. A.,
Gwaltney, A. Y., & Gogan, H. C. (2016). Management assistance for child welfare, work
first, and food & nutrition services in North Carolina (v3.2). Retrieved 5/18/16 from the
University of North Carolina at Chapel Hill Jordan Institute for Families website. URL:
http://ssw.unc.edu/ma/
Ghosh Ippen, C., Harris, W. W., Van Horn, P., & Lieberman, A. F. (2011). Traumatic and
stressful events in early childhood: Can treatment help those at highest risk? Child Abuse
and Neglect, 35, 504-513.
Lieberman, A. F., Ghosh Ippen, C., Van Horn, P. J. (2006). Child-parent psychotherapy: Six
month follow-up of a randomized control trial. Journal of the American Academy of Child
and Adolescent Psychiatry, 45(8), 913-918.
Lieberman, A. F., Van Horn, P. J., & Ghosh Ippen, C. (2005). Toward evidence-based
treatment: Child-parent psychotherapy with preschoolers exposed to marital violence.
Journal of the American Academy of Child and Adolescent Psychiatry, 44, 1241-1248.
National Alliance for Mental Illness. (2007). Choosing the right treatment: What families need
to know about evidence-based practices. Arlington, VA: Author. Retrieved April 15, 2010
from http://www.nami.org.
National Child Traumatic Stress Network. (2010). Early childhood trauma. Los Angeles, CA &
Durham, NC: Zero to Six Collaborative Group, National Center for Child Traumatic
Stress.
National Child Traumatic Stress Network. (2012). TF-CBT: Trauma-focused cognitive
behavioral therapy fact sheet. Retrieved 5/21/16 from
http://www.nctsn.org/sites/default/files/assets/pdfs/tfcbt_general.pdf
Oxford University Press. (2016). Oxford dictionaries. Retrieved 6/01/16 from
http://www.oxforddictionaries.com/
Putnam, F., Harris, W., Lieberman, A., Putnam, K. & Amaya-Jackson, L. (2015). Opportunities
to change the outcomes of traumatized children: The childhood adversity narratives
[presentation]. Durham, NC: Authors. Retrieved 6/01/16 from http://bit.ly/1ZdB8lv.
Society of Clinical Child and Adolescent Psychology. (2016). What is evidence-based practice?
Retrieved 5/18/16 from http://effectivechildtherapy.org/content/what-evidence-based-practice