Form ETSC_Providers

Form Approved

OMB No. 0930-0276

Exp. Date:xx-xx-xxxx

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is_____. Public reporting burden for this collection of information is estimated to average __ minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

Evaluation of the National Child Traumatic Stress Network

EBP AND TRAUMA-INFORMED PRACTICE AND SYSTEM CHANGE SURVEY

PROVIDER VERSION

Survey Index Page

Thank you for agreeing to participate!

Navigating the Survey:

This page is called the Survey Index. To complete the survey, you will be guided through the following four sections (i.e., sections A., B., C., D., and E. listed below). Once you begin work on any section, the section headings below will become hyperlinked. You may leave the survey at any time and return to complete it. When you return to the Survey Index, you will be able to click on a section heading on this page and go directly to that section of the survey. As you navigate the survey, use the “Back” button or click “Save and Return to Survey Index” to return to a previous section.

1. Background

2. Trauma-Informed Systems and Practices

3. Provider Practice Impact

4. Organizational Impact

5. Clinical Practice Impact

If you would like to skip a question to obtain additional information, you may do so; you will receive a warning message once regarding incomplete responses, and then will be allowed to move forward. One question is considered mandatory for survey completion (this question is identified by a + symbol). This survey will “time-out” eight hours after the last point at which you saved your responses. If the survey times out, you will be able to access the survey again using the same login and password, unless you have submitted the survey. Once the survey is submitted, you will not be able to access the survey again.

Reminder: Please be assured that all responses are kept confidential. We will not match names to individual responses or to any of the survey data. Please feel free to be as open and honest in your answers as possible.

Part A: Background

1. Today’s Date:  /  / 

Month Day Year

2. Please identify the National Child Traumatic Stress Network (NCTSN) centers you have collaborated with or received training from. Select all that apply.

INSERT PULL-DOWN MENU OF ALL CURRENTLY-FUNDED
AND AFFILIATE CENTERS

3. Name of agency, center or organization by which you are employed:

4. Please select the service system(s) listed below that your agency, center or organization represents (please consider the primary types of services that are provided and select all of the systems below that apply)

Direct Mental Health Services

Child Welfare (including foster care)

Education

Juvenile Justice

Primary Health Care

Other (specify):

Part B: Trauma-Informed Systems and Practices

SAMHSA states that trauma-informed services are designed to 1) reduce the impact of trauma on children/adolescents through screenings, assessments, referrals, supportive services, outreach, crisis response; 2) train service providers around specific services or interventions; and/or 3) implement service system changes to improve delivery of trauma treatment and services. Trauma-informed services also include interventions that target service providers such as informing them of the impact of trauma in their service populations and/or improving their response to traumatized children/adolescents.

However, there is currently no consensus as to what exactly being “trauma-informed” means for different types of systems. To better understand the current behaviors of various child-serving systems, we are asking a series of questions about policies and procedures in the following sections of this survey.

Screening for Trauma

Please read the statements below and indicate the one statement that best describes the screening procedures at your agency, center or organization

1. All children are screened (quickly, but systematically, assessed) for trauma exposure at intake/entry into services

2. Children are screened when there is information or concern that they have had trauma exposure

3. Children who self-report having experienced a trauma are formally screened for trauma exposure

4. Children are screened at the discretion of a professional at/involved with our agency/organization. (teacher, counselor, caseworker, PO, therapist, etc.)

5. Other (please describe):

Please indicate if the screening procedure at your agency, center or organization involves using a:

1. Screening measure with a few questions on trauma

2. Trauma-specific screening measure

Assessing Trauma Impact

Please read the statements below and indicate the one statement that best describes the assessment procedures at your agency, center or organization

1. All children are screened for trauma exposure, and if they screen positive for one or more traumas they are assessed for trauma impact (psychological injuries caused by exposure to trauma)

2. Children are assessed for trauma impact when there is information/concern that they have been exposed to trauma

3. Children who self- report having experienced a trauma are assessed for trauma impact

4. Children are assessed for impact at the discretion of a professional at/involved with our agency/ organization (teacher, counselor, caseworker, PO, etc.)

5. Other (please describe):

Trauma-informed Services Referral and Provision

Please read the statements below and indicate the one statement that best describes the trauma-informed services referral and service provision procedures at your agency, center or organization

1. All children assessed positive for trauma impact are assigned to trauma-specific services with a trained provider who is on staff at our agency

2. Children assessed positive for trauma impact are referred out for trauma-specific services from a trained provider

3. Children assessed positive for trauma impact receive/are referred for trauma-specific services from a trained provider at the discretion of a professional at or involved with our agency (teacher, counselor, caseworker, PO, etc.)

4. Our agency does not play a specified role in connecting youth with trauma-specific services from a trained provider

5. Other (please describe):

In the previous section, we described trauma-informed services as “services that are designed to 1) reduce the impact of trauma on children/adolescents through screenings, assessments, referrals, supportive services, outreach, crisis response; 2) train service providers around specific services or interventions; and/or 3) implement service system changes to improve delivery of trauma treatment and services. Trauma-informed services also include interventions that target service providers such as informing them of the impact of trauma in their service populations and/or improving their response to traumatized children/adolescents.”

Given this definition, please tell us:

1. If the services and treatments you provide currently in your agency, center or organization are not trauma-informed, what do you believe are the reasons for this?

2. From your perspective, what are the barriers to providing trauma-informed services/treatments in your agency, center or organization?

3. What are the facilitators to providing trauma-informed services/treatments in your agency, center or organization?

____________________________________________________________________________________

4. What is involved in transforming your agency, center or organization to ensure that it is trauma-informed?

____________________________________________________________________________________

Part C: Provider Practice Impact

Please answer the below questions thinking about clinical practice at your agency, center or organization. Rate your agency from 1= not at all true for my agency to 5 = completely true for my agency on your perspective of clinical practice related to trauma-informed services at your agency.

In my agency, center or organization*:

1. Providers receive ongoing trauma-informed services training opportunities and ready access to trauma-focused services materials (manuals, handouts).	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable
2. My supervisor actively supports implementation of evidence-based trauma-informed services.	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable
3. Quality assessment/treatment adherence monitoring (e.g., adherence checklists, session recording review, collection of and review of outcomes, training in the agency) are consistently used to improve our services.	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable
4. Providers who use trauma-informed services are rewarded.	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable If “A little true” or more, please check all that apply below: specific case/reimbursement rate recognition in the organization financial incentives (raise or promotion) reduction in productivity requirement other: ________________________

*Modified from the Berliner, Kolko, & Dorsey Organization Checklist

Part D: Organizational Impact

Please rate the following statements regarding your agency, center or organization as it currently operates. Your rating will help us understand your perception of trauma-informed system change. Rate your agency from 1= Not at all true for my agency to 5 = Completely true for my agency on your perspective of clinical practice related to Trauma-Informed Services (TIS) at your agency/organization.

In my agency, center or organization*:

1. Written policy is established committing to trauma-informed practices	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable
2. The agency has a formal system for reviewing whether staff are using trauma-informed practice	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable
3. There is system of communication in place with other agencies working with the child for making trauma-informed decisions about the child or family	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable
4. There are structures in place to support consistent trauma-informed responses to children and families across roles within the agency	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable
5. Families and children are given systematic opportunities to voice needs, concerns, and experiences	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable
6. The agency has a system in place to develop/sustain common trauma-informed goals with other agencies	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable
7. Understanding of impact of trauma is incorporated into daily decision- making practice at my agency	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable
8. Supervision at my agency includes ways to manage personal and professional stress	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable
9. Trauma-informed safety plans are written/available for each child (i.e., triggers, behaviors when over- stressed, strategies to lower stress, support people for child)	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable
10. Staff receive supervision from a supervisor who is highly knowledgeable about, and skilled in the use of, trauma-informed services	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable
11. Timely trauma-informed assessment is available and accessible to children served by my agency	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable
12. A continuum of trauma-informed intervention is available for children served by my agency.	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable
13. A child’s definition of emotional safety is included in treatment plans at my agency.	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable
14. The prevention of secondary trauma is included in trainings for all employees, including new employee orientation	1 = Not at all true for my agency 2 = A little true for my agency 3 = Somewhat true for my agency 4 = Mostly true for my agency 5 = Completely true for my agency 6 = Not applicable

* Southwest Michigan’s Children’s Trauma Assessment Center; Richardson, Coryn, Henry, & Unrau (2010)

NOTE: Complete the following section only if you provide direct mental health treatment services at your agency, center or organization. If you do not, skip to End

Part E: Clinical Practice Impact

Please answer the following questions* thinking about your clinical practice at the agency, center or organization where you are currently providing services.

1. In the past month, what was the total number of clients on your caseload? (Please include all clients seen at least ONCE during the past month.)	Enter a number between 0 and 100. ______
2. In my first one to two meetings with a new client, I directly ask the child and/or the child’s caregiver about the child’s exposure to traumatic events.	1 = Never 2 = Rarely 3 = Occasionally 4 = Regularly 5 = Almost always
3. I use standardized measures or questionnaires to identify and measure specific clinical conditions (depression, PTSD, ADHD, behavior problems). Which of the following assessment measures did you administer to at least one client during the past month? In the past month, with how many cases did you PERSONALLY administer at least one of the measures?	1 = Never 2 = Rarely 3 = Occasionally 4 = Regularly 5 = Almost always (Please check all that apply) (Pull down list of assessments) Enter 0 (zero) if you administered no measures:_________________
4. I re-administer standardized measures or questionnaires to continue measuring the specific clinical conditions (depression, PTSD, ADHD, behavior problems) to inform decisions about treatment (intensity, focus, type) and end of treatment.	1 = Never 2 = Rarely 3 = Occasionally 4 = Regularly 5 = Almost always
5. I give verbal or written feedback about my diagnostic or clinical impressions to the child and/or the child’s caregiver and establish agreement on the problems to address in treatment.	1 = Never 2 = Rarely 3 = Occasionally 4 = Regularly 5 = Almost always
6. I provide information about the evidence-based treatment options for that condition/problem. For example, I might provide a handout and/or discuss key features of the problem and key features of the treatment.	1 = Never 2 = Rarely 3 = Occasionally 4 = Regularly 5 = Almost always
7. When I perceive a lack of engagement , I routinely use a specific set of methods to: Problem-solve barriers to treatment (concrete obstacles to attendance, problems completing homework, negative attitude towards treatment) address ambivalence about treatment motivation (e.g., rating importance of change, decisional balance exercise, articulation of the pro’s/con’s of treatment involvement)	1 = Never 2 = Rarely 3 = Occasionally 4 = Regularly 5 = Almost always 1 = Never 2 = Rarely 3 = Occasionally 4 = Regularly 5 = Almost always
8. I routinely use a specific evidence-based intervention approach/model or a set of methods from a specific approach that is matched to the identified clinical condition.	1 = Never 2 = Rarely 3 = Occasionally 4 = Regularly 5 = Almost always
9. If you answered “occasionally” or more, please check or enter the ones used (choose up to three that you most commonly use, and up to two “others”):	(List will be drawn from the ESC/expert panel) __TF-CBT __ARC __PCIT __CPP __Etc… __Other: ___________ __Other: ___________
For each named EBT, ask the following questions (pipelined for web-based survey): In the past month, with how many of your cases did you use _______? In the past month, what was the average number of sessions you had with your ______ cases? During the past month, what was the average number of minutes you spent each week in supervision (individual or group) focused on ______? During the past month, what was the average minutes you spent each week in peer consultation focused on _______?	Enter a number between 0 and 100: ______ Enter a number between 0 and 100: ______ Enter the number of minutes:_______ Enter the number of minutes:_______

*Modified from the Clinician Checklist (Berliner, Kolko, & Dorsey), and the Kempe CTPSurvey (Fitzgerald & Shipman)

Thank you for your participation!

Note: You will NOT be able to return to the survey once your submission has been finalized.

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