The Children's Crisis Care Center Model

The Child Trauma Academy (CTA)  www.ChildTrauma.org
Department of Psychiatry and Behavioral Sciences
Baylor College of Medicine
Texas Children?s Hospital
Houston, Texas

** Children?s Crisis Care Center of Harris County
Harris County Child Protective Services
Houston, Texas

This is a special web version of an article in preparation for Child Welfare.

Background

1. Why Child Protective Services?

Humans are born vulnerable and dependent. In healthy human living groups (e.g., families, communities or societies) there are customs, beliefs, behaviors, policies and practices to ensure that helpless infants and children are protected, nurtured, enriched and educated. Throughout history, when infants and children are valued in these ways, society thrives; and when they are neglected and maltreated, society dissolves. Transgenerational attention and care of children are the most important and adaptive practices of any culture. With healthy investment in children there can be positive sociocultural evolution; without it there will be sociocultural devolution.

For the first two hundred and fifty thousand years our species spent on Earth, we lived in small hunter-gatherer groups of thirty to fifty members. There was no privacy. Infants and young children were continually in the presence of several invested and attentive adults during the day. Protecting, nurturing and enriching the young was the work of all, in the interests of all, and the responsibility of all. With years of supportive, attentive, nurturing and enriching experiences, the helpless infant could become a flexible, caring, creative and contributing member of the community.

During the last five thousand years, however, humans have lived in increasingly complex groups (e.g., city-states, kingdoms, nations). As part of this process, family life and work became increasingly compartmentalized. Over the last few hundred years as work left the home, the birth rate increased and household composition changed, the ratio of available caregiving adult for each young child decreased. In the last few generations, Western households have been shifting from multi-family to extended family to multi-generation single family to nuclear to single parent (Burguiere, Klapisch-Zuber & Segalen. 1996). The increasing complexity of society combined with the compartmentalization and isolation of many families allowed neglectful or abusive child-rearing behaviors to escape the attention (and therefore the intervention) of the community. As a partial response to this, societies were forced to address issues related to the maltreatment of children through non-familial, private systems (i.e., church or charitable organizations). Over the last century, public systems (i.e., child protective services) have assumed an increasing share of the responsibility for identifying and protecting neglected or maltreated children.

2. Infants and Young Children: Out of sight - Out of mind

The majority of child maltreatment takes place in the home (Straus. 1974). Parents rarely report themselves. The public systems mandated to identify and protect these maltreated children, therefore, rely upon a network of responsible community members to identify these children. These responsible adults rarely witness maltreatment in the home. As a result, the public systems must identify potential abuse and neglect by indirect means. Understanding and acting on the complex emotional, behavioral, cognitive, social or physical signs and symptoms of maltreatment can be very difficult. The result is an inefficient "identification" process; typically, abused and neglected children come to the attention of the community only after years of damaging neglect and abuse.

Identification of maltreated children is more likely when they enter the public eye. Abuse may be identified in the school-age child with visible manifestations of abuse ? a bruise, a cut, a burn ? and when the child can, if willing, disclose the source of the injury. Physical evidence along with the child?s verbal narrative is often required before intervention by any public system. Lack of any clear physical manifestation of abuse often delays or even prevents maltreated children from being identified. This poses two major problems: (1) under-identification of maltreated children and (2) a more pervasive under-identification of maltreated infants and young children.

Abused and neglected children that are not in the public eye (e.g., infants that do not leave the home) or who are not capable of verbally communicating (e.g., infants, very young or disabled children) are rarely identified by the public systems mandated to identify and protect them. The implications of this for the individual child, and for society, are devastating. Contrary to popular belief, infants and young children are the most vulnerable to the adverse effects of abuse and neglect. Indeed, early life maltreatment can permanently rob children of their potential by altering the organization of the developing brain.

The human brain is an amazing and complex organ that allows each of us to think, feel and act. The qualities of humanity which have allowed us to create a democratic government, complex economies, astounding technologies and all other manifestations of our current society are mediated by the human brain. In turn, these brain systems that allow us to think, feel, and act are shaped by experience. Furthermore, it is increasingly clear that the experiences of childhood act as primary architects of the brain?s capabilities throughout the rest of life. The experiences of childhood define and determine functioning for life.

The brain is undeveloped at birth. Research in developmental neurobiology, early child education, developmental psychology and related fields has demonstrated the many ways that experience organizes the developing brain (Shore. 1997). During the first years of life, the brain develops itself in a ?use-dependent? way, mirroring the pattern, timing, nature, frequency and quality of the experiences of the young child(Perry, Pollard, Blakley, Baker, & Vigilante. 1995). The neural systems underlying emotional, behavioral, cognitive, social and physiological functioning depend upon the experiences of infancy and childhood to organize properly. By age three, the brain is 90 percent the size of the adult brain and the majority of these key neural systems have been organized (Thoenen. 1995).

These organizing childhood experiences can be consistent, nurturing, structured and enriched, resulting in flexible, responsible, empathic and creative members of society. Optimizing experiences provided in a safe setting result in optimal brain organization and function. All too often, however, childhood experiences can be neglectful, chaotic, violent and abusive, resulting in impulsive, aggressive, remorseless, and anti-social individuals. Chaos, neglect, pervasive fear and direct violence in early childhood result in disorganized and under-developed brains (see Perry and Pollard. 1998).

The implications for maltreated children are tragic. Abuse and neglect in childhood impact emotional, behavioral, cognitive, social and physiological functioning in negative ways. Maltreatment increases risk for neuropsychiatric disorders including PTSD (Green. 1998; Perry. 1994), dissociative disorders (Putnam. 1993), depression (Kaufman. 1991), substance abuse and dependence and a host of other emotional and behavioral problems (Neuman, Houskamp, Pollock, & Briere. 1996). Maltreatment increases risk for anti-social, aggressive and criminally-violent behaviors (Myers, Scott, Burgess, & Burgess. 1995; Burton, Foy, Bwanausi, & Johnson. 1994; Lyons-Ruth, Alpen, & Repacholi. 1994; Lewis, Mallouh, & Webb. 1989). Maltreatment may increase risk for various medical problems including asthma (Klee & Halfon. 1987) and various cardiovascular problems such as hypertension (Henry, Liu, Nadra, et al. 1993; Giller, Perry, Southwick, & Mason. 1990). Neglect in early childhood can result in permanent cognitive impairment or learning problems (Buchanan & Oliver. 1977; Spitz. 1945), endocrine problems (Money. 1977; De Bellis, Chrousos, Dorn, et al. 1994), pervasive developmental delays (Perry, Pollard, Blakley, Baker, & Vigilante. 1995) and other developmental disorders (Spitz. 1946; Green, Voeller, Gaines, et.al. 1981).

The cost to the maltreated individual is incalculable. The lost promise of millions of maltreated children diminishes us all. The economic costs to identify, protect, heal, educate and sustain these wounded children are staggering. The relative inefficiency of the child protective systems in identifying high-risk infants and young children, therefore, has profound public health implications (Hertzman & Weins. 1996). Clearly, it is in society?s best interests ? and in the best interests of the abused, neglected child ? to better identify, protect and care for maltreated infants and young children.

4. Hope for Maltreated Children ? Hope for Society: Early Identification and Intervention

The brain can be changed. Systems in the brain that have been poorly organized or altered by abuse and neglect can change. The human brain is plastic ? it changes with repetitive, patterned and enriched experiences. The brain?s malleability and plasticity ? this capacity for change ? varies over the life span. The brain is easiest to modify (i.e., most malleable) in early childhood and becomes less malleable with age (Figure 1). The older a child is, the more time, effort and resources are required to alter those brain systems that have been impacted by maltreatment. Furthermore, for a variety of reasons, brain areas that develop first (the relatively less complex areas responsible for regulation of attention, arousal, sleep, impulsivity, the fear-response) are less plastic ? less malleable ? than areas that develop later (i.e., the cortex, responsible for thinking).

The implications for intervention are obvious. Early intervention will be more effective. Early intervention will requires fewer resources. Early intervention will result in healthier children with fewer economic and human resources. A number of studies have demonstrated the efficacy (including economic) of well-designed intervention models with high-risk infants and children (Karoly, Greenwood, Everingham, et al. 1998).

Yet, early intervention requires early identification. The CPS systems in the United States identify more high-risk infants and children than any other public system. In this capacity, the CPS system is in a unique position to have a positive impact on maltreated children and, thereby, society. Unfortunately, this opportunity is often lost ? in part due to the lack of practical, proactive models for assessing young children and, in part, due to a CPS system under a tremendous resource challenge.

In 1995, nearly 3 million children were exposed to traumatic abuse and neglect in the United States, a 42% increase from a decade earlier (Petit & Curtis. 1997). To put this in perspective, this is the same number of young adults that served our country in combat during the entire ten-year Vietnam Era. It is important to know that of these 3.1 million Vietnam Veterans, over one million (1/3) developed Post-traumatic Stress Disorder (PTSD) at some point in the 20 years following their tour (Kulka, Schlenger, & Fairbank. 1990). In comparison, maltreated children do not rotate out of combat after a one-year tour. Presuming a comparable vulnerability to trauma in children (a very conservative presumption), as many as 12 million children will develop emotional, behavioral, cognitive and physiological problems (such as PTSD) related to traumatic abuse, violence and neglect (Perry. 1994; Perry & Pollard. 1998).

In contrast to popular mythology, young children are more vulnerable to trauma and maltreatment than older children, adolescents or adults. This is sobering considering that more than 33% of the 3 million maltreated children in 1995 were under the age of 6 (Petit & Curtis. 1997). Of the 45,000 children reported for abuse and neglect in Texas during 1996, 51% were under the age of 6 (TDPRS. 1997). Despite their vulnerability, these youngest maltreated children receive the least assessment and the fewest services, even after being temporarily removed from an abusive setting.

6. Systemic Problems: Optimizing Placement and Services for Maltreated Children

Children?s Protective Services (CPS) in all states have the critical responsibility for finding suitable (if not optimal) placement for the children removed from parental care. In 1995, on any given day, 486,000 children were placed in out-of-home care ? a 74% increase from 1986 (Petit & Curtis. 1997). In Texas, approximately 12,000 children were placed in foster care in 1997 (TDPRS. 1997).

Once the CPS system removes children, they have additional responsibilities of attending to the medical, psychological, social and academic needs of these children. The problems in this high-risk population are significant. As noted above, these children are at great risk for a host of emotional, behavioral, cognitive, social and physical problems related to neglect or traumatic abuse. Yet each of these children will have unique combinations of strength and vulnerability; and each deserves the opportunity for placement and services that match their needs. This is a challenge under optimal situations.

In the overburdened CPS and family court systems, this challenge is often faced blind; little objective information about the child?s emotional, social or academic needs is available. The quality of decision-making is dependent upon the quality of the information available to those making decisions. Unfortunately, good decisions about placement and services are difficult with the limited information typically available following removal. Few CPS systems have proactive, multidimensional evaluations that provide information to decision-makers during the first weeks in the CPS system (Urquiza, Wirtz, Peterson, & Singer. 1994).

With these limited resources, the "matching" of children to appropriate placements is important to avoid costly placement disruptions. Unfortunately, the majority of placements are made based upon availability of beds in the foster-care system rather than the specific needs of the children placed.

Resources are even more limited for the mental health, medical, psychosocial and academic needs of these children. Again, appropriate targeting of available services is essential to maintain the economic integrity of the system and to provide optimal care for the maltreated child. Medical, academic, psychological, early childhood intervention and other services are provided in a reactive fashion - after the child has demonstrated some significant medical, behavioral or academic problem, disrupted placement or otherwise failed in some dramatic fashion. In the case of older children, psychological evaluations are required for placement in therapeutic or residential treatment facilities.

Placement decisions are even more random for infants and young children than for older children. Early intervention services are rarely provided, as these youngest children rarely "disrupt" placement and they are not yet capable of failing in school. They are small, compliant and not as noisy, disruptive or difficult as their older siblings. They are easier to care for. In a reactive system, therefore, they will rarely be evaluated. Without appropriate assessment, their developmental problems will go undetected. No interventions will be provided.

These young maltreated children will grow up. They will become maltreated adolescents and adults. Most of them will absorb this maltreatment and carry the scars of the abuse and neglect in their diminished potential. Some, however, will pass the pain on when they are old enough to disrupt the adult world with violence or old enough to bear children. Any services they receive by this point will be targeting a more mature brain, more ingrained patterns of behavior and a more complex set of problems. Interventions at this point will be more expensive and less effective.

Developing a practical, cost-effective process for early identification of high-risk infants and children, therefore, is an essential step in addressing the complex problems related to the abuse and neglect of children.

In 1993, the Harris County Children?s Protective Services Fund Board, a private organization founded by the corporate community in Houston, Harris County, Texas, commissioned a Task Force. The CPS Fund Board had been providing the Harris County child welfare community with the seed resources to develop innovative programs that could help Harris County CPS better serve the children and families in their care.

The Task Force was an interdisciplinary group representing every sector of the community: child welfare, social services, law, medicine, mental health, education, child advocates, corporate and community leaders. The mandate of the Task Force was to formulate strategies and make recommendations to improve services for children in CPS custody. Of specific concern were children with emotional and behavioral problems that had failed in multiple placements. The original focus of the Task Force was an actual physical "center" to house and evaluate the most difficult children. Over time, however, the Task Force recognized this as yet another reactive and expensive solution. The Task Force recommended the development and testing of a more proactive method to identify the highest risk children as they entered the CPS system. This multidisciplinary assessment process would become the Children?s Crisis Care Center Program, or as one Task Force member referred to it, "an assessment center without walls."

The Children?s Crisis Care Center (CCCC) was established as a public-private partnership in Harris County. The three primary partners in this collaborative effort were: (1) Harris County CPS, including the Harris County CPS Fund Board; (2) the Texas Department of Protective and Regulatory Services (TDPRS) and; (3) the ChildTrauma Programs of Baylor College of Medicine in Houston. The ChildTrauma Programs at Baylor College of Medicine was selected by the Task Force to develop and implement the proactive assessment process for the Children?s Crisis Care Center. This choice was based upon the extensive experience that the ChildTrauma Programs had in the areas of assessment, information management, program development and clinical research with maltreated children. The CCCC staff was selected on the basis of past experience and familiarity with the CPS system, interpersonal skills, leadership and flexibility.

At this time, the ChildTrauma Program was a partnership between Baylor College of Medicine, Texas Children?s Hospital and CIVITAS Initiative.  CIVITAS Initiative invested in this partnership with the hope of developing exportable program elements that could be used in other public systems across the country (i.e., CPS, juvenile justice). Through the ChildTrauma Programs, CIVITAS Initiative provided approximately one-third of the total planning and pilot phase costs. These costs included time and personnel for program development, software re-design, direct service delivery and training activities provided to the CCCC. The remaining two thirds of the total CCCC pilot phase costs were provided through a grant from the CPS Fund Board. Harris County CPS was the technical recipient of this grant and hired the CCCC staff, including the Program Director. In Harris County, TDPRS is the legal custodian of all children in the foster care system while Harris County CPS provides ancillary services to foster care children. Both Harris County CPS and TDPRS provided support for the CCCC by assigning CPS personnel, space, administrative support and technical resources from pre-existing budget sources for the units assigned to the CCCC Program.

Table 1: Key differences: CTA/CCCC Core Assessment Process vs. CPS-Standard Approach to Assessment

During the planning phase, the CCCC partnership further articulated its objectives. The overarching objective of the CCCC project was to develop, implement and evaluate a proactive, practical and timely assessment process for children and their families and, thereby, provide the data necessary to better match placement and target services for children in the care of Harris County CPS. This process had to include: (1) cost-effectiveness; (2) clinical validity and reliability; (3) rapidly available and ?readable? reports; (4) inter-institutional and multi-disciplinary teams for decision-making; (5) capacity to evaluate children of all ages, including 0 to 6; (6) computerized information management; (7) capacity for individual and program outcomes evaluation; (8) capacity to be expanded to include all Harris County children and (9) capacity to be exported, in modules, to other public systems (e.g., juvenile justice, CPS in other locations, mental health/mental retardation and public education).

The ChildTrauma Programs and CCCC staff worked together to identify the primary areas related to successful implementation of the program. Success in two broad areas was necessary: (1) program content ? the actual assessment, report, materials for caregivers and (2) process ?how the individual staff from partner organizations meet, communicate, share, learn, solve problems and provide services.

4. Program Development: Focus on the Systemic Resistance to Change

Organizations are "dynamic entities continually interacting with their environment, changing and adapting to develop congruence between people, process, structures, and external environment" (Beer. 1980). Even though organizations are "dynamic," directed, purposeful change is a difficult process. It is more difficult to integrate an innovative program into an organization (or system) than it is to develop the innovation itself. This is understandable and should be anticipated by any group serious about taking successful programs "to scale." Resistance to innovations within any system is related to the perceived threat to the status quo and the challenge to existing values, interests, and rewards (Huff. 1980).

From the outset, the CCCC partners were aware of these systemic issues. With the expectation of exporting elements of the CTA/CCCC process, the partners focused on content and process issues that could reduce the threat, challenge, discomfort or confusion for caseworkers, supervisors and administrators in the CPS system. These key personnel might reasonably be resistant to the introduction of a yet another "new program."

The key to successful process was inclusion. In the planning phase and throughout the two-year pilot, CPS caseworkers, supervisors and administrators were invited into and respected as full members of an interdisciplinary, inter-institutional partnership. Effort was focused on inclusion, effective communication and development of an assessment (and reporting format) that helped caseworkers in their everyday tasks. Practicality and utility of the process were crucial. This process step, inclusion, served to develop positive coalitions with caseworkers and administrators as well as provide CCCC and ChildTrauma Program staff with valuable feedback on improving the assessment process, report format and the protocols.

Concept of a Core Assessment: The CTA/CCCC Core Assessment process is a modification of the assessment and information management process developed by the ChildTrauma Program for its clinical services at Texas Children?s Hospital. The central concept of the Core assessment is to obtain an accurate and useful "snapshot" of the child?s strengths and vulnerabilities in six major domains: (1) physical/medical; (2) family/social; (3) life history/traumatic life events; (4) emotional/behavioral; (5) cognitive/academic and (6) developmental (Figure 2). For each of the six domains, quantitative data are gathered using standardized, developmentally appropriate measures, instruments or psychometric tools. The CTA/CCCC Core Assessment involves age-specific evaluation, thereby allowing assessment of infants and young children. Qualitative and subjective data are added to these data. The clinician responsible for the report identifies the child?s strengths and weaknesses within each domain and provides an initial recommendation to address the problem areas (contact authors for sample report). The CTA/CCCC Core Assessment acts to identify key problem areas, focuses further evaluation, suggests appropriate placement and directs the initial treatment and service plan (Table 1).

A Semi-Structured Interview for Caregivers administered by the CCCC staff examines various aspects of family composition, history and functioning. Combined with the family information and CPS history gathered by the CCCC staff, this objective review of the family?s strengths and weaknesses complements the child?s assessment.

Design of the Assessment and Reports: All measures were selected for reliability, validity, and practicality for the real world front-line work of CPS. The time required to administer all of the testing was short and not overtaxing for young children.

Crucial elements of this process were report turn-around time and the capacity to communicate the findings of the assessment. It was critical that the decision-makers had the assessment findings available while they were making plans for the children (i.e., within 14 days of removal). In a similar fashion, the busy judge or caseworker does not want to read ten pages of single spaced report designed for mental health professionals to get to "the bottom line."

The report "format" is important. Humans selectively process and absorb information presented in visual and familiar formats. In the CPS system, the language of the psychologist or psychiatrist may be useless to the caseworker or judge during decision-making. The CTA/CCCC Core Assessment report format was designed to be structured, repetitive, explanatory and graphical with clear articulation of strengths, weaknesses, problems and recommendations for each problem. The "look and feel" of these reports is very different from typical psychological reports utilizing graphical, visual representations of data and sub-domain listing of key strengths, weakness, problems and treatment recommendations (sample reports available upon request). Universally, the initial impression of the caseworkers was discomfort with the report format. Over time, however, the caseworkers and judges preferred these reports to standard psychological report formats. More important, however, the judges and caseworkers were more likely to read these reports and utilize the recommendations for placement type and services.

The CTA/CCCC Core Developmental Assessment Protocol: From the moment of removal, admitting a child to the Children?s Crisis Care Center (CCCC) involves cross-institutional collaboration between the partners. As a child is removed from their previous placement and enters CPS custody, CCCC staff is notified. Within 72 hours, CCCC staff have gathered family information and reviewed the case with the CPS caseworker. Family and caregiver psychometric measures (part of the CTA/CCCC Core Assessment) are given to the biological parents by the caseworker at the time they meet. The CCCC staff organizes historical information about the parents, children, and the reason for the current CPS referral. This narrative is electronically sent to the examining clinician in the ChildTrauma Program prior to the child?s assessment. The child is scheduled for assessment at the ChildTrauma Program at Texas Children?s Hospital.

All clinicians (CCCC or CTA staff) conducting the assessments are supervised masters or doctoral level professionals who have experience working with traumatized and maltreated children. The details of the Pilot assessment are listed in Table 2.

Children between the ages of 6 months and 6 years are administered the CTA/CCCC Core Developmental Assessment (see Table 2). Children who enter custody at birth (e.g., drug positive at birth, abandoned in the hospital) are tested after their 6^th month to allow the child to stabilize in foster placement. These children are often medically fragile at intake due to abusive and negligent perinatal conditions.

The Core Developmental Assessment consists of a normed developmental screening test (Denver II; see Table 2), a comprehensive Semi-Structured Caregiver Interview, and standardized questionnaires about the child?s behavior and the family?s/parent(s)? functioning. This Interview is designed to elicit information about the child across several domains and asks standard developmental questions as articulated in guidelines recommended by the National Center for Infants, Toddlers and Families (Meisels & Fenichel. 1996; Meisels & Provence. 1998). These developmental questions are combined with questions focusing on trauma-related symptoms, adjustment difficulties, or other problems relating to the child?s CPS custody.

Following developmental testing, the CTA clinician produces a report (see Appendix). This report summarizes conclusions about each area of functioning and provides practical recommendations for the caseworker and CCCC staff. The ChildTrauma Academy has produced a series of materials for caregivers working with maltreated children (e.g., Perry, Runyan & Sturges, 1998). When these materials may be of use, they are attached to the reports so they can be provided to the child?s caregiver.

Following initial assessment,CTA and CCCC staff continue to work together with the caseworker to ensure that the child is monitored and that given recommendations are beneficial to the child. When necessary, the ChildTrauma Clinic at Texas Children?s Hospital participates in more in-depth psychiatric evaluation as well as outpatient mental health services.

The Children?s Crisis Care Center Project was started in March of 1996. Two units of CPS were attached to the CCCC (pilot units) and all children removed by these two units participated in the CTA/CCCC Assessment process. Two comparison units were followed to aid in program outcome evaluation. In the pilot units, the assessment was repeated at specific intervals.

The CCCC completed the two-year pilot phase on March 1, 1998. During the two-year pilot period, initial, six-month and annual assessments were completed on over 300 children ranging in age from 6 months to 18 years. Of the over 300 children assessed, 54% were younger than six years of age at the time they came into care. Approximately 9% of the children evaluated were taken into custody at birth. The reasons for removal were classified using standard CPS labels and included physical abuse, physical neglect, medical neglect, neglectful supervision, abandonment, and refusal to accept parental responsibility, and risk to a child.

2. Sample characteristics

Young Children (0-6): The young children entering the CPS system demonstrated significant problems across multiple domains. Indeed, 23% of these children (0-6) were unable to be completely tested due to unresponsiveness, opposition, and/or high emotional distress. Of the remaining children, 62% were found to have at least one developmental delay and 79% were found to have more than one caution and/or at least one delay on the Denver II (a measure that may under-identifiy some developmental problems). Of those children found to have delays at their initial screening, 76% were found to have delays in language skills. In other areas, delays were significant with gross motor development (18 % delayed) being the least effected. Also significant, was that at intake, 56% of children had more than 1 caution and/or at least delay in language skills, while 15% of the children studied had > 1 caution and/or at least 1 delay in gross motor skills. The longer a child had been in the neglectful or abusive setting, the more pervasive and severe were the problems.

Of this sample of children, 60 % had delays or a clinical presentation that warranted further evaluation or enrollment in specialized early childhood intervention services. Specialized information targeted to the child?s special problems (e.g., attachment and bonding, aggressive behavior, grief and mourning) and needs was provided to foster parents and caseworkers.

Children and Adolescents (7-17): As a group, the children and adolescents removed from their families by the CPS demonstrated many problems (see Table 3). Two of the most striking findings appear to be related to being raised in chaotic and threatening environments. At least mild post-traumatic stress symptoms were reported by 86 % of these children, with 22 % reporting very severe PTSD symptoms. As a group, these children were more proficient at processing non-verbal versus verbal information (Table 3). Academic problems and other neuropsychiatric problems were more common in these children than in a general pediatric population. The complete findings from these samples will be reported in more detail elsewhere (in preparation).

The Children?s Crisis Care Center process helped caseworkers provide more consistent, well-coordinated, proactive services to the children in their care. This was accomplished in a number of ways. For example, cases were staffed within 72 hours of removal. During the staffing, in-depth family histories were compiled and measures of family functioning were administered. This information provided detailed background data for clinicians as they completed the child?s assessment and report. During the CCCC pilot phase, this information was available to caseworkers soon after a child entered custody, providing dramatic improvement over the standard CPS assessment process. Under the standard CPS process, detailed quantitative family information is generally not available, if at all, until weeks or months after the child has come into the custody of CPS.

Children in the pilot units benefited from the multi-dimensional assessment process and the reports that were prepared within 10-20 days of entering custody. The written reports were provided to the caseworker, guardians ad litem, and judges by the 14-day Show Cause Hearing. Subjective reports from caseworkers and judges were favorable and were noted for helping guide decision-making.

Table 3. Key Findings: Children Entering the CPS System

• 23 % of young children were "un-testable" due to significant behavioral problems
• 80 % of the remaining children have some form of developmental delays or problem
• Number and severity of developmental delays increase with age (i.e., more maltreatment = more delay)

• The prevalence of asthma was higher in these children than in the general pediatric population

• Few of these children would have been evaluated or referred for services in the standard CPS model

• 86 % of the children (7-17) had clinically significant post-traumatic stress (PTSD) symptoms
• 50 % of children (7-17) had some form of academic problem
• 36 % of children performed higher in non-verbal than on verbal; while only 3 % performed higher on verbal rather than non-verbal tasks

4. Value of Program

Children in the CCCC pilot units group were much less likely to experience placement disruptions than were children in the comparison units. Children in the pilot units were also moved from an emergency placement into a permanent placement much more quickly. During the first year of the pilot phase, children in the pilot spent 32.1 days in initial shelter care compared to 49.2 days for children in the comparison unit. Children from pilot units also returned home more quickly. After year one of the pilot phase, 10.8% of the children in the pilot units had returned home in contrast to the comparison units where only 3.7% of the children had returned. As the number of placements increased, children in comparison units were more likely to experience placements that were more restrictive and expensive, such as residential treatment centers or emergency shelters.

Table 4. Economic Analysis of CCCC Pilot Project: Year One

Based upon the findings and experiences from the pilot, it is clear that there is significant value in the CTA/CCCC Core Assessment process. This value is present in several areas: (1) improved CPS staff clinical skills, and an increased awareness of and sensitivity to the manifestations of maltreatment in young children; (2) improved foster parent understanding and interactions with developmentally-delayed young children; (3) improved systemic (i.e., judges, case workers, therapists) decision-making with qualitative and objective data; (4) more rapid and timely delivery of critical services; (5) opportunity to evaluate aspects of the CPS process including "fit" of placement and efficacy of clinical services and (6) data to help continue to revise and improve the CPS process and programs. These areas of "value" are often difficult to assign a specific dollar amount in any traditional economic cost-benefit analysis. The ultimate true value to society will be in the creative and productive potential of the children benefiting from appropriate protection, placement and well-targeted therapeutic, educational or enrichment services. These children will be healthier in emotional, behavioral, cognitive, social and physical domains, thereby costing public systems much less, enabling them to contribute more to society as they grow into adolescents and adults (see Karoly, Greenwood, Everingham, et al. 1998).

Independent of these areas of value, however, the immediate economic benefit of the CTA/CCCC Core Assessment process can be demonstrated (Table 4). The data from the proactive assessment allows more rapid decision-making; therefore, fewer days in CPS care, fewer days in shelter care and fewer disrupted placements (see above). The cost savings from these factors alone could save the CPS system in Texas over 23 million dollars a year. Simple analysis of the economics of the CCCC project in its first year (see Table 4) illustrates the cost-effective impact the CTA/CCCC Core Assessment process could have if taken to scale in Texas in a thoughtful fashion.

1. Taking CCCC to Scale

   Successful pilot programs mean very little unless they can be translated to impact the larger system. Taking pilots "to scale" is difficult. Typical pilots benefit from well-trained, motivated staff with solid (often charismatic) leadership and good resource support. The public systems that attempt to integrate innovative pilot programs are often resource-depleted, with overwhelmed, under-supported staff and too many passive (or indifferent) people in supervisory and leadership positions. For these and other reasons, the innovations of any promising pilot have a difficult time "translating" to the larger system.

   The CCCC pilot phase was developed and conducted with the explicit understanding that any innovations had to be capable of being taken to scale in the Texas CPS system and exported to other systems. This guided decision-making regarding psychometric instruments, the design of the report formats, the attention to the information management model, the focus on interdisciplinary teams and the focus on process and organizational issues that would be central to the translation and export processes.

2. Focus on Organizational Structures and Process:

   One of the major problems with taking any successful pilot program to scale is lack of attention to process and system issues. The content of the CTA/CCCC Core Assessment is relatively simple. A competent clinical group can replicate the actual assessment component of this process. The success of the CTA/CCCC Core Assessment process, however, is due to the focus on the process as much as the content of the assessment. The assessment independent of these process elements will fail. The success of the CCCC project was due to the hard work, personal qualities of the staff and the development of an organizational structure that valued and rewarded these qualities. Indeed a recent study of various public service systems in Tennessee demonstrated the crucial role of organizational climate (cooperation, low conflict, personalization, role clarity, and support) in improving the quality of care and outcomes for the children the organizations serve (Glisson & Hemmelgarn, 1998).

3. Dependence on Quality Staff and Clinicians

Selection: Quality counts. The personnel in any of the interdependent roles of the CTA/CCCC Core Assessment process (e.g., administrators, contract clinicians, psychometricians, assessment team staff, caseworkers, case aides, supervisors) must be flexible, willing to learn, capable of sharing, respectful of other disciplines, work hard and, most important, care for and about these children. Sadly, this may be one of the most difficult aspects of ?exporting? this process. There is no way to avoid these key personnel issues, however. If these qualities are not present in a majority of the staff, the leadership of any agency should not attempt to integrate this process into their system.

Training: Even with all of the necessary personal qualities, personnel need training. This proactive approach requires knowledge of information management models, psychometrics, small group dynamics, child maltreatment and related areas. In the CCCC Post-pilot phase, training is the cornerstone of the "to scale" process. New clinicians will be trained to administer the assessment, prepare the reports and participate in the interdisciplinary teams. Ongoing training opportunities will be provided in the context of actual case experiences, continually looking for areas to improve the process.

Table 5. CTA/CCCC Core Assessment: Harris County CCCC Post-Pilot Project

Support: The best trained, most motivated staff person can quickly be consumed by the difficult workload, emotionally-difficult situations and sense of helplessness that can be part of working in the CPS system. Ongoing support for staff must be integrated into any successful program in the CPS system. The CCCC Post-pilot includes ongoing support for staff with a focus on opportunities for staff to minimize secondary trauma,

1. Revising the CTA/CCCC Assessment Process for Post-Pilot

Following review of the CCCC pilot phase, several modifications of the assessment process were made (see Table 5). While the pilot included 6-month and annual re-assessment, these are being deleted from the Post-pilot process until more practical "end-points" can be defined. It is clear that for very young children, more frequent follow-up will be required, and for some older children only annual re-evaluation will be necessary.

The major revision of the post-pilot process related to changes in TDPRS policy (in response to federal law) that requires decisions about permanent placement for children to be made within one year of entering CPS custody. This policy altered the timelines for decision-making, requiring a family evaluation within 10 days following removal. The CTA/CCCC Core Assessment was split into two major phases: the Family Evaluation Phase (completed within 10 days of removal) and the Child or Developmental Assessment Phase (available before completion of the child?s 30-day Plan of Service). Additional revisions to the Assessment content included replacing several psychometric instruments with the hope of better capturing neuropsychiatric symptoms.

Even as elements of the original CCCC pilot are taken to scale in Harris County, the original program partners, the ChildTrauma Programs and the CCCC staff, are continuing with further program development. The next steps in the CTA/CCCC program development are: (1) to define the appropriate and practical points for follow-up assessments; (2) define the nature of these follow-up assessments and (3) pilot a proactive, quantitative assessment to be used during the investigative phase of the CPS process. Each of the current and evolving CTA/CCCC program innovations has been aided by modern computer technologies. With the increasing practicality of distance learning, consultation, and video communication with inexpensive phone-line mediated cybercasting, the CTA/CCCC programs will pilot processes for erasing the cross institutional and logistic boundaries that face rural or resource-challenged systems wishing to import elements of the CTA/CCCC Core Assessment process.

With the continuing support of TDPRS, the original CCCC pilot process will be repeated for these next steps. Planning, pilot and post-pilot phases will develop and implement practical program innovations. Elements that are proven effective will be taken to scale in a graded fashion. With ongoing support, the CTA/CCCC partnership will continue to serve as an R& D site for TDPRS and as a source of innovation for other public systems.

In most states the assessment and treatment of maltreated children in the custody of CPS systems is by private clinicians under contract with the agency. The CTA/CCCC Core Assessment can be adapted for use by these individual clinicians or other private clinical groups. Indeed the process of taking this to scale will require adaptation by CPS systems and the clinicians providing assessment services. At present, utilization of standardized psychometrics in traditional clinical settings is more common for children over age 6 than for younger children. Expansion of early intervention programs targeting younger children will require more quantitative assessment options for this age group. The CTA/CCCC Core developmental assessment as used in this process provides one model.

The advantages of this assessment and reporting format for standard clinical uses are clear. Increasingly third party providers are demanding stricter documentation and outcome measures. Indeed, most CPS contracts will be including outcome measurement as part of awarded contracts. The primary advantage, however, is the capacity of this multidimensional assessment to focus intervention. With some understanding of a child?s cognitive style and strengths, the history of life events, and the current physical, emotional and behavioral symptoms the treating clinician can formulate an initial treatment approach. Modifications of this assessment process are now in use in a traditional mental health clinical site (Texas Children?s Hospital) and in a pilot program in the juvenile justice system in Harris County.

Millions of young children experience abuse or neglect during the crucial formative first years of life. Of those children identified by the CPS systems, few are evaluated in a fashion that allows aggressive, proactive intervention. The CTA/CCCC Core Assessment process provides multi-dimensional assessment for children (0-17) entering the CPS system. This proactive process involves interdisciplinary teams to administer standard psychometric instruments, modern information management techniques, timely production of reports for caseworkers and judges and outcome evaluations. In a pilot of over 300 children, this process was demonstrated to be clinically effective, systemically practical and economically sensible. The CTA/CCCC Assessment process is being taken "to scale" in Harris County and by 1999, all children removed from parental care in Harris County (over 1200/year) will benefit from this model. Additional program innovations for the CPS system are being developed by the CTA/CCCC public-private partnership.

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Acknowledgements:

This work was supported, in part, by grants from CIVITAS Initiative, The Harris County CPS Fund Board, The Harris County Children?s Crisis Care Center, The Hogg Foundation for Mental Health, Maconda Brown O?Connor, the Thomas S. Trammell Endowment, the Ella T. Fondren Trust and the Pritzker Cousins Foundation.