Program Profile: Massachusetts Child Trauma Project (MCTP)

This program was designed to improve well-being and permanency outcomes for children with complex trauma in state care. The program is rated Ineffective. Overall, findings were mixed. There were statistically significant findings favoring the treatment group, including increased likelihood of adoption; however, there were also statistically significant findings favoring the control group. Overall, the preponderance of evidence suggests the program did not have the intended effects on children.

An Ineffective rating implies that implementing the program is unlikely to result in the intended outcome(s).

An Ineffective rating implies that implementing the program is unlikely to result in the intended outcome(s).

Program Goals/Target Population

The Massachusetts Child Trauma Project (MCTP) was designed to improve safety, well-being, and permanency outcomes (including family reunification, adoption, and guardianship) for children with complex trauma under the care of the Department of Child and Family Services. MCTP was implemented from 2011 to 2016 as a partnership between the state child welfare system; the Massachusetts Department of Child and Family Services (DCF); two behavioral health agencies; and two large, urban medical centers.

The key goals of MCTP were to 1) improve identification and assessment of children exposed to complex trauma; 2) enhance service provider capacity for the delivery of trauma-specific, evidence-based (or evidence-supported) treatments (EBTs) in agencies serving children in child welfare; 3) increase linkages with and referrals of children to EBTs; and 4) boost caregivers’ understanding about and sensitivity to child trauma (Bartlett et al. 2016).

Program Components/Key Personnel

MCTP focused on three central activities: 1) training child welfare staff and foster parents to recognize and respond to child trauma; 2) disseminating three trauma-focused EBTs in community-based, mental health agencies; and 3) forming child welfare-led, trauma-informed leadership teams to integrate mental health providers, child welfare workers, and consumers in implementing, maintaining, and spreading trauma-informed practices.

Child welfare staff first completed basic and advanced child trauma trainings in screening, assessment, and treatment services. These trainings included the Intensive Learning Community (ILC) workforce development training design and the Breakthrough Series Collaborative (BSC) method. The ILC is designed for mental health providers and aims to improve clinical outcomes (Markiewicz et al. 2006), whereas the BSC is designed to improve trauma-informed child welfare casework practices (Conradi et al. 2011). Foster parents were given the option to complete the National Child Traumatic Stress Network (NCTSN) Child Welfare Training Toolkit and Caring for Children Who Have Experienced Trauma: A Workshop for Resource Parents (Child Welfare Collaborative Group, 2012).

Second, MCTP implemented three evidence-based trauma treatments: attachment self-regulation and competency (Blaustein and Kinniburgh 2010), child-parent psychotherapy (Lieberman and Van Horn 2005), and trauma-focused cognitive-behavioral therapy (Cohen, Mannarino, and Deblinger 2006). These programs were selected based on national and state data on trauma exposure among children in Massachusetts state care, the accessibility of trainers, and the practicality of the model for service-delivery settings and meeting the needs of children who have been exposed to chronic complex trauma (Fraser et al. 2014).

Third, trauma-informed leadership teams (TILTs) were formed and composed of individuals who were trained in the BSC model in child welfare and individuals trained in the ILC model of mental health. TILTs focused on installing and supporting trauma-informed care at the community level through systems integration. Team members represented all areas of child-serving care, including education, primary care, early intervention, and legal services (Fraser et al. 2014; Bartlett et al. 2016).

Program Theory

MCPT used guidelines outlined in the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Concept of Trauma and Guidance for a Trauma-Informed Approach, to help child welfare workers, clinicians, and caregivers better understand the feelings, beliefs, and thoughts driving a child’s behavior. The approach emphasizes the importance of understanding how trauma responses are linked to children’s difficult behavior and encouraging adults to respond calmly with empathy. Appropriate responses to difficult behaviors can increase children’s placement stability, which paves the way to adoption and reduces the likelihood of future child maltreatment (SAMSHA 2014).

Study

Barto and colleagues (2018) conducted a quasi-experimental design study to examine whether the Massachusetts Child Trauma Project (MCTP) improved placement stability, permanency, and the prevention of child abuse and neglect recurrence for children involved in the child welfare system. MCTP was implemented from 2011 to 2016 as a collaboration among the state child welfare system; the Massachusetts Department of Children and Families (DCF); two behavioral health agencies; and two large, urban medical centers, including one that was university-based.

Participants included 91,253 children, ages 0 to 19, who were in involved in DCF between October 2012 and September 2013. There were 55,145 children in the intervention group, which was drawn from the northern and western areas of the state and received services from child welfare offices that had implemented MCTP. The intervention group was 51.5 percent male. Of this group, 52.0 percent were white, 9.0 percent were Black, 4.0 percent were multiracial, 2.0 percent identified as other, and 37.9 percent also identified as Hispanic. The average age was 9. Intervention group participants had an average of 2.7 prior 51a reports, which are reports sent to the DCF if a professional who works with children suspects a child is being abused or neglected. The average number of all other prior reports was less than 1, including initial reports, CHINS (child in need of services) reports, voluntary intakes, physical abuse reports, neglect reports, sexual abuse reports, emotional abuse reports, substance-abused newborn reports, and failure to thrive (FTT) reports,.

The comparison group comprised 36,108 children and youth from Boston and the southern areas of the state who received services from child welfare offices that had not implemented MCTP. The comparison group was 51.5 percent male. Of this group, 45.0 percent were white, 23.0 percent were Black, 5.0 percent were multiracial, 2.0 percent identified as other, and 24.0 percent also identified as Hispanic. The average age was 9. Comparison group participants had an average of 2.3 prior 51a reports. The average number of all other prior reports was less than 1, including initial reports, CHINS (child in need of services) reports, voluntary intakes, physical abuse reports, neglect reports, sexual abuse reports, emotional abuse reports, substance-abused newborn reports, and failure to thrive (FTT) reports.

There were statistically significant differences on some background characteristics at the baseline. The researchers did not specify on which characteristics the groups differed. To account for these differences, the researchers conducted an inverse probability of treatment weighted analysis. This form of propensity scoring is designed to replicate the conditions of a randomized experiment by creating a weighted sample in which the distribution of baseline covariates is similar between treated and control subjects.

Rates of placement stability, permanency (return home, adoption, guardianship), and recurrence of maltreatment (physical abuse, sexual abuse, neglect) among children served by child welfare offices that had implemented MCTP were compared with those of children served by child welfare offices that had not implemented MCTP. Information on child maltreatment, out-of-home placements, and adoption was obtained from child welfare administrative data. All outcomes were assessed at baseline and again one year later at follow up. Treatment effects were estimated using weighted regression, with inverse propensity scores used as weights. Weighted logistic regression was used for binary outcomes, such as whether the child was adopted, and weighted negative binomial regression was used for “count” outcomes, such as total number of placements. For the time-to-event outcome (days in placement), an adjusted Kaplan–Meier survival curve was estimated, accompanied by a modified log-rank test for weighted samples. A weighted Cox proportional hazard model was used to examine the effect of the intervention on the hazard of leaving placement during the year-long intervention. Effect sizes were reported as odds ratios (ORs) for binary outcomes, incident rate ratios (IRRs) for count outcomes, and hazard ratios (HRs) for time-to-event outcomes. The researchers did not conduct subgroup analyses.

The Massachusetts Child Trauma Project was implemented with guidance from the National Child Traumatic Stress Network, Substance Abuse and Mental Health Services Administration, evidence-based treatment developers, federal grantees, state agencies, mental health providers, consumers, and large systems of care (Barto et al. 2018).

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Bartlett, Jessica Dym, Beth Barto, Jessica L. Griffin, Jenifer Fraser, Jenifer Goldman, Hilary Hodgdon, Ruth Bodian, Rochelle F. Hanson and Jason Lang. 2016. “Trauma-Informed Care in the Massachusetts Child Trauma Project.” Child Maltreatment 21(2):101–112.

Blaustein, M., and K. Kinniburgh. 2010. Treating Traumatic Stress in Children and Adolescents: How to Foster Resilience through Attachment, Self-Regulation, and Competency. New York, N.Y.: Guilford.

Child Welfare Collaborative Group, National Child Traumatic Stress Network, and the California Social Work Education Center. 2012. Child Welfare Trauma Training Toolkit: Trainer’s Manual (1st ed.). Los Angeles, CA, and Durham, NC: National Center for Child Traumatic Stress.

Cohen, J., A. Mannarino, and E. Deblinger. 2006. Treating Trauma and Traumatic Grief in Children and Adolescents. New York, N.Y.: Guilford.

Conradi, L., J. Agosti, E. Tullberg, L. Richardson, H. Langan, S. Ko, and C. Wilson. 2011. “Promising Practices and Strategies for Using Trauma-Informed Child Welfare Practice to Improve Foster Care Placement Stability: A Breakthrough Series Collaborative." Child Welfare 90(6):207–25.

Fraser, Jenifer Goldman, Jessica L. Griffin, Beth L. Barto, Charmaine Lo, Melodie Wenz-Gross, Joseph Spinazzola, Ruth A. Bodian, Jan M. Nisenbaum, and Jessica Dym Bartlett. 2014. “Implementation of a Workforce Initiative to Build Trauma-Informed Child Welfare Practice and Services: Findings from the Massachusetts Child Trauma Project.” Children and Youth Services Review 44:233–42.

Hodgdon, Hilary B., Margaret Blaustein, Kristine Kinniburgh, Mark L. Peterson, and Joseph Spinazzola. 2016. “Application of the ARC Model with Adopted Children: Supporting Resiliency and Family Well Being.” Journal of Child and Adolescent Trauma 9(1):43–53.

Lieberman, A. F., and P. Van Horn. 2005. Don't Hit My Mommy! A Manual for Child-Parent Psychotherapy for Young Witnesses of Family Violence. Washington, D.C.: Zero to Three.

Markiewicz, J., L. Ebert, D. Ling, L. Amaya-Jackson, and C. Kisiel. 2006. Learning Collaborative Toolkit. Los Angeles, Calif., and Durham, N.C.: National Center for Child Traumatic Stress.

Substance Abuse and Mental Health Services Administration. 2014. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. Rockville, Md.: Substance Abuse and Mental Health Services Administration.