A Program Evaluation of the Complex Care and Intervention Program
Dr. Kirk Austin
Complex Trauma Resources
Correspondence concerning this article should be addressed to
Email: Dr. Kirk Austin
Vulnerable children, ACE, complex trauma, toxic stress
It’s hard to believe that the seminal Adverse Childhood Experiences (ACEs) research of Felitti and Anda is in its third decade (Felitti, et.al.,1998). In their original research, the Center for Disease Control and Kaiser Permanente demonstrated a profound link between ACEs and human disease progression. The literature since that time has continued to confirm initial findings. In October 2019, leading medical journal, the Lancet, published a meta-analysis of research spanning from 1990 to 2018 (Bellis, et.al.,2019). Their findings corroborated earlier research and went further by analysing the estimated annual costs on unresolved ACEs to society. In summary, researchers concluded that ACEs attributed to 30% of anxiety diagnoses and 40% of depression diagnoses in North America. Total annual costs were estimated as $748 billion dollars in the United States and $581 billion dollars in Europe with just 2 ACEs predicting 75% of annual costs. Researchers concluded that governments should prioritize funding evidence-based programs for children that provided strategies to address ACEs. Further, they proposed coordinated programming efforts that integrate social, judicial, educational, and other departments to partner their support of vulnerable children.
Community based support and rehabilitation programs for children experiencing maltreatment are abundant in communities across Canada and the United States. Many address the disabilities, emotions and behaviors presented by these children. Many offer programmed support and rehabilitative assistance. Few tailor their programs to address the unique features of ACEs and their impact on children. Few conduct research regarding their effectiveness in supporting the spectrum of children that they care for. The Complex Care and Intervention program (CCI) conducted a program evaluation to explore its efficacy with children impacted by ACEs.
The Complex Care and intervention program (CCI) is based on literature in the field of complex trauma in children (Cook, et.al., 2005). As such, CCI is a recent, theory driven, evidence-based program that has supported children in the province of British Columbia, Canada since 2010. Supporting over 250 cases in 33 communities, CCI has worked with careteams (social, educational, judicial, etc.) to create a wrap-around support model for the children they serve. To date 50% of children supported by CCI live in staffed homes, 40% are in foster care, 54% are Aboriginal/First Nations and 13% are from failed adoptions. All children supported by CCI have experienced multiple ACEs.
At the onset of the CCI program, the child’s careteam (social workers, educators, counsellors probation officers, and supporting adults) participates in a guided structured interview called the Functional Developmental Assessment (FDA). The FDA evaluates 7 developmental domains exploring the strengths and challenges of every child pertaining each domain. Based on the FDA, individualized intervention strategies are developed to promote positive change in the child. Care teams meet monthly to support the child’s progress. The FDA is reconducted at the 6, 12- and 18-month intervals to explore whether change has occurred. CCI conducted a program review and examined data from 163 cases. Cases represented children between the ages of 4 to 16. Data sets pertaining to 98 males and 65 females were considered.
The FDA formally explores the impact of ACEs on the child’s neurological & biological maturity (N), over-reactive stress response (O), emotional regulation (E), attachment style (A), identity development (I), behavioural regulation (B) and cognitive & language development (C) are discussed and rated by the careteam. Ratings are based on a 4-point scale between 1 and 5. A score of ‘5’ represents no difficulty regarding the prompt. A score of ‘4’ represents mild difficulty. A score of ‘3’ represents moderate difficulty. A score of ‘2’ represents significant difficulty. A score of ‘1’ represents extreme difficulty. The care team unanimously agrees on the rating before it is officially recorded.
Neurological & biological maturity (N) considers how trauma effects the brain development of the child. Initial raw score data were reported as 3.1 (moderate difficulty). 6-month raw data were reported as 3.8 (mild difficulty). 12-month raw data were reported as 4 (mild difficulty). 18-month raw data were reported as 4.2 (mild difficulty). This represented a 27% positive change and suggests improvements may have occurred pertaining the child’s sleep quality, bodily-sensory awareness and sensitivity to heat, light, sound, stimulation and textures. Further, positive changes may have occurred with the child’s fine and gross motor functioning.
Over-reactive stress response (O) refers to how trauma effects the sensitivity of the child to stress. Initial raw score data were reported as 1.8 (significant difficulty). 6-month raw data were reported as 2.7 (moderate difficulty). 12-month raw data were reported as 3 (moderate difficulty). 18-month raw data were reported as 3.7 (near-mild difficulty). This represented a 98% positive change and suggests that improvements may have occurred pertaining the child’s state of anxiety, arousal and vigilance. Further, their tendency toward fight flight and freeze responses were lessened. This finding is important. As children learned to be calm within their home and academic environments they would experience less ‘triggerability’. This would translate into less volatility and in turn would result in fewer behavioural incidents.
Emotional regulation (E) refers to how trauma effects the emotions of the child and their ability to regulate their moods. Initial raw score data were reported as 2 (significant difficulty). 6-month raw data were reported as 2.9 (moderate difficulty). 12-month raw data were reported as 3.1 (moderate difficulty). 18-month raw data were reported as 3.8 (mild difficulty). This represented an 81% positive change and suggests that improvements may have occurred pertaining the child’s ability to regulate their emotions. Further it suggests that over time children had a greater ability to identify and describe their emotions and communicate their emotional needs. This finding is significant. In relation to lowering over reactive stress response, children were able to learn to recognize the sensory cues related to emotion. With this, social and emotional learning supports could be taught. With learning, children could better regulate their emotions. This in turn would result in fewer behavioural incidents.
Attachment style (A) refers to how trauma effects the child’s desire and ability to connect with others (adults and peers). Initial raw score data were reported as 2.1 (significant difficulty). 6-month raw data were reported as 2.9 (moderate difficulty). 12-month raw data were reported as 3.2 (moderate difficulty). 18-month raw data were reported as 4.2 (mild difficulty). This represented a 98% positive change and suggests that improvements may have occurred pertaining the child’s ability to form trust and relationships with peers and caregivers. This finding is important. If children are able to learn to trust healthy and safe adults, their trust may generalize to other adults and environments. Healthy attachment would be a central feature in introducing positive future activities.
Identity development (I) refers to how experience affects the child’s core beliefs about themselves. Initial raw score data were reported as 2.1 (significant difficulty). 6-month raw data were reported as 2.9 (moderate difficulty). 12-month raw data were reported as 3.2 (moderate difficulty). 18-month raw data were reported as 3.8 (mild difficulty). This represented a 70% positive change and suggests that improvements may have occurred pertaining the child’s self-esteem and self-efficacy. Further, it suggests that children began to form a stronger sense of belonging and life story and experienced a reduction in shame.
Behavioural regulation (B) refers to how trauma effects the child’s ability to regulate their behaviours. Initial raw score data were reported as 1.9 (significant difficulty). 6-month raw data were reported as 2.8 (moderate difficulty). 12-month raw data were reported as 3 (moderate difficulty). 18-month raw data were reported as 3.6 (moderate-mild difficulty). This represented a 90% positive change and suggests that improvements may have occurred pertaining the child’s impulse control and inattention. Further, findings suggest that over time children expressed less destructive and aggressive behavior and controlling behavior. This finding is important. Should children become calmer and less ‘triggerable’, they will have fewer behavioural outbursts. The implication of this is that they will have greater successes socially and academically as they will be removed from environments less frequently.
Cognitive & language development (C) refers to how trauma effects the learning, language and thinking ability of the children affected by maltreatment. Initial raw score data were reported as 2.5 (moderate-significant difficulty). 6-month raw data were reported as 3 (moderate difficulty). 12-month raw data were reported as 3.2 (moderate difficulty). 18-month raw data were reported as 3.8 (mild difficulty). This represented a 49% positive change and suggests that improvements may have occurred pertaining the child’s expressive and receptive language ability. Further, findings suggest that children may have demonstrated increases in information processing and problem solving.
When considered together, findings suggest that significant positive change occurred in all areas measured by the FDA. This should matter. Positive change in neurological and biological maturity (N) and overreactive stress response (O) means that a child will have a lower set-point for reactivity. A calmer child is less reactive to the people and situations that they experience. Positive change with emotional regulation (E), attachment style (A) and identity development (I) may correspond to fewer behavioral outbursts, and a child that is more accepting of themselves and makes better connections with others. Positive change in behaviour regulation (B) and cognitive and language development (C) could correspond to better life success in social and academic environments. Addressing ACEs in this way could significantly impact the annual costs associated with them.
A review of the CCI program has suggested that it is effective in addressing ACEs in children. Having a trauma informed practice framework that guides the child’s careteam is beneficial for all adults working with the child. It provides a cohesive framework that directs discussion and intervention strategies in residential, educational and community settings. This in turn provides a predictable and consistent structure for the child in all settings. Future research could explore the integration of the NOEAIBC model within academic and school-based settings. Application of the model has begun within indigenous contexts (Geddes, et. al. 2016). Training educators in the model is in keeping with this literature. Similar training is suggested for community-based resources that support children who experience ACEs. Continued research exploring the mechanisms of positive change is also recommended.
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Author Biographical Notes
Dr. Kirk Austin is a Registered Clinical Counsellor in the province of British Columbia, Canada. He is actively involved in training foster parents, psychotherapists, social workers, and educators in the effective use of the Complex Care & Intervention (CCI) model. He received his undergraduate degree in Psychology from Trinity Western University before completing his MA in Counselling Psychology at Liberty University. Prior to earning his doctorate in the field of positive psychology, at the University of South Africa, he completed a Diploma in adult education at Vancouver Community College. He currently works in psychosocial oncology at the BC Cancer Agency and has served as Training Director of Complex Trauma Resources since 2012.
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