CHILDREN 

AFFECTED BY 

TRAUMA 

Selected States 

Report Various 

Approaches and 

Challenges to 

Supporting Children

Report to Congressional Requesters

April 2019

GAO-19-388

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-19-388, a report to 

congressional requesters

April 2019

CHILDREN AFFECTED BY TRAUMA

Selected States Report Various Approaches and 

Challenges to Supporting Children

What GAO Found

The Department of Health and Human Services (HHS) and the Department of 

Education (Education) provide grants, disseminate information, and fund training 

and technical assistance to help state and local agencies support children 

affected by trauma. HHS’s Administration for Children and Families and 

Substance Abuse and Mental Health Services Administration (SAMHSA) have 

awarded discretionary grants specifically to address childhood trauma. In 

addition, state and local officials reported making use of other discretionary 

grants from HHS and Education—as well as formula funds meant for broad 

purposes like mental health, substance abuse, child welfare, and education—to 

support their work with children affected by trauma. In terms of non-financial 

support, state and local officials in six selected states all referred to the National 

Child Traumatic Stress Network, which is funded by SAMHSA, as an important 

resource for information, training, and technical assistance. Both HHS and 

Education have also made other guidance and informational resources available 

to states.

Officials in child welfare and education agencies in the six selected states 

reported using a range of approaches to help children affected by trauma, 

including training staff, screening children, and providing services and support 

systems. To train child welfare workers, educators, and birth and foster parents

to understand trauma and its effects on children, agencies in the six selected 

states used various approaches, such as learning communities, which include inperson learning and coaching, and online courses. Several state child welfare 

agencies also used learning communities to train clinicians in trauma-focused 

therapies. In addition, child welfare and education agencies in five states used

screening tools to identify children exposed to and exhibiting symptoms of 

trauma. Children identified as experiencing trauma are referred for a traumainformed mental health assessment. Also, to help children affected by trauma, 

child welfare and education agencies in five of the six states provide support and 

services. For example, in one state, caseworkers provide specialized services, 

including weekly visits, to children and families.

Officials in the six selected states reported facing various challenges in their 

efforts to support children affected by trauma, and they emphasized the 

importance of engaged leadership in establishing and sustaining support for 

these children. In three states, officials said that a lack of such leadership 

hindered their efforts, and they described cases that included delayed, 

incomplete, or unsuccessful implementation of initiatives. Officials in all six states 

also talked about limitations on their agency’s capacity to support children 

affected by trauma, including:

• high rates of staff turnover, especially in child welfare;

• limited staff time to dedicate to trauma initiatives;

• lack of clinicians trained in trauma-focused therapies; and

• insufficient funding to support trauma initiatives.

Officials in some states reported strategies they have used to help address these 

challenges, including providing additional support to employees and coordinating 

with partner agencies to jointly leverage resources, expertise, and data.

View GAO-19-388. For more information, 

contact Kathryn A. Larin at (202) 512-7215 or 

larink@gao.gov.

Why GAO Did This Study

Trauma is a widespread, harmful, and 

costly public health problem, and its 

effects are especially detrimental to 

children. Any frightening, dangerous, 

or violent event that threatens a child 

or their loved ones can potentially be 

traumatic. While not every child who 

experiences trauma will suffer lasting 

effects, trauma significantly increases 

the risk of mental health problems, 

difficulties with social relationships and 

behavior, physical illness, and poor 

school performance. GAO was asked 

to review selected states’ efforts to 

support children affected by trauma.

This report describes (1) the 

assistance that HHS and Education 

provide to help state and local 

agencies support children affected by 

trauma; (2) how child welfare and 

education agencies in selected states 

support these children; and (3) the 

challenges these agencies have faced 

in selected states in supporting these 

children.

GAO interviewed state and local 

officials in six states that were selected 

based on recommendations from 

subject-matter experts and federal 

officials, among other factors; 

administered a questionnaire to 16

state agencies in the selected states;

interviewed federal officials from HHS 

and Education; and reviewed relevant 

federal, state, and local agency 

documents, such as reports and 

guidance. Although our findings cannot 

be generalized to all states, they 

provide insight into government 

support for children affected by trauma.

GAO is not making recommendations 

in this report.
Page i GAO-19-388 Children Affected By Trauma

Letter 1

Background 4

HHS and Education Provide Grants, Disseminate Information, and 

Fund Training and Technical Assistance to Help State and 

Local Agencies Support Children Affected by Trauma 9

Selected States Use Various Approaches to Support Children 

Affected by Trauma 17

Child Welfare and Education Agencies in Selected States 

Identified Leadership and Capacity Limitations as Challenges to 

Supporting Children Affected by Trauma 22

Agency Comments 33

Appendix I Selected State Information 35

Appendix II Selected County Information 37

Appendix III GAO Contact and Staff Acknowledgments 39

Tables

Table 1: Selected Evidence-Based Treatments 7

Table 2: Selected Federal Funding Sources Used to Support 

Children Affected by Trauma as Cited by Selected State 

Officials 12

Table 3: Summary of Substance Abuse and Mental Health 

Services Administration’s Trauma-Informed Care 

Framework for State, Local, or Nonprofit Organizations 16

Table 4: Examples of State Child Welfare Agencies’ Initiatives to 

Support Children Affected by Trauma in the Six Selected 

States 35

Table 5: Examples of State Education Agencies’ Initiatives to 

Support Children Affected by Trauma in Selected States 36

Table 6: Examples of County and Local Agency Initiatives to 

Support Children Affected by Trauma in the Six Selected 

States 37

Contents
Page ii GAO-19-388 Children Affected By Trauma

Abbreviations

ACF Administration for Children and Families 

CMS Centers for Medicare and Medicaid 

Services

Education U.S. Department of Education

HHS U.S. Department of Health and Human 

Services

MCO managed care organization

NCTSI National Child Traumatic Stress Initiative

NCTSN National Child Traumatic Stress Network

Project AWARE Project Advancing Wellness and Resilience 

Education

SAMHSA Substance Abuse and Mental Health 

Services Administration

STS secondary traumatic stress

TF-CBT Trauma-Focused Cognitive Behavioral 

Therapy

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

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necessary if you wish to reproduce this material separately.
Page 1 GAO-19-388 Children Affected By Trauma

441 G St. N.W.

Washington, DC 20548

April 24, 2019

The Honorable Danny K. Davis

Chairman

Subcommittee on Worker and Family Support

Committee on Ways and Means

House of Representatives

The Honorable Richard J. Durbin

United States Senate

Trauma is a widespread, harmful, and costly public health problem, and 

its effects are particularly detrimental to children, according to the U.S. 

Department of Health and Human Services (HHS). Children can be 

exposed to various types of trauma. Any frightening, dangerous, or violent 

event that threatens the life or safety of a child or their loved ones can 

potentially be traumatic. For example, in fiscal year 2017, HHS reported 

that there were approximately 674,000 victims of child maltreatment, 

including neglect and physical and sexual abuse.1 In addition, in 2016, 

students ages 12 through 18 experienced an estimated 749,400 

victimizations (theft and nonfatal violent victimization) at school and 

601,300 victimizations away from school.2 While not every child who 

experiences trauma will suffer lasting effects, studies have shown that for 

many there are serious short- and long-term consequences. As GAO has 

previously reported, trauma significantly increases the risk of mental 

health problems, difficulties with social relationships and behavior, 

physical illness, and poor school performance.3

 1

U.S. Department of Health and Human Services, Administration for Children and 

Families, Administration on Children, Youth and Families, Children’s Bureau, Child 

Maltreatment 2017 (Washington, D.C.: Jan. 28, 2019).

2

For the estimate of victimizations at school, the 95 percent confidence intervals range 

from 585,000 to 913,000; and for the estimate of victimizations away from school, the 95 

percent confidence intervals range from 460,000 to 743,000 for students ages 12-18. See 

L. Musu-Gilette, A. Zhang, K. Wang, J. Zhang, J. Kemp., M. Diliberti, and B.A. Oudekerk, 

Indicators of School Crime and Safety: 2017, NCES 2018-036 / NCJ 251413 (Washington, 

D.C.: U.S. Department of Education, National Center for Education Statistics & U.S. 

Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, March 

2018).

3

GAO, Children’s Mental Health: Concerns Remain about Appropriate Services for 

Children in Medicaid and Foster Care, GAO-13-15 (Washington, D.C.: Dec. 10, 2012).

Letter
Page 2 GAO-19-388 Children Affected By Trauma

You asked us to review how selected states identify and treat children 

and families who have experienced or are at risk of experiencing trauma. 

This report examines:

1. the assistance HHS and the U.S. Department of Education 

(Education) provide to help state and local agencies support children 

affected by trauma;

2. how child welfare and education agencies in selected states are 

supporting children affected by trauma; and

3. the challenges child welfare and education agencies in selected 

states have faced in supporting children affected by trauma.

To address these objectives, we conducted in-person and telephone 

interviews with state and local officials in six states, and administered a 

questionnaire to 16 state agencies. The states we selected were 

Colorado, Massachusetts, North Carolina, Ohio, Washington, and 

Wisconsin. These states were selected based on four criteria: (1) 

recommendations from subject-matter experts and federal agency 

officials; (2) reviews of state child welfare and education agency websites 

to locate statewide initiatives to support children affected by trauma; (3) 

variation in state child welfare system administrative frameworks (two 

state-administered, three county-administered, and one hybrid partially 

administered by the state and partially administered by counties); and (4) 

geographic diversity.4 We spoke with state child welfare officials in all six 

states and with state education and Medicaid5

 4

For purposes of this report, the term “education agency” includes state educational 

agencies and local educational agencies (specifically, school districts). 

5

Medicaid is a joint federal-state program that finances health coverage for low-income 

and medically needy individuals. See 42 U.S.C. § 1396 et seq. Certain children in foster 

care are categorically eligible for Medicaid, such as those receiving foster care 

maintenance payments under title IV-E of the Social Security Act. States are required to 

provide Medicaid coverage to such children. Children in foster care who are not eligible 

under this category may qualify for Medicaid under optional eligibility criteria established 

by a particular state. According to the Congressional Research Service, nearly all children 

who are in foster care are eligible for health care services funded via Medicaid. In addition, 

some children in foster care may be eligible for the State Children’s Health Insurance 

Program, a federal-state program that provides health care coverage to children living in 

families whose incomes exceed the eligibility requirements for Medicaid. We spoke with 

Medicaid officials in Colorado, Massachusetts, North Carolina, and Ohio to obtain their 

perspective because child welfare officials in those states reported challenges in using 

Medicaid to support children affected by trauma. We did not conduct interviews with state 

Medicaid agencies in Washington or Wisconsin because child welfare officials in those 

states did not report facing challenges using Medicaid.
Page 3 GAO-19-388 Children Affected By Trauma

officials in four states.6 Also, in each state we selected two localities and 

interviewed local officials from the respective child welfare and education 

agencies, where practicable. These localities were selected based on 

recommendations from state officials and geographic diversity (one urban 

and one rural). In addition, we interviewed officials from other selected 

state and local agencies and organizations, such as departments of 

health, interagency trauma groups, universities, and hospitals, as 

appropriate. We also reviewed relevant state and local child welfare and 

education agency documents, such as annual reports and policy 

guidance.

We supplemented and confirmed the information obtained during 

interviews with state officials through a questionnaire sent to 16 state 

agencies7 across the six states from August to October 2018.8 We pretested the questionnaire with three state agencies in Washington and 

updated the questions based on feedback from those agencies. All 16 

agencies completed the questionnaire.

To obtain additional information about the assistance federal agencies 

provide to help child welfare and education agencies in selected states in 

their efforts to support children affected by trauma, we interviewed 

officials from HHS’s Administration for Children and Families (ACF), 

Substance Abuse and Mental Health Services Administration (SAMHSA) 

and the Centers for Medicare and Medicaid Services (CMS). We also 

interviewed officials from Education, including officials with the Office of 

Elementary and Secondary Education. We reviewed relevant agency 

documents, such as guidance provided to states, issue briefs, and budget 

documents. Our findings cannot be generalized to states or localities 

outside our selection sample.

We conducted this performance audit from January 2018 to April 2019 in 

accordance with generally accepted government auditing standards. 

 6

State education officials in North Carolina and Ohio told us that they did not have 

statewide initiatives to support children affected by trauma, so we did not interview them.

7

In one of the selected states, two state agencies collaborate on a statewide initiative. We 

sent the questionnaire to officials in both agencies, but one official was primarily 

responsible for completing it.

8

The 16 agencies represent all state-level government agency officials we interviewed, 

except for state Medicaid agencies. Our interviews with state Medicaid officials were 

narrowly focused on challenges raised by child welfare officials, so we did not ask state 

Medicaid officials to complete the questionnaire.
Page 4 GAO-19-388 Children Affected By Trauma

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

Trauma or adverse childhood experiences9 may include physical and 

sexual abuse, neglect, bullying, community-based violence, extreme 

poverty, the loss of a parent or primary caretaker, or natural disasters, 

among other things. These experiences may overwhelm a child’s natural 

ability to cope10 and can cause stress reactions in children, including 

feelings of intense fear, terror, and helplessness.11 When children are 

exposed to chronic stressful events, their neurodevelopment can be 

disrupted. As a result, a child’s cognitive functioning or ability to cope with 

negative or disruptive emotions may be impaired, causing long-term harm 

to their physical, social, and emotional well-being.12 These adverse 

effects may include changes in a child’s emotional responses; ability to 

think, learn, and concentrate; impulse control; self-image; attachments to 

caregivers; and relationships with others. Traumatic experiences have 

been linked to a wide range of health-related conditions, including 

addiction, depression and anxiety, and risk-taking behavior, and may also 

 9

Adverse childhood experiences are stressful or traumatic events, including abuse and 

neglect. In a landmark study, researchers from the Centers for Disease Control and 

Prevention and Kaiser Permanente found a “strong graded relationship between the 

breadth of exposure to abuse or household dysfunction during childhood and multiple risk 

factors for several of the leading causes of death in adults.” V. Felitti, MD, FACP; R. Anda, 

MD, MS; D. Nordenberg, MD; D. Williamson, MS, PhD; A. Spitz, MS, MPH; V. Edwards, 

BA, M. Koss, PhD; and J. Marks, MD, MPH, “Relationship of Childhood Abuse and 

Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse 

Childhood Experiences (ACE) Study,” American Journal of Preventive Medicine, Volume 

14, Number 4, (1998), p. 245. 

10U.S. Department of Health and Human Services, Children’s Bureau, Child Welfare 

Information Gateway, Developing a trauma-informed child welfare system (Washington, 

D.C.: 2015). 

11Vanessa Sacks and David Murphey, Child Trends, The prevalence of adverse childhood 

experiences, nationally, by state, and by race or ethnicity (Feb. 12, 2018), accessed 

March 13, 2018.

12Child Welfare Information Gateway, Developing a trauma-informed child welfare system. 

Background

Childhood Trauma 
Page 5 GAO-19-388 Children Affected By Trauma

increase the likelihood of chronic ill health conditions, such as obesity, 

diabetes, heart disease, cancer, and even early death. Not all children will 

experience all of these effects. Children’s responses to traumatic events 

are unique and affected by many factors, including their age at the time of 

the event, the frequency and perceived severity of trauma, and the child’s 

innate sensitivity, as well as protective factors such as the presence of 

positive relationships with healthy caregivers, physical health, and natural 

coping skills.13

While all children can be affected by trauma, trauma is common among 

children who enter the child welfare system.14 Many of these children 

have been abused or neglected, and involvement in the child welfare 

system, primarily through placements into a foster care home, may cause 

additional trauma due to the separation from family; changes in school 

placement, neighborhood, and community; as well as fear and uncertainty 

about the future. Child welfare experts generally believe that child welfare 

systems that use trauma-informed approaches15 are better able to 

 13Child Welfare Information Gateway, Developing a trauma-informed child welfare system. 

14Other subpopulations may also be likely to experience trauma, such as homeless 

children, children who live in unsafe neighborhoods, and unaccompanied alien children—

those under 18 years old with no lawful immigration status and no parent or legal guardian 

in the United States available to provide care and physical custody. During the 2015-16 

school year, there were 1.3 million homeless students enrolled in the nation’s public 

school districts. Also, in 2017, GAO reported that the safety of a child’s environment, 

including their neighborhood, can affect a wide range of health, functioning, and quality-oflife outcomes and risks, including a child’s sense of security and well-being. See National 

Center for Homeless Education, Federal Data Summary: School Years 2013-14 to 2015-

16, Education for Homeless Children and Youth (Browns Summit, NC: Dec. 2017); GAO, 

Child Well-Being: Key Considerations for Policymakers, Including the Need for a Federal 

Cross-Agency Policy Goal, GAO-18-41SP (Washington, D.C.: Nov. 9, 2017); and 

Statement of Jack P. Shonkoff, M.D., Director, Center on the Developing Child at Harvard 

University, before the Energy and Commerce Committee, Subcommittee on Oversight and 

Investigations, United States House of Representatives, February 7, 2019. 

15According to SAMHSA, a program, organization, or system that is trauma-informed: (1) 

realizes the widespread impact of trauma and understands potential paths for recovery; 

(2) recognizes the signs and symptoms of trauma in clients, families, staff, and others 

involved with the system; (3) responds by fully integrating knowledge about trauma into 

policies, procedures, and practices; and (4) seeks to actively resist re-traumatization. 
Page 6 GAO-19-388 Children Affected By Trauma

address children’s safety, permanency, and well-being needs.16 Although 

trauma-informed frameworks may vary, they generally include 

interventions as well as a change in culture; thus if an agency or 

organization is taking a trauma-informed approach, it is incorporating 

knowledge of trauma and its effects into its policies, procedures, and 

practices. A trauma-informed child welfare system may offer services to 

help identify and mitigate the effects of trauma, including screening and 

assessing children for trauma, and providing or referring children to 

services. These approaches may produce improved outcomes for 

children in the child welfare system, including fewer children requiring 

crisis services, such as residential treatment, and fewer foster home 

placements, placement disruptions, and reentries into foster care. Other 

trauma-informed approaches may result in reduced lengths of stay in 

foster care and improved child functioning and increased well-being.17

In addition to child welfare agencies, school staff and members of the 

school community can play a key part in recognizing and responding to 

children who have experienced trauma. In a 2017 report on child wellbeing, GAO reported that an expert noted that health and human service 

agencies are not the only entities needed to address child well-being and 

suggested that community stakeholders work together to determine what 

resources are needed for the children in their community.18 A traumainformed school, characterized by an understanding and a commitment of 

teachers and staff to an awareness of how trauma affects students, is an 

example of a coordinated approach to trauma. Trauma-informed teachers 

and staff are aware of trauma’s impact on students’ behavior, their 

relationships, their ability or inability to self-regulate behavior, and how it 

 16Federal funding is available to states to support their child welfare and foster care 

programs under Titles IV-B and IV-E of the Social Security Act. In 2018, the Act was 

amended to enable states to use federal funds provided under Title IV-B and Title IV-E to 

provide enhanced support to children and families and prevent foster care placements 

through the provision of mental health and substance abuse prevention and treatment 

services, in-home parent skill-based programs, and kinship navigator services. The law 

requires that any such services provided under Title IV-E be trauma-informed. Bipartisan 

Budget Act of 2018, Pub. L. No. 115-123, §§ 50701-50734, 132 Stat. 64, 232-253. ACF 

published program instructions about the Title IV-E prevention and family services 

programs in November 2018. Department of Health and Human Services, Administration 

on Children, Youth and Families, Administration for Children and Families, Children’s 

Bureau, Program Instruction: State Requirements for Electing Title IV-E Prevention and 

Family Services Programs, ACYF-CB-PI-18-09 (Washington, D.C: Nov. 30, 2018).

17Child Welfare Information Gateway. Developing a trauma-informed child welfare system.

18GAO-18-41SP.
Page 7 GAO-19-388 Children Affected By Trauma

contributes to their classroom behavior. Specific elements of a traumainformed school may include addressing and treating traumatic stress, 

developing partnerships with students and families, evaluating and 

revising school discipline policies and practices, and creating a traumainformed learning environment.19

Federal agencies, academic institutions, and community-based treatment 

centers have generated evidence-based trauma treatments that clinicians 

and therapists can use when working with children and their families.20

See table 1 for examples of treatments.

Table 1: Selected Evidence-Based Treatments

Attachment, Self-Regulation, 

and Competency 

Includes multiple modalities, such as individual, group and family treatment; parent workshops; 

and a home-based prevention program. The approach addresses how a child’s entire system of 

care can become trauma-informed to better support trauma-focused therapy.

Child-Parent Psychotherapy Focuses on the way the trauma has affected the parent-child relationship, and the family’s 

connection to their culture and cultural beliefs, spirituality, immigration experiences, and parenting 

practices, among other things.

Early Pathways Focuses on helping caregivers better understand and manage their child’s behavior and 

emotional problems; strengthening the child’s prosocial behaviors and setting limits on 

challenging behaviors; and learning trauma-informed strategies to include safety, calming 

techniques, and recovery, among other things. 

Parent-Child Interaction 

Therapy 

Treats young children exposed to interpersonal violence. It offers concrete, practical parenting 

skills. The emphasis is on changing negative parent/caregiver child patterns.

Structured Psychotherapy for 

Adolescents Responding to 

Chronic Stress

Designed as a group treatment to improve the emotional, social, academic, and behavioral 

functioning of adolescents exposed to chronic interpersonal trauma (such as ongoing physical 

abuse) and/or separate types of trauma (e.g. community violence, sexual assault).

Trauma Focused-Cognitive 

Behavioral Therapy

Focuses on development of skills for regulating behavior; improving relationships; and enhancing 

safety, trust, parenting skills, and family communication

Source: GAO summaries from National Child Traumatic Stress Network fact sheets. | GAO-19-388

 19Individuals with experiences of trauma are found in multiple service sectors. In addition 

to child welfare and education agencies, trauma-informed approaches can be adapted to 

other sectors, such as criminal and juvenile justice, primary health care, the military and 

other settings that have the potential to ease or exacerbate an individual’s capacity to 

cope with traumatic experiences. Department of Health and Human Services, Substance 

Abuse and Mental Health Services Administration, SAMHSA’s Concept of Trauma and 

Guidance for a Trauma-Informed Approach, 14-4884 (Rockville, MD: 2014).

20Evidence-based programs generally indicate those interventions and activities that 

evaluations have shown to be effective at addressing a particular outcome.

Trauma Treatments and 

Approaches
Page 8 GAO-19-388 Children Affected By Trauma

Recent studies have also found that trauma-informed approaches that are 

infused into the practices and work of child welfare and school staff can 

help children, their families, and others. While these studies are limited in 

terms of the number of participants, they indicate the positive effects of 

including trauma-informed approaches into the work of child welfare staff 

and educators. For example, one study that used child welfare 

administrative data for about 1,500 children from Kansas found that 

implementing a trauma-informed approach was associated with improved 

child well-being and placement stability for children in foster care.21

Another study of two public child welfare agencies that involved 52 

children, as well as child welfare staff, mental health providers, and foster 

parents and kinship caregivers, suggests, among other things, that fewer 

children exited foster homes for negative reasons, such as running away 

or moving to a group home, when families were trained in a traumainformed approach.22 In addition, a study of 126 female youths residing in 

two treatment centers in Massachusetts suggests that the youth at the 

center receiving the trauma-informed approach experienced a reduction 

in post-traumatic stress disorder symptoms compared with the youth in 

the residential center that did not offer this approach.23 A study of five 

schools that adopted a trauma-sensitive approach also reported positive 

outcomes. For example, the study found a decrease in disciplinary 

actions, and staff at one school reported that the school felt safer and 

calmer. School staff also reported improved relations among colleagues 

 21Researchers studied the effectiveness of a research-informed therapeutic model, 

Trauma Systems Therapy, implemented across a child welfare system. K. Murphy, K. 

Anderson Moore, Z. Redd, K. Malm, “Trauma-informed child welfare systems and 

children's well-being: A longitudinal evaluation of KVC's bridging the way home initiative,” 

Children and Youth Services Review, 75 (2017): 23–34. 

22This study examined how a trauma-informed care approach (Trauma Systems TherapyFoster Care, an adapted version of Trauma Systems Therapy for foster care) was 

implemented in two child welfare agencies. Jessica Dym Bartlett, Berenice Rushovich, 

Martha Beltz, Esther Gross, and Ann Schindler, Child Trends, Evaluation of the 

Implementation of Trauma Systems Therapy-Foster Care in a Public Child Welfare Setting 

(Nov. 17, 2017), accessed March 28, 2018.

23The residential treatment centers used the evidenced-based, trauma-informed treatment 

Attachment, Regulation and Competency, an intervention for children with complex 

trauma. H. B. Hodgdon, K. Kinniburgh, D. Gabowitz, M. E. Blaustein, and J. Spinazzola, 

“Development and Implementation of Trauma-Informed Programming in Youth Residential 

Treatment Centers Using the ARC Framework,” Journal of Family Violence, vol. 28 

(2013): 679–692.
Page 9 GAO-19-388 Children Affected By Trauma

and with students, as well as better relations between students and 

increased parent engagement.24

HHS’s ACF and SAMHSA have awarded discretionary grants to states 

specifically to address childhood trauma. From 2011 to 2013, ACF 

awarded 20 state and local agencies and other organizations 

discretionary grants to address childhood trauma, according to ACF 

officials, totaling about $58 million.25 Each grantee, including two state 

child welfare agencies and a county agency as well as two universities in 

five of the six states we selected to review, received up to 5 years of 

 24“The Trauma and Learning Policy Initiative, a joint program of Massachusetts Advocates 

for Children and Harvard Law School, developed an inquiry-based process for creating 

trauma-sensitive schools, which was implemented by educators in four elementary and 

one middle-high school over the course of two school years.” Wehmah Jones, Juliette 

Berg, and David Osher, Trauma and Learning Policy Initiative (TLPI): Trauma-Sensitive 

Schools Descriptive Study (Washington, D.C.: American Institutes for Research, October 

2018). 

25These funding opportunities were referred to as: Integrating Trauma-Informed and 

Trauma-Focused Practice in Child Protective Service Delivery; Initiative to Improve 

Access to Needs-Driven, Evidence-Based/Evidence-Informed Mental and Behavioral 

Health Services in Child Welfare; and, Promoting Well-Being and Adoption after Trauma. 

All three grants were administered under the authority of the Adoption Opportunities 

Program, see 42 U.S.C. § 5113. As part of its administration of these grants, ACF 

provided technical assistance to states and convened annual conferences so grantees 

could share information with each other. Several grantees collaborated to publish articles 

about their efforts to support children affected by trauma.

HHS and Education 

Provide Grants, 

Disseminate 

Information, and Fund 

Training and 

Technical Assistance 

to Help State and 

Local Agencies 

Support Children 

Affected by Trauma

HHS and Education 

Provide Multiple Sources 

of Funding That State and 

Local Agencies Can Use 

to Support Children 

Affected by Trauma
Page 10 GAO-19-388 Children Affected By Trauma

funding. The grants were used to screen and refer children to treatment, 

implement or expand trauma-focused, evidence-based treatments, and 

bridge the gap between child welfare and mental health. According to 

HHS officials, funding for the last of these grants will end in September 

2019.

SAMHSA also awards discretionary grants specifically to address 

childhood trauma to state and local agencies, universities, and other 

organizations through an initiative to transform mental health care for 

children and adolescents affected by trauma. The National Child 

Traumatic Stress Network (NCTSN), a collaborative network of experts 

created through the National Child Traumatic Stress Initiative (NCTSI),26

conducts research on trauma treatment approaches and provides 

services to children affected by trauma. In fiscal year 2017, SAMHSA 

received over $48 million for the NCTSN, and it awarded four new grants 

and supported 82 5-year grant continuations through NCTSI. Officials that 

we spoke with from one state child welfare agency, three universities, and 

two nonprofits in four of the selected states received grants through this 

initiative. Several of these entities used these funds to train clinicians and 

educate other child serving professionals about trauma and mental health 

conditions.

In addition to grants that were specifically meant to address childhood 

trauma, the selected states used other HHS discretionary grants to 

support children affected by trauma. For example, officials from five state 

education agencies in the selected states told us that they received 

SAMHSA’s Project Advancing Wellness and Resilience Education 

(Project AWARE) grant.27 Wisconsin officials also said they received 

 26NCTSI is authorized under the Children’s Health Act of 2000, see 42 U.S.C. § 290hh-1. 

Established in 2000, the National Child Traumatic Stress Initiative (NCTSI) seeks to 

improve the quality of community-based trauma treatment and services and increase 

access to effective trauma-focused interventions.

27Through Project AWARE, education agencies may receive funds to increase awareness 

of mental health conditions among school-age youth, prepare educators and other adults 

to detect and respond to such conditions, and connect youth with appropriate services. 

These Project AWARE grants are authorized under the Public Health Service Act, as 

amended, see 42 U.S.C. § 290bb-32. 
Page 11 GAO-19-388 Children Affected By Trauma

Education’s School Climate Transformation Grant,28 which was used to 

create the state’s trauma-sensitive schools initiative. Washington officials 

credited SAMHSA’s Mental Health Transformation Grant29 with driving the 

state’s initial trauma-informed work, including its guide about trauma in 

schools.30

State agency officials also reported using formula funds, meant for broad 

purposes like mental health, substance abuse, child welfare, and 

education, to support their work with children affected by trauma. Officials 

from five agencies in the selected states reported using formula funding 

from Title IV-E of the Social Security Act to help children affected by 

trauma.31 According to Colorado officials, the state’s Title IV-E waiver has 

allowed child welfare workers to screen, assess, and provide 

interventions that are trauma-informed.32 Also, North Carolina officials told 

us that Title IV-E, combined with other funding sources, has helped pay 

for trauma-informed learning communities to help counties build traumainformed programming. Two states reported using the Substance Abuse 

 28Education administers the School Climate Transformation Grant program, which 

provides competitive grants to state and local educational agencies to develop, enhance, 

or expand systems of support for schools implementing an evidence-based, multi-tiered 

behavioral framework for improving behavioral outcomes and learning conditions for all 

students. These grants are authorized under Title IV-F of the Elementary and Secondary 

Education Act of 1965, as amended, see 20 U.S.C. § 7281.

29The Mental Health Transformation Grant program was intended to support changes in 

the organization, management, and delivery of public mental health services. Grants were 

administered by SAMHSA and authorized under the Public Health Service Act, see 42 

U.S.C. 290bb-32. The final 5-year grants were awarded in fiscal year 2010, according to 

HHS officials.

30Ray Wolpow, Mona M. Johnson, Ron Hertel, and Susan O. Kincaid, The Heart of 

Learning and Teaching: Compassion, Resiliency, and Academic Success (WA: 

Washington State Office of Superintendent of Public Instruction, September 2009), 

accessed July 23, 2018.

31Title IV-E authorizes the large majority of federal funding dedicated to child welfare, with 

funds chiefly available for specific foster care and adoption expenses. Title IV-E is codified 

at 42 U.S.C. §§ 670-679c. 

32HHS was authorized to waive certain Title IV-E requirements to enable states to carry 

out approved demonstration projects. HHS was authorized to approve new demonstration 

projects through FY 2014. Demonstration projects are generally limited to five years and 

may not continue after September 30, 2019. See 42 U.S.C. § 1320a-9.
Page 12 GAO-19-388 Children Affected By Trauma

and Mental Health Block Grants.33 (See table 2 for additional grants 

states reported using to support children affected by trauma.)

Table 2: Selected Federal Funding Sources Used to Support Children Affected by Trauma as Cited by Selected State Officials 

Federal funding sources CO MA NC OH WA WI

Department of Health and Human Services

 Discretionary grants

Administration for Children and Families trauma grantsa

- ✓ ✓ - ✓ -

Mental Health Transformation Grants - - - ✓ ✓ -

National Child Traumatic Stress Initiative Grants - - ✓ - - ✓

Project Advancing Wellness and Resilience Education (Project AWARE) Grants ✓ - ✓ ✓ ✓ ✓

Safe Schools, Healthy Students Initiative Grantsb

- - - - - ✓

System of Care Expansion Planning Grantsc

✓ - - ✓ - -

Formula funds

Medicaidd

✓ ✓ ✓ ✓ ✓ ✓

State Opioid Response Grantse

- - - ✓ - -

State Targeted Response to the Opioid Crisis Grantsf

- - - ✓ - -

Social Services Block Grantsg

- - ✓ - ✓ -

Substance Abuse and Mental Health Block Grants - - - ✓ - ✓

Temporary Assistance for Needy Familiesh

- - ✓ - ✓ -

Title IV-B of the Social Security Acti

- - ✓ ✓ ✓ ✓

Title IV-E of the Social Security Act ✓ - ✓ ✓ ✓ ✓

Department of Education

 Discretionary grants

State Personnel Development Grantsj

✓ - - - - -

School Climate Transformation Grants - - - - - ✓

 Formula funds

Title I-A of the Elementary and Secondary Education Actk

- - - - ✓ -

 33The Substance Abuse Prevention and Treatment Block Grant and the Community 

Mental Health Services Block Grant (Substance Abuse and Mental Health Block Grants) 

provide funds and technical assistance for substance abuse and mental health services. 

These grants are administered by SAMHSA and authorized under the Public Health 

Service Act. See 42 U.S.C. § 300x et seq.
Page 13 GAO-19-388 Children Affected By Trauma

Federal funding sources CO MA NC OH WA WI

Title IV-A of the Elementary and Secondary Education Actl

- - - - ✓ -

Legend: ✓ = Officials at one or more state agencies reported using funding source to support children affected by trauma.

Source: GAO analysis of questionnaire responses received August-November 2018. | GAO-19-388

Note: With two exceptions, officials are points of contact at the 16 state child welfare, education, and 

other agencies—such as departments of health—which completed our questionnaire across the six 

states. For Massachusetts and Wisconsin, statements about Medicaid from our interviews with state 

child welfare officials were used to supplement questionnaire responses. Additionally, North Carolina 

and Ohio education agencies were not asked to complete the questionnaire because officials in these 

states told us that they did not have statewide initiatives to support children affected by trauma, but a 

state education official in each state told us that they have received Project Advancing Wellness and 

Resilience Education grants.

a

The ACF’s Children’s Bureau awarded trauma-focused discretionary grants across three cohorts 

from 2011 to 2013.

b

Launched in 1999 as a joint program of the Departments of Education, Health and Human Services, 

and Justice, the Safe Students, Healthy Schools Initiative has awarded grants to school districts to 

prevent youth violence and promote healthy development of youth. c

System of Care Expansion Planning Grants are administered by SAMHSA and intended to facilitate 

adoption of a system of care approach for children and youth with serious emotional disturbances.

SAMHSA has not awarded these grants since 2014, according to officials. d

Although the Massachusetts and Wisconsin officials who completed our questionnaire did not 

mention Medicaid as a source of funding to support children affected by trauma, under the Medicaid 

program, states are required to provide eligible children under age 21 with coverage for certain health 

services, which may include mental health services, through the Early and Periodic Screening, 

Diagnostic, and Treatment (EPSDT) benefit. Additionally, state child welfare officials we interviewed 

in both of these states talked about using Medicaid to support children affected by trauma. For 

example, the Wisconsin Department of Health Services and the Department of Children and Families 

partnered to implement Care4Kids, a program designed to offer comprehensive and coordinated 

health services for children in foster care. The Care4Kids program creates a “medical home” team for 

children in foster care, assuring that children receive individualized treatment plans in order to

address their specific health care needs, including trauma-related care. e

State Opioid Response Grants are administered by SAMHSA and aim to address the opioid crisis by 

increasing provision of prevention, treatment, and recovery activities for opioid use disorder.

f

State Targeted Response to the Opioid Crisis Grants are administered by SAMHSA and aim to 

address the opioid crisis by increasing provision of prevention, treatment, and recovery activities for 

opioid use disorder.

g

Social Services Block Grant goals include, among others, preventing or remedying child abuse and 

neglect, preventing or reducing inappropriate institutional care, and achieving or maintaining selfsufficiency.

h

Temporary Assistance for Needy Families is a block grant that supports four overarching goals, 

including providing assistance to needy families so that children can live in their homes or the homes 

of relatives.

i

Title IV-B of the Social Security Act authorizes federal funds to support state child welfare programs 

and services. In addition to formula grants under the Stephanie Tubbs Jones Child Welfare Services 

program and the Promoting Safe and Stable Families program, Title IV-B also authorizes some 

discretionary grants.

j

The Individuals with Disabilities Education Act authorizes federal funds for the State Personnel 

Development Grants program. The program provides grants to help state educational agencies 

reform and improve their training and professional development systems for individuals who serve 

children with disabilities.

k

Title I-A of the Elementary and Secondary Education Act of 1965, as amended, provides formula 

grants to states for their school districts to improve educational programs in schools with high 

concentrations of students from low-income families.

l

Title IV-A of the Elementary and Secondary Education Act of 1965, as amended by the Every 

Student Succeeds Act, authorizes the Student Support and Academic Enrichment program, which is 

intended to increase the capacity of state and local education agencies, schools, and local 

communities to provide all students with a well-rounded education and to improve school conditions 

and the use of technology.
Page 14 GAO-19-388 Children Affected By Trauma

In addition to federal funding, officials in the six selected states reported 

receiving state funding to support children affected by trauma. For 

example, officials in North Carolina told us that, in 2013, the North 

Carolina General Assembly appropriated $1.8 million in annually recurring 

funds to train clinicians in evidence-based trauma treatments. Also, in 

Massachusetts, state funding may be used to create and support traumasensitive initiatives in schools, among other things. In addition to state 

funding, officials in three of the selected states reported using nonprofit 

funding to support their efforts.

HHS offers information and funds training and technical assistance to 

help state and local agencies support children affected by trauma.34 For 

example, state and local child welfare officials in each of the six selected 

states cited the National Child Traumatic Stress Network (NCTSN) as an 

important resource for information, training, or technical assistance.35

State and local officials in four of the selected states told us that they use 

the NCTSN’s Child Welfare Trauma Training Toolkit curriculum to train 

their staff. The curriculum, designed to be completed in about 13 hours, 

covers topics such as the essential elements of a trauma-informed child 

welfare system, the impact of trauma on the brain and body, and the 

 34The Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment 

(SUPPORT) for Patients and Communities Act, which was enacted on October 24, 2018, 

directs federal agencies to take several actions related to trauma-informed care. Among 

other things, it authorizes HHS to collect and report data on adverse childhood 

experiences, and it requires HHS to disseminate information and resources to early 

childhood care and education providers on how to recognize children impacted by trauma 

and respond appropriately. The act also establishes an Interagency Task Force on 

Trauma-Informed Care, comprised of various components within HHS, Education, and the 

Departments of Veterans Affairs and Justice, among others, to identify, evaluate, and 

make recommendations regarding: (1) best practices with respect to children and youth 

who have experienced or are at risk of experiencing trauma, and (2) ways in which federal 

agencies can better coordinate to improve the federal response to families impacted by 

substance use disorders and other forms of trauma. In addition, the act authorizes HHS to 

award grants, contracts, or cooperative agreements to state and local education agencies 

for the purpose of increasing student access to evidence-based trauma support services 

and mental health care. See Pub. L. No. 115-271, §§ 7131-7135, 132 Stat. 3894, 4046-56 

(2018). Given its recent enactment, we did not review the implementation of this law for 

this report.

35The NCTSN develops and disseminates interventions and resource materials, offers 

education and training programs, and engages in data collection and evaluation, among 

other activities, to help education and child welfare agencies and others support children 

affected by trauma. As noted earlier, NCTSN is part of SAMHSA’s NCTSI and is 

comprised of its current and former grantees. 

HHS and Education Share 

Information and Fund 

Training and Technical 

Assistance to Help State 

and Local Agencies 

Support Children Affected 

by Trauma
Page 15 GAO-19-388 Children Affected By Trauma

identification of trauma-related needs of children and families.36 Also, two 

state child welfare agencies told us that they use the Resource Parent 

Curriculum to train foster parents and others about trauma, and another 

used the Think Trauma curriculum to prepare trainers of group home and 

residential center staff; both curricula are provided through the NCTSN.37

In addition, the NCTSN makes other resources available to state and 

local communities on its website. For example, NCTSN offers fact sheets 

about various assessments and treatments, including those mentioned in 

table 1, as well as two evidence-based treatments for use in school 

settings.38

In addition to information and training provided through the NCTSN, in 

2012, HHS’s ACF issued guidance to encourage state child welfare 

directors to focus on improving behavioral and social-emotional outcomes 

for children who have experienced abuse or neglect. In 2013, SAMHSA, 

in collaboration with ACF and CMS, issued joint guidance to encourage 

the integrated use of trauma-focused screening, functional assessments, 

and evidence-based practices in child-serving settings.39 Also, in 2014, 

SAMHSA, in an effort to help service sectors, such as child welfare, 

education, and juvenile justice, become more trauma-informed, released 

Concept of Trauma and Guidance for a Trauma-Informed Approach. This 

 36The NCTSN also offers a Child Trauma Toolkit for Educators.

37The Resource Parent Curriculum helps foster parents to understand how traumatic 

events may impact children and to recognize behaviors as symptoms of those 

experiences. Think Trauma provides an overview for juvenile justice staff of how to work 

towards creating a trauma-informed juvenile justice residential setting. According to a 

summary of the curriculum, creating a trauma-informed setting is a process that requires 

not only knowledge acquisition and behavioral modification, but also cultural and 

organizational paradigm shifts and policy and procedural change at every level of the 

facility.

38The two evidence-based treatments, Bounce Back and Support for Students Exposed to 

Trauma, are aimed at relieving symptoms of child traumatic stress, anxiety, depression, 

and functional impairment among children, ages 5-11 and 10-16, respectively. Bounce 

Back includes group sessions where children learn and practice feelings of relaxation, 

problem solving, and conflict resolution, among other activities. Support for Students 

Exposed to Trauma includes 10 lessons in which children learn about common reactions 

to trauma, practice relaxation, learn problem solving skills, build social support, and 

process the traumatic event. Between sessions, children practice the skills they have 

learned. For more information, see NCTSN fact sheets on Bounce Back and Support for 

Students Exposed to Trauma. 

39As GAO noted in a previous report, enhancing the well-being of children requires a 

coordinated federal approach

that takes into account the interrelatedness of federal actions and policies that aim to 

improve the lives of children. See GAO-18-41SP.
Page 16 GAO-19-388 Children Affected By Trauma

document included a framework of key assumptions and principles of a 

trauma-informed approach. SAMHSA intended that the trauma framework 

be relevant to its federal partners and their state and local system 

counterparts and to practitioners, researchers, and trauma survivors, 

families, and communities. (See table 3.)

Table 3: Summary of Substance Abuse and Mental Health Services Administration’s Trauma-Informed Care Framework for 

State, Local, or Nonprofit Organizations

Key assumptions

Realization Staff realize and understand trauma’s effects on individuals, families, groups, 

organizations, and communities.

Recognize Staff recognize the signs of trauma.

Respond Staff respond to people with the understanding that traumatic events affect all people 

involved.

Resist re-traumatization Staff seek to not re-traumatize their clients.

Key principles

Safety Staff and clients should feel physically and psychologically safe.

Trustworthiness and transparency Staff build and maintain trust with their clients and each other to ensure transparency.

Peer support Children or family members who have also experienced trauma support each other to 

promote recovery.

Collaboration and mutuality Staff and clients build and maintain relationships, recognizing that everyone can help 

people heal from trauma.

Empowerment, voice, and choice Staff foster clients’ empowerment and support clients’ shared decision making.

Cultural, historical, and gender issues Staff respond to the racial, ethnic, and cultural needs of their clients by overcoming 

stereotypes and biases.

Examples for implementing a trauma-informed care organization

Organization’s physical environment Physical spaces feel safe, open, and transparent, and there are shared spaces for staff 

and clients.

Screening, assessment, and treatment 

services

Practitioners are trained in and use evidence-based therapies that reflect traumainformed care principles.

Evaluation Staff design trauma-informed care focused evaluations that measure service and 

program implementation.

Source: GAO summary of SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. | GAO-19-388

Note: Besides SAMHSA’s framework, other organizations, such as nonprofits, have developed 

models to help organizations incorporate awareness of trauma into their work.
Page 17 GAO-19-388 Children Affected By Trauma

In addition to the information and training and technical assistance 

referenced above, HHS and Education fund technical assistance centers 

and make other resources available to states, including:

• SAMHSA’s National Center for Trauma-Informed Care and 

Alternatives to Seclusion and Restraint offers technical assistance to 

various publicly-funded systems and organizations on issues relating 

to trauma education, among other things.

• Education’s Readiness and Emergency Management for Schools 

Technical Assistance Center helps local education agencies before, 

during, and after emergency situations. Among its various activities, 

this technical assistance center offers information and technical 

assistance to local education agencies and others on Psychological 

First Aid for Schools, which is an intervention model to assist 

students, staff, and families in the immediate aftermath of an 

emergency.

• Education’s National Center on Safe Supportive Learning 

Environments as well as its Positive Behavioral Interventions and 

Supports Technical Assistance Center offer an array of materials 

about trauma and approaches to supporting children affected by it.

• ACF, through its Child Welfare Information Gateway website, provides 

information on building trauma-informed systems, assessing and 

treating trauma, and addressing secondary trauma in caseworkers. It 

also offers trauma resources for caseworkers, caregivers, and 

families, as well as information about trauma training. In some 

instances, the website directs users to SAMHSA or the NCTSN’s 

website.

Officials we spoke with in the six selected states told us they used a 

variety of approaches to help staff understand trauma and its effects on 

children, identify children affected by trauma, and provide support to 

them. These approaches range from training child welfare workers, 

educators, and clinicians to screening children for symptoms caused by 

traumatic experiences. They also include developing support systems, 

including providing services, to children and their families who need more 

help. While we did not evaluate the effectiveness of the selected state 

and county initiatives, many of them incorporate key trauma principles 

and activities cited in the SAMHSA framework above.40 For additional 

 40For this review, we did not evaluate the effectiveness of the selected states’ or counties’ 

initiatives. Also, we did not independently verify the information provided, but 

Selected States Use 

Various Approaches 

to Support Children 

Affected by Trauma
Page 18 GAO-19-388 Children Affected By Trauma

information on examples of approaches taken in each selected state and 

in selected counties, see appendixes I and II.

State and local child welfare and education agency officials in the six 

selected states use various approaches to train staff and birth and foster 

parents41 about trauma and its effects on children and families. Child 

welfare officials in two states, Wisconsin and North Carolina, told us that 

they use learning communities to train staff, and in some instances, foster 

parents. For example, North Carolina’s child welfare agency used a 

learning community approach—which included face-to-face training, as 

well as coaching and practice, over an extended period—to work with 

child welfare staff in 32 of the state’s 100 counties, according to a state 

official. In a 2016 agency report, state officials reported that the 9- to 12-

month learning community process was designed to allow staff the time 

required to become steeped in trauma knowledge, to learn how to spread 

that knowledge into skills and practices, and to develop a sustainable 

program. Conversely, state and local education and child welfare officials 

in three states told us that they use online learning or university 

coursework to train staff. For example, Wisconsin education agency 

officials told us that they developed a three-tiered training, including 

online modules for educators and school staff. The modules are designed 

for self-study and, among other things, include guidance on making 

policies and procedures more trauma-sensitive, as well as information 

about the characteristics of safe, supportive learning environments. Also, 

Massachusetts state child welfare officials told us that they partnered with 

three universities to provide trauma-focused courses to child welfare 

workers, and local school officials told us that a university offers a 

graduate certificate in trauma and learning to area educators.

In addition to training staff, state and local child welfare agency officials in 

four of six selected states told us they train clinicians in trauma-focused, 

evidence-based therapies. For example, Wisconsin child welfare officials 

told us that clinicians participate in learning communities where they 

receive training in Trauma-Focused Cognitive Behavioral Therapy (TFCBT), an evidence-based therapy. Clinicians participate in 5 days of inperson training, receive 16 consultation calls with a trainer, and complete 

 corroborated, when possible, the information we received during our state and county 

interviews with relevant state documents. We provided officials the opportunity to review 

the content for accuracy and provide revisions or corrections.

41These parents can also include kinship caregivers. 

Training
Page 19 GAO-19-388 Children Affected By Trauma

a 10-hour, self-paced webinar. According to Wisconsin’s child welfare 

website, clinicians who complete the training are eligible for certification 

as TF-CBT therapists and can be listed on a national website of certified 

clinicians.42 Similarly, North Carolina’s state child welfare agency, in 

partnership with a nonprofit organization, trains clinicians in four traumafocused, evidence-based therapies, including TF-CBT and Parent-Child 

Interaction Therapy. Similar to the Wisconsin effort, over the course of a 

year, clinicians learn about these therapies and practice them with 

children and families.

While training staff and parents is important to broaden understanding of 

trauma and its impact on affected children, identifying these children is 

also key to helping them receive needed support, including traumafocused treatment. State and local child welfare and education officials in 

five of the six selected states told us that they screen certain children to 

determine whether they have experienced trauma, are exhibiting 

symptoms of trauma, or need to be referred for a trauma-informed mental 

health assessment. For example, North Carolina and Washington child 

welfare officials told us they screen children for trauma when they enter 

the child welfare system. North Carolina counties that participated in the 

state’s training efforts, described above, use two screening tools: one for 

children under age 6 and the other for those ages 6 through 21. The 

social worker, with input from the caregiver, completes the screening tool 

for children under age 6. Older children are asked questions about their 

exposure to trauma, including physical abuse, domestic violence, sexual 

abuse, and other traumatic events. According to the North Carolina child 

welfare agency, the trauma screen has a number of benefits for child 

welfare practice, including informing placement decisions for the youth, 

prioritizing children who might need to receive treatment quickly, and 

providing the mental health professional with a better understanding of a 

child’s issues. Child welfare officials in Washington also reported 

integrating trauma screening into the state’s child screening program, 

using a 2012 ACF trauma grant.43 Children and youth are screened within 

30 days of placement in foster care if officials expect them to remain in 

 42When we spoke with Wisconsin officials in May 2018, they planned to expand their 

training program for clinicians to include Child-Parent Psychotherapy. The 18-month 

program would be coordinated by the University of Wisconsin-Madison.

43As described earlier in this report, ACF awarded trauma-related discretionary grants in 

2011, 2012, and 2013. Among the recipients of these grants are university and state 

government entities in four of the six selected states—Colorado, Massachusetts, North 

Carolina, and Washington. 

Screening
Page 20 GAO-19-388 Children Affected By Trauma

care 30 days or more. With these grant funds, officials reported that 

Washington’s child welfare agency added a tool to screen for children’s 

trauma symptoms and developed a protocol that rescreens these children 

every 6 months.44 In addition, education agency officials from three states 

told us that schools have developed processes to identify students who 

may have experienced trauma. For example, one Wisconsin school 

district official told us that any staff member, family member, or student 

can refer a student for screening. This official explained that the school 

district formed school-based teams to review information, such as data on 

suspensions and class disruptions, to identify at-risk students. In addition 

to the screening process, the school district developed school-based and 

community mental health service partnerships at 23 schools where 

therapists provide mental health services, according to this official.

State and local child welfare and education agency officials in five of six 

selected states told us they have developed support systems, which can 

include providing services, to try to help children affected by trauma. For 

example, Colorado and Ohio child welfare agencies have spearheaded 

efforts to provide services and support to children who may have 

experienced trauma. The Colorado child welfare agency, as part of its 

system of care, uses an evidence- and team-based planning model, 

referred to as high-fidelity wraparound services, to manage care for 

children with or at risk of serious emotional disturbance and who are 

involved in multiple systems, such as the child welfare and juvenile justice 

systems.45 As part of these wraparound services, county child welfare 

staff and local service providers and professionals work with the family to 

create a plan for them and their children. A coordinator sets up meetings, 

oversees the plan, and makes sure all team members participate in 

achieving the plan’s goals. In addition to the coordinator, a family 

advocate provides peer support, via weekly visits, to parents and 

caregivers of youth receiving wraparound services. In addition, depending 

on the needs of the child, wraparound services may include participating 

 44Trauma screening tools include the Pediatric Symptom Checklist and Screen for Child 

Anxiety Related Emotional Disorders. A Washington child welfare official explained that 

they started using the Screen for Child Anxiety Related Emotional Disorders tool to screen 

for trauma because it is more sensitive than the Pediatric Symptom Checklist to identify 

symptoms of trauma, such as anxiety and Post-Traumatic Stress Disorder. In addition to 

these two screening tools, they reported piloting other trauma screening tools to use for 

children ages 3-7.

45The Colorado child welfare agency collaborates with the Office of Behavioral Health to 

implement Colorado’s Trauma Informed System of Care, or COACT Colorado. As of 

February 2019, 17 counties participate in this effort.

Support Systems
Page 21 GAO-19-388 Children Affected By Trauma

in a support group or meeting with a therapist or grief counselor, among 

other things. In Ohio, child welfare officials in two counties told us about a 

partnership that provides services to children and their families who have 

experienced trauma because of parents’ substance use disorder.46 As 

part of the program, children and parents are screened for trauma and 

may get referred for treatment and services. Families receive wraparound 

services that are provided by a caseworker and family peer mentor; the 

family peer mentor has personal experiences with addiction and is in 

recovery.

In addition, state education agency officials in four selected states told us 

that they had at least one statewide effort administered by the state 

education agency to help support all children, including those affected by 

trauma.47 Colorado, Washington, and Wisconsin encourage schools to 

implement tiered systems of behavioral support, according to state 

officials. Tiered systems of support generally consist of three tiers of 

support: (1) universal supports that apply to all children; (2) specialized 

supports for smaller groups of children; and (3) supports for individual 

children who need intensive interventions. To implement the first tier, 

school staff support students in various ways, such as interacting with 

students and setting up a dedicated space in a classroom for students to 

regulate their behavior. The second tier may include convening small 

groups to help children with similar behavioral issues learn how to 

regulate their emotions, and the last tier may include intensive support for 

students who need more help, such as developing and implementing 

wraparound services plans. School district officials that we spoke with in 

Massachusetts told us that although they do not use tiered systems of 

behavioral support, they help children affected by trauma by employing 

practices to create safe classroom environments for all students, such as 

developing and building upon relationships and engaging students in 

structured conversations.

 46Ohio’s Sobriety, Treatment, and Reducing Trauma is administered by the Public 

Children Services Association of Ohio, an organization representing Ohio’s county child 

welfare agencies. The program is primarily funded by the Ohio Attorney General’s Office 

through a Victims of Crime Act grant, according to a state official. Child welfare agencies 

participating in the program partner with local behavioral health providers and juvenile and 

family courts. As of March 2019, 32 counties participate in this effort.

47North Carolina and Ohio do not have statewide education initiatives that support children 

affected by trauma, according to state education agency officials.
Page 22 GAO-19-388 Children Affected By Trauma

Officials in all six selected states spoke of the importance of having 

engaged leadership in establishing and sustaining support for children 

affected by trauma.48 They cited a wide range of leaders, including state 

government officials; managers and supervisors; and those in partner 

agencies, such as schools or nonprofits, who supported these states’

trauma efforts. In some cases, these leaders helped establish new 

trauma initiatives. For example, Wisconsin’s former First Lady launched 

the work of a statewide, interagency trauma initiative. Additionally, Ohio 

county child welfare officials spoke about the value of obtaining 

management support for their plan to become a trauma-informed 

organization. In other cases, leaders were seen as important to sustaining 

trauma initiatives and ensuring their impact. In Massachusetts, university 

officials said that, to ensure the continued availability of evidence-based 

therapies, they train not only clinicians, but also the individuals who 

supervise them. Also, a county public health official in Washington, whose 

agency is implementing trauma initiatives in schools, told us that their 

efforts tend to be unsuccessful unless they first engage school leadership 

and align their health initiatives with the schools’ existing efforts.

Federal officials and reports have also cited leadership as an important 

factor in the implementation of trauma initiatives, with some maintaining 

that leadership is necessary to support children affected by trauma 

 48Officials in this context include education and child welfare officials, as well as officials 

from other agencies and organizations we interviewed, including a university and other 

government bodies, such as interagency groups and departments of public health. 

Child Welfare and 

Education Agencies 

in Selected States 

Identified Leadership 

and Capacity 

Limitations as 

Challenges to 

Supporting Children 

Affected by Trauma

Officials in Selected States 

Reported That Leadership 

Is Important for Supporting 

Children Affected by 

Trauma
Page 23 GAO-19-388 Children Affected By Trauma

because of the need to change an organization’s culture. In 2013, 

NCTSN reported on takeaways from a learning collaborative in which 

nine teams led by child welfare agencies developed, implemented, and 

tested trauma-informed child welfare practices.49 Based on the 

experiences of the teams, the NCTSN report stated that strong and 

consistent leadership is necessary to implement trauma-informed practice 

because it requires a shift in organizational culture. SAMHSA’s 2014 

guidance for a trauma-informed approach similarly suggests that 

organizations consider the importance of leadership to initiate a systemswide change.50 In addition, HHS officials, who worked with states on a 

series of trauma-related grants awarded between 2011 and 2013, also 

told us that leadership commitment was important for their grantees in 

building organizational and worker resiliency, acting upon data and 

evaluation, and sustaining initiatives. These documents and statements 

echo previous GAO work on organizational transformation; for example, 

in 2003 we reported on key practices found at the center of successful 

transformation efforts, noting that leadership must set the direction, pace, 

and tone and provide a clear, consistent rationale that brings everyone 

together behind a single mission.51

In addition to discussing the important role that leadership plays in 

establishing and sustaining support for children affected by trauma, 

officials in three states highlighted instances in which a lack of leadership 

hindered their efforts to support these children. The cases they described 

included delayed, incomplete, or unsuccessful implementation of trauma 

initiatives.

• Delayed implementation. Officials in one school district said they 

had developed policies around multi-tiered system of supports in 2009 

but did not receive support from political leaders or funding for the 

 49J. Agosti, L. Conradi, J. H. Goldman, and H. Langan, Using Trauma-Informed Child 

Welfare Practice to Improve Placement Stability Breakthrough Series Collaborative: 

Promising Practices and Lessons Learned (Los Angeles, CA & Durham, NC: NCTSN, 

June 2013).

50Substance Abuse and Mental Health Services Administration, SAMHSA’s Concept of 

Trauma and Guidance for a Trauma-Informed Approach.

51GAO, Results-Oriented Cultures: Implementation Steps to Assist Mergers and 

Organizational Transformations, GAO-03-669 (Washington, D.C.: July 2, 2003). For more 

recent work in this area, see GAO, Government Reorganization: Key Questions to Assess 

Agency Reform Efforts, GAO-18-427 (Washington, D.C.: June 13, 2018).
Page 24 GAO-19-388 Children Affected By Trauma

initiative until 2016. They told us that this hindered the initiative’s 

implementation.

• Incomplete implementation. State education officials in that same 

state said that a lack of leadership hindered their ability to track school 

districts’ implementation of the state’s trauma initiatives. These 

officials said that a lack of requirements for districts to scale up 

trauma work was a barrier to collecting data on local activities. In 

another state, there was a county child welfare initiative to implement 

universal trauma screening which was conducted in partnership with a 

local university. The university reported that less than half of children 

with open cases were screened during the project period, which 

university officials attributed to some supervisors not supporting the 

screening initiative.

• Unsuccessful implementation. According to officials in a third state, 

turnover among high-level leaders contributed to difficulties integrating 

trauma-informed practices at the state’s child welfare agency, and the 

agency was not successful at implementing a trauma screening 

process.

Officials in all six selected states talked about limitations on their agency’s 

or organization’s capacity to support children affected by trauma. 

Limitations included high rates of staff turnover, limited staff time to focus 

on trauma, insufficient numbers of clinicians trained in trauma-focused, 

evidence-based therapies, and insufficient funding for trauma initiatives. 

Some agencies and organizations had taken actions to address these 

challenges.

Staff Turnover

High rates of staff turnover were reported in all six selected states. This 

limitation was more commonly raised by child welfare agencies than by 

Child Welfare and 

Education Officials in 

Selected States Also 

Reported Capacity 

Limitations and Other 

Challenges to Supporting 

Children Affected by 

Trauma

Capacity Limitations
Page 25 GAO-19-388 Children Affected By Trauma

education agencies. Child welfare officials in all six states talked about 

high rates of staff turnover, while education officials did so in two states 

(Colorado and Wisconsin).52 Staff turnover resulted in difficulties 

maintaining staff trained in trauma-informed approaches and sustaining 

institutional trauma knowledge and trauma-related activities, according to 

officials. Colorado university officials partnering with a county child 

welfare agency said that staff turnover forced them to invest additional 

time in training replacement staff and made it more difficult for child 

welfare officials to conduct regular follow-ups. Similarly, one education 

official in another part of Colorado said that high turnover at many 

agencies, including education and child welfare, hindered the county’s 

efforts to maintain institutional knowledge about trauma-informed 

practices and sustain the services these agencies were providing to 

children affected by trauma. Some state and local officials in three states 

attributed high rates of staff turnover to fatigue and secondary traumatic 

stress, which is the emotional duress that staff may experience when they 

hear about children’s traumatic experiences (see sidebar). Some 

agencies said that they sought to address staff turnover by supporting 

employees through training on secondary traumatic stress; at least one 

agency in each of the six states offered such training. Officials from Ohio 

and Wisconsin told us that another way they were addressing the issue 

was by participating in an HHS-funded project to improve child welfare 

workforce outcomes.53

 52In four states, officials from other agencies and organizations partnering with child 

welfare agencies also commented on the high rates of staff turnover in that field. GAO has 

previously reported on the high rate of staff turnover in child welfare and its associated 

challenges. In 2003, we reported that child welfare staff turnover had been estimated at 

between 30 and 40 percent annually nationwide, with the average tenure of child welfare 

workers being less than 2 years. We found that turnover hampered agencies’ attainment 

of some key federal safety and permanency outcomes by producing staffing shortages 

which increased the workloads of remaining staff. We further found that these increased 

workloads left less time for staff to establish relationships with children and families, to 

conduct frequent and meaningful home visits, and to make thoughtful and well-supported 

decisions regarding safe and stable placements. GAO, Child Welfare: HHS Could Play a 

Greater Role in Helping Child Welfare Agencies Recruit and Retain Staff, GAO-03-357 

(Washington, D.C.: Mar. 31, 2003).

53The Quality Improvement Center for Workforce Development was established in 2016 

under a 5-year cooperative agreement with HHS’s Children’s Bureau. This center is 

working with eight public and tribal child welfare agencies in different states to develop 

strategies for improving child welfare workforce outcomes. Quality Improvement Center for 

Workforce Development, Building Knowledge to Strengthen the Child Welfare Workforce, 

accessed Jan. 31, 2019, https://www.qic-wd.org/sites/default/files/about-qicwd.pdf.

Secondary Traumatic Stress

According to the National Child Traumatic 

Stress Network (NCTSN), Secondary 

Traumatic Stress (STS) is the emotional 

duress experienced when hearing about 

another person’s traumatic experiences. 

Professionals working with children affected 

by trauma, such as child welfare workers, are 

commonly at risk of developing STS. STS can 

compromise these professionals’ ability to do 

their jobs and may drive them to leave their 

job or their professional field.

NCTSN notes that several factors can 

increase the risk for developing STS, 

including heavy caseloads of children affected 

by trauma, social or organizational isolation, 

and feeling unprepared for the job due to lack 

of training. NCTSN suggests taking a multidimensional approach to STS, which includes 

both prevention and intervention. This could 

include strategies such as establishing selfcare groups, helping workers maintain worklife balance, and training organizational 

leaders on STS.

Source: National Child Traumatic Stress

Network | GAO-19-388
Page 26 GAO-19-388 Children Affected By Trauma

Limited Staff Time

Many agencies also said they faced limitations on the time that staff could 

dedicate to trauma initiatives. This issue was more commonly raised by 

education agencies than by child welfare agencies. Education agency 

officials reported this limitation in three of four states that had education 

initiatives,54 whereas child welfare officials reported it in two of the six 

selected states. Some of these officials explained that lack of staff time to 

focus on trauma may have limited the implementation of their trauma 

initiatives. State education officials in Washington and local education 

officials in Massachusetts told us that they have the expertise to provide 

trauma training to schools and community groups, but time limitations 

restrict their ability to do so. A Colorado county child welfare official told 

us that some caseworkers see trauma screening as an additional burden 

due to their already large workload, and a child welfare official in another 

Colorado county told us that many caseworkers forget to do trauma 

screening because they are busy. At least one agency we interviewed in 

each of the six states has or had a staff position dedicated to trauma 

work, which could help address this limitation.

Lack of Clinicians

Officials in all six selected states said that there were not enough 

clinicians trained in trauma-focused, evidence-based therapies to serve 

children affected by trauma.55 GAO has previously reported on difficulties 

finding specialty care for children.56 For example, in 2017 we found that 

limited access to mental health services was a challenge for several 

 54State education officials in two of our six selected states told us that they did not have 

statewide trauma initiatives. 

55Though this issue was raised in all six states by child welfare or Medicaid officials, it was 

not reported by any education officials.

56In a 2010 national survey of physicians, in which GAO asked about difficulties referring 

children to specialty care and the particular specialties for which making a referral is 

difficult, one of the specialist types most frequently cited was mental health specialists, 

such as psychiatrists, psychologists, drug counselors, and other therapists. Physicians 

surveyed offered various explanations for why making referrals is difficult, including the 

short supply of specialists in their area and long waiting lists for specialists. GAO, 

Medicaid and CHIP: Most Physicians Serve Covered Children but Have Difficulty 

Referring Them for Specialty Care, GAO-11-624 (Washington, D.C.: June 30, 2011). GAO 

has also reported on behavioral health workforce shortages for low-income adults, see 

GAO, Behavioral Health: Options for Low-Income Adults to Receive Treatment in Selected 

States, GAO-15-449 (Washington, D.C.: June 19, 2015).
Page 27 GAO-19-388 Children Affected By Trauma

selected states due to a variety of factors, including insufficient numbers 

of providers in certain specialties, such as child psychiatrists.57 Some 

officials indicated that a shortage of clinicians trained in trauma-focused, 

evidence-based therapies can limit the ability of child welfare agencies to 

address trauma. For example, state child welfare officials in 

Massachusetts specifically noted that identifying children affected by 

trauma is not helpful if there are not enough clinicians trained in these 

therapies to treat them. County child welfare officials in Massachusetts 

and local healthcare partners in Ohio said that providers sometimes rely 

on interns to address the shortage of clinicians, but Massachusetts 

officials viewed this as problematic because interns have short tenures 

that prevent them from establishing relationships with the children. 

Officials in five of the six selected states told us about initiatives to 

address the shortage by training clinicians in trauma-focused, evidencebased therapies, and university officials in Massachusetts described an 

initiative to make trained clinicians more accessible. (See text box.)

 57This challenge was identified by state and county officials in four of the seven selected 

states and five of the nine national organizations that were interviewed for the report. 

GAO, Foster Care: HHS Has Taken Steps to Support State’ Oversight of Psychotropic 

Medications, but Additional Assistance Could Further Collaboration, GAO-17-129

(Washington, D.C.: Jan. 5, 2017).
Page 28 GAO-19-388 Children Affected By Trauma

LINK-KID: A centralized trauma treatment referral service

The Child Trauma Training Center at the University of Massachusetts 

Medical School trains clinicians and operates a centralized referral 

service called LINK-KID. The goal of LINK-KID is to facilitate 

connections between children in need of trauma-focused, evidencebased therapies and clinicians who have been trained to provide such 

therapies. LINK-KID maintains an active database of trained clinicians 

throughout the state of Massachusetts.

University officials told us that anyone in Massachusetts with concerns 

about a child, including family, teachers, clinicians, and child welfare 

workers, may call the service. LINK-KID collects information about the 

child and family, works with them to decide which treatment is most 

appropriate, and ensures the child is referred for that treatment.

University officials said that using LINK-KID is easier for families and 

child welfare workers, who otherwise might have to call multiple service 

providers to determine who offers the needed treatment and accepts 

their insurance. These officials also said they have seen a reduction in 

the time children must wait for treatment when using LINK-KID. They 

said that prior to LINK-KID, they saw many children waiting 6 months to 

a year to receive treatment after having been identified as having 

experienced trauma, whereas wait times are generally between 25 and 

40 business days with LINK-KID.

Source: GAO and Child Trauma Training Center. | GAO-19-388

Limited Funding

Finally, some agencies said they had difficulties getting or maintaining 

sufficient funding to support trauma initiatives. Officials in Washington, 

including, among others, state and local education officials and a local 

public health partner, reported this issue. In addition, local officials in four 

other states noted limited funding to support trauma initiatives. School 

district officials in Washington indicated that a lack of funding limited their 

implementation support for one major trauma initiative to approximately 

one-quarter of their schools. These schools were chosen based on need, 

as demonstrated by measures such as discipline and absenteeism rates. 

County child welfare officials in Ohio said they had to stop one of their 

trauma initiatives 3 years ago because the state funding supporting the 

initiative ran out. Those Ohio officials said they have relied on 

relationships and collaboration to address the issue of scarce funding. For 

example, they said that county organizations, including local government 

agencies, private healthcare providers, and nonprofits, share data 
Page 29 GAO-19-388 Children Affected By Trauma

extensively and pool funding to support various initiatives. One initiative 

they pointed to is a local interagency council which provides services to 

children affected by trauma.

Child welfare and other officials in the six selected states, including 

officials with nonprofit partners, a state department of health, and a state 

interagency collaborative, also raised at least one other challenge. 

Challenges included sharing data while remaining in compliance with 

state and federal privacy laws; sharing data across incompatible systems; 

limitations on services billable to Medicaid; and Medicaid reimbursement 

rates. Some agencies had taken actions to address or avoid data sharing 

challenges. In the states where child welfare officials identified Medicaidrelated challenges, state Medicaid officials offered a different perspective 

on perceived Medicaid challenges and cited alternative ways to support 

children affected by trauma.

58

Officials in all six states talked about sharing data with other agencies for 

various purposes; however, privacy laws and regulations were sometimes 

cited by these officials as a barrier to sharing data about children affected 

by trauma.59 For example, officials in two Massachusetts school districts 

told us they are notified by police or child welfare workers when a child 

has been involved in an incident with those agencies. One official 

described the goal of this effort as making staff aware of incidents and 

events that may affect children’s learning and behavior and ensuring that 

children feel supported. However, child welfare officials in four of the six 

selected states and other officials in two states said that it was difficult to 

share data while remaining in compliance with state and federal privacy 

 58Child welfare and Medicaid programs share responsibility for providing for the health 

care needs of children in foster care. In its June 2015 report to Congress, the Medicaid 

and CHIP Payment and Access Commission noted that collaboration among agencies 

responsible for the health care needs of such children is critical, but can be hampered by 

a lack of knowledge among staff regarding benefits, among other things. Medicaid and 

CHIP Payment and Access Commission, Report to Congress on Medicaid and CHIP

(Washington, D.C.: June 2015).

59For various reasons, not all agencies we interviewed reported collecting or wanting to 

share data specific to children’s traumatic experiences or their initiatives to support 

children affected by trauma. For example, Washington state education officials reported 

that they did not have the resources for formalized data collection on their trauma 

initiatives, while an official from an interagency collaborative in the same state said they 

lacked the administrative power or capacity to collect such data. Massachusetts state and 

Ohio county child welfare officials said they did not want to track traumatized children as a 

distinct population, as they assume every child entering the child welfare system has been 

exposed to trauma.

Other Challenges
Page 30 GAO-19-388 Children Affected By Trauma

and confidentiality laws and regulations, though the reasons they cited for 

these difficulties varied.60 State child welfare officials in Massachusetts 

told us that the state has strict privacy laws in addition to federal laws 

such as the Health Insurance Portability and Accountability Act of 1996.61

These officials said that data sharing is possible but generally requires a 

specific memorandum of understanding because of privacy laws. In 

contrast, a state child welfare official in North Carolina said they had 

difficulties with counties not understanding what data they are allowed to 

share. That official told us that the state tries to mitigate this challenge by 

helping counties understand what they can share and encouraging them 

to share screening information with mental health and medical providers. 

Additionally, a North Carolina university has published state-specific 

guidance on sharing education, mental health, and other records.

Systems incompatibility and technology issues were also sometimes seen 

as barriers to sharing data about children affected by trauma. Child 

welfare officials in three of the six selected states, and state health 

 60Various GAO reports have outlined challenges states have faced in navigating federal 

privacy and security protections for health, child welfare, education, and other data. These 

challenges have included uncertainty over the types of data that states are able to share 

under these laws. See GAO, Foster Care: HHS Has Taken Steps to Support States’ 

Oversight of Psychotropic Medications, but Additional Assistance Could Further 

Collaboration, GAO-17-129 (Washington, D.C.: Jan. 5, 2017); Human Services: Sustained 

and Coordinated Efforts Could Facilitate Data Sharing While Protecting Privacy, 

GAO-13-106 (Washington, D.C.: Feb. 8, 2013); and Postsecondary Education: Many 

States Collect Graduates’ Employment Information, but Clearer Guidance on Student 

Privacy Requirements Is Needed, GAO-10-927 (Washington, D.C.: Sept. 27, 2010). In 

response to a GAO recommendation from GAO-13-106, HHS published a “Confidentiality 

Toolkit” in August 2014 that aims to support state and county data sharing efforts by 

bringing greater clarity to the rules governing confidentiality in certain human services 

programs. In response to a GAO recommendation from GAO-10-927, the Department of 

Education revised its Family Educational Rights and Privacy Act regulations in December 

2011 to, among other things, clarify the means by which states can collect and share 

graduates’ employment information consistent with federal requirements. Additionally, the 

Department of Education published a data-sharing tool kit for civic and community leaders 

in March 2016.

61The Health Insurance Portability and Accountability Act of 1996 required HHS to 

promulgate regulations addressing the privacy and security of health information. Pub. L. 

No. 104-191, tit. II, subtit. F, 110 Stat. 1936, 2021-34 (codified at 42 U.S.C. §§ 1320d–

1320d-8). HHS has published Standards for Privacy of Individually Identifiable Health 

Information (the Privacy Rule) and Security Standards for the Protection of Electronic 

Protected Health Information (the Security Rule). 45 C.F.R. pts. 160 and 164. The Privacy 

Rule establishes national standards for safeguarding individually identifiable health 

information that is transmitted or maintained in any form or medium (protected health 

information). The Security Rule establishes nationwide standards for safeguarding 

protected health information that is held or transferred electronically.
Page 31 GAO-19-388 Children Affected By Trauma

officials in a fourth state, said that incompatibility among various systems 

made data sharing very difficult or impossible.62 For example, county 

officials in Wisconsin said that the state’s child welfare and juvenile justice 

offices use one data reporting system while the state’s mental and 

behavioral health offices use another, and these two statewide data 

systems are unable to communicate. While state child welfare officials in 

Colorado also reported systems incompatibility issues, county child 

welfare officials in that state talked about efforts to make data systems 

more accessible to relevant partners. Officials in one county said that they 

have a database which is accessible by all members of the county’s multiagency partnership, including child welfare, school districts, public health, 

and others. Those officials also said they use a universal release-ofinformation which includes all partner agencies, enabling them to share 

data at multi-agency meetings.63

Additionally, child welfare officials in Colorado, Ohio, and Massachusetts 

said that certain services for children affected by trauma or certain service 

providers were not billable to Medicaid, although Medicaid officials in 

these states offered a different perspective and cited alternative ways to 

support these children.64 Depending on the state, child welfare officials 

said they could not bill wraparound services, trauma assessments, 

transportation, or non-traditional therapies, such as animal therapy or 

 62HHS officials also told us that data integration was a challenge for the recipients of the 

trauma-related grants ACF awarded from 2011 to 2013. They said that moving and 

integrating data between systems was a problem for grantees even though states were 

able to develop memoranda of understanding and data sharing agreements.

63This release-of-information is an authorization, signed by the individual receiving 

services or a parent or legal guardian, which allows specified county agencies to receive, 

use, and disclose certain types of confidential information for specified purposes.

64NCTSN has also reported on Medicaid challenges faced by those serving children and 

families affected by trauma. In 2016, they conducted a financing and sustainability survey 

of NCTSN members. Of 110 responders from 33 states and the District of Columbia, 52 

percent reported difficulties with Medicaid reimbursements as a financing challenge. 

NCTSN, NCTSN Financing and Sustainability Survey Report (November 2016).
Page 32 GAO-19-388 Children Affected By Trauma

community and relationship building.65 County child welfare officials in 

Ohio also mentioned restrictions on providers; they said that potential 

peer support specialists with a criminal background and interns could not 

bill Medicaid.66 However, Medicaid officials in these states generally said 

that such services were billable to Medicaid, and Ohio Medicaid officials 

said that interns and those with a criminal background could bill Medicaid, 

under certain circumstances. For example, they said that while certain 

severe criminal offenses, such as homicide, could exclude someone from 

providing services, those with lesser offenses could become eligible after 

a waiting period. Colorado and Ohio Medicaid officials we spoke with 

offered some alternative ways to use Medicaid to support children 

affected by trauma in cases where services could not be billed to 

Medicaid. For example, a Colorado Medicaid official and a child welfare 

official both said that Medicaid does not pay providers for travel time or 

mileage and that this can be a problem in rural areas; however, the state 

Medicaid official said that telehealth is available to address this issue and 

that reimbursement rates for services in rural areas can be higher to 

reflect the additional cost of travel.67

Finally, child welfare and Medicaid officials in Colorado and North 

Carolina also had different perspectives regarding Medicaid 

reimbursement rates. Child welfare and other officials in these states said 

that certain services for children affected by trauma, such as trauma 

assessments and trauma-focused, evidence-based therapies, are 

expensive, and that Medicaid reimbursement rates are too low to 

incentivize providers to offer these services. However, Colorado and 

North Carolina Medicaid officials explained that most children in Medicaid 

in their states receive mental health care through managed care, where 

 65While the theme of certain services not being billable to Medicaid was reported by child 

welfare officials across these three states, the specific services the officials mentioned 

varied by state. The variance of reimbursable services across states is consistent with 

differences in state approaches to supporting children affected by trauma and with the 

state-by-state variance of Medicaid programs generally. Medicaid, by design, allows 

significant flexibility for states to design and implement their programs, which has resulted 

in over 50 distinct state-based programs. Federal law requires state Medicaid programs to 

cover a wide array of mandatory services, such as physician, laboratory, and preventive 

services, and permits states to cover additional services at their option. GAO, Medicaid: 

Key Issues Facing the Program, GAO-15-677 (Washington, D.C.: July 30, 2015).

66Officials noted that individuals who have gone through the criminal justice system may 

have life experiences that make them uniquely well-suited to be peer support specialists.

67The official said that Colorado Medicaid does pay for transportation for children to 

receive medically necessary services covered by Medicaid.
Page 33 GAO-19-388 Children Affected By Trauma

the state pays a set rate per child to managed care organizations (MCOs) 

to provide or arrange for any mental health services a child may need, 

including trauma-related care. MCOs, in turn, reimburse providers for the 

services they deliver, and MCOs set the rates they pay providers for 

those services rather than the state. Medicaid officials in Colorado and 

North Carolina noted that MCOs have flexibility to negotiate rates with 

providers and may choose to reimburse at a higher rate.68 North Carolina 

Medicaid officials said that some MCOs in their state were reimbursing 

providers at a higher rate for comprehensive, trauma-informed mental 

health assessments, and a Colorado Medicaid official also noted that 

MCOs in their state may vary reimbursement rates based on provider 

availability, offering higher rates in areas where there are shortages.

We provided a draft of this report to HHS and Education for review and 

comment. HHS did not provide written comments. Education provided 

technical comments, which were incorporated into the report as 

appropriate.

 68Used effectively, Medicaid managed care may help states reduce Medicaid program 

costs and better manage utilization of health care services. However, GAO has also 

previously reported on problems associated with managed care. For example, in 2018 we 

reported that managed care payments have the potential to create program integrity risks 

and that there exist multiple challenges to program integrity oversight for managed care. 

GAO, Medicaid Managed Care: Improvements Needed to Better Oversee Payment Risks, 

GAO-18-528 (Washington, D.C.: July 26, 2018). We also found that CMS has provided 

states with limited information on how to fulfill regulatory requirements related to oversight 

of MCO data, and we recommended that CMS provide states with additional information 

on this topic. GAO, Medicaid Managed Care: Additional CMS Actions Needed to Help 

Ensure Data Reliability, GAO-19-10 (Washington, D.C.: Oct. 19, 2018).

Agency Comments
Page 34 GAO-19-388 Children Affected By Trauma

As agreed with your offices, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies of this report to the 

Secretaries of HHS and Education, congressional committees, and other 

interested parties. In addition, this report will be available at no charge on 

the GAO website at https://www.gao.gov

If you or your staff have any questions about this report, please contact 

me at (202) 512-7215 or larink@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff who made key contributions to this report are 

listed in appendix IV.

Kathryn A. Larin

Director, Education, Workforce, and Income Security Issues
Appendix I: Selected State Information

Page 35 GAO-19-388 Children Affected By Trauma

Table 4: Examples of State Child Welfare Agencies’ Initiatives to Support Children Affected by Trauma in the Six Selected 

States

State Initiative Description of the initiative that supports children affected by trauma

Colorado Trauma Informed System of 

Care (known as COACT 

Colorado)

Uses an evidence-based and collaborative approach to help families of 

children and youth with complex needs involved in multiple systems in 17 

counties throughout the state. Agencies involved with this initiative include 

child welfare, juvenile justice, and education. Dedicated staff exist to 

assist families and provide them with support as children receive services. 

Massachusetts Child Trauma Projecta Provided a series of training and activities organized throughout the state 

that expanded on inter-agency collaboration to support children affected 

by trauma. It also created leadership teams focused on trauma in all of 

Massachusetts’ child welfare offices. In addition, it trained clinicians in 

three trauma-focused, evidence-based therapies, including TraumaFocused Cognitive Behavioral Therapy.

North Carolina Project Broadcast Trains county child welfare workers over a 9-12 month period to 

incorporate an understanding of trauma and its effects into their every day 

practices. It also trains staff to use two screening tools—one for children 6 

and under and one for children ages 6-21—to identify whether they have 

experienced trauma and refer them for an assessment if needed. 

Additionally, it trains clinicians on four trauma-focused, evidence-based 

therapies to treat children’s trauma symptoms.

Ohio Child Welfare Training 

Program 

Provides training on core and specialized competencies for child welfare 

caseworkers, supervisors, and foster parents. The training program 

includes courses for the three groups that teach about the effects of 

trauma on children. For example, caseworkers can take trainings on the 

impact of emotional abuse and interventions for children who have 

suffered trauma while caregivers can take trainings on providing discipline 

that is trauma-informed and dealing with the effects of complex trauma. 

Washington Child Health and Education 

Tracking Program

Screens children in five areas, including physical and behavioral health, 

within the first 30 days of entering the child welfare system. In addition, 

dedicated staff are trained to use tools to identify children’s trauma 

symptoms, including anxiety and attention problems. One tool includes 

questions about children’s anxiety, such as whether they are scared to go 

to school. Children are rescreened every 6 months using these tools.

Wisconsin Trauma Project Consisting of three parts, this initiative trains clinicians who treat children 

affected by trauma in trauma-focused, evidence-based therapies; holds 

workshops for foster, birth, adoptive, and kinship parents attended by 

social workers and others to learn about trauma and its effects; and 

provides learning communities for state and county child welfare staff that 

infuse an understanding of trauma into staff’s every day work.

Source: GAO analysis of state child welfare agency documents and Administration for Children and Families grant reports. | GAO-19-388

a

A Massachusetts child welfare official told us that this initiative, funded by an Administration for 

Children and Families grant, ended in 2017. According to another Massachusetts state child welfare 

official, once the funding was eliminated for the full-time staff person who organized the Child Trauma 

Project, the agency could not sustain it throughout the state.

Appendix I: Selected State Information
Appendix I: Selected State Information

Page 36 GAO-19-388 Children Affected By Trauma

Table 5: Examples of State Education Agencies’ Initiatives to Support Children Affected by Trauma in Selected States

Statea Initiative Description of the initiative that supports children affected by trauma

Colorado Positive Behavioral 

Interventions and Supports 

and Multi-Tiered System of 

Supportsb

Encourages the use of Positive Behavioral Interventions and Supports 

and Multi-Tiered System of Supports as prevention frameworks for 

improving the outcomes of all students. This occurs through partnerships 

with families, schools, and communities. It also uses multiple evidencebased practices at the classroom, school, district, region, and state levels.

Massachusetts The Safe and Supportive 

Schools Grant Program

Helps school districts ensure that a school creates a safe, positive, 

healthy and inclusive learning environment. This state-funded grant 

program also makes sure there is use of a system for integrating services 

and aligning initiatives that promote, among other things:

• students’ behavioral health, including social and emotional learning, 

and trauma sensitivity,

• children’s mental health, and

• positive behavioral approaches that reduce suspensions and 

expulsions.

Washington Compassionate Schools 

and Social and Emotional 

Learning

Provides universal supports to all students through these initiatives, which 

include creating a positive school climate and culture.

• Compassionate Schools support all students and focus on helping 

teachers understand fundamental brain development, interpret and 

manage children’s behaviors successfully, and engage students, 

families, and the community.

• Social and emotional learning is the process through which children 

learn how to understand and manage emotions, set and achieve 

goals, feel and show empathy for others, establish and maintain 

positive relationships, and make responsible decisions.

Wisconsin Trauma Sensitive Schools Modeled after the Positive Behavioral Interventions and Supports school 

improvement process, this initiative focuses first on universal practices 

(Tier 1), followed by strategies for groups of students who need additional 

support (Tier 2), and intensive interventions for students who require 

ongoing support (Tier 3).

Source: GAO analysis of state agency documents and interviews with agency officials. | GAO-19-388

a

Four of the six selected states had at least one statewide initiative administered by state education 

agencies to support children affected by trauma. North Carolina and Ohio do not have statewide 

education initiatives, according to state education agency officials.

b

Positive Behavioral Interventions and Supports and Multi-Tiered System of Support utilize evidencebased, prevention-oriented practices and systems. Positive Behavioral Interventions and Supports’

framework provides academic, social, emotional, and behavioral support to all students while MultiTiered System of Support focuses on addressing students’ academic issues. Both models comprise 

three tiers—the first uses universal practices to support children, such as changing a classroom’s 

environment; the second uses strategies, such as small group cognitive behavioral therapy, for 

students who need additional support; and the third provides intensive interventions for students who 

require ongoing support, such as developing and implementing wraparound services plans.
Appendix II: Selected County Information

Page 37 GAO-19-388 Children Affected By Trauma

Table 6: Examples of County and Local Agency Initiatives to Support Children Affected by Trauma in the Six Selected States

County, State Initiative Description of the initiative that supports children affected by trauma

Boulder County, CO Integrated Managed 

Partnership for Adolescent 

and Child Community 

Treatment 

Consisting of 11 public agencies and nonprofit organizations, including the 

Boulder Valley School District and a nonprofit organization that provides 

mental health services, this initiative is an interagency collaborative 

partnership. The group provides case coordination and ensures 

participating agencies and organizations have consistent practices and 

processes for children involved in multiple systems. Services, such as 

trauma-focused, evidence-based therapies and mentoring for youth in the 

juvenile justice system, are also available through this effort. 

Plymouth County, MA Brockton 

Public Schools

Creating trauma-sensitive schools has been Brockton Public Schools’

focus, one official explained. Among other things, the schools create safe 

and supportive environments by enhancing relationships with students 

and ensuring educators are aware of students’ behavior, according to this 

same official. In addition, Brockton Public Schools collaborates with the 

county district attorney’s office on two trauma-focused initiatives—the 

Childhood Trauma Initiative and Handle With Care. The Childhood 

Trauma Initiative trains educators and law enforcement, among others, 

about trauma’s effects on children’s development. Handle With Care 

allows police officers or caregivers to notify a school that a child may have 

experienced a traumatic event.

Rowan County, NC Partnering for 

Excellence

Consisting of the county department of social services, the county’s 

mental health managed care organization, and private mental health 

providers, this initiative supports children ages 5-17 and families involved 

in the child welfare system. Key elements of Partnering for Excellence 

include screening children for trauma and, if needed, trauma-intensive 

comprehensive clinical assessments. The initiative also facilitates 

improved communication, coordination, and monitoring of child and family 

treatments by ensuring staff train together and participate in ongoing 

collaborative meetings.

Athens County, OH School Outreach 

Caseworkers 

Placing caseworkers in local elementary schools, the county child welfare 

agency’s initiative supports students, families, and teachers by promoting 

positive school relationships to enhance student success and strengthen 

families. Among other responsibilities, caseworkers help coordinate 

services for individual students and bring outside resources into schools. 

They also support parents by providing home and school-based services 

and coordinating parenting classes to help strengthen skills.

King County, WA King County Department 

of Public Health

Beginning in 2017, King County’s Department of Public Health 

implemented changes to become a trauma-informed agency. One official 

explained that the agency has three areas of focus—creating a traumainformed care training plan and standardized curriculum; awarding minigrants to agency “champions” who create small projects connected to the 

agency’s trauma-informed care principles, which includes fostering 

compassionate relationships; and making policy and human resources 

changes, including the investigation process for internal human resources 

complaints.

Appendix II: Selected County Information
Appendix II: Selected County Information

Page 38 GAO-19-388 Children Affected By Trauma

County, State Initiative Description of the initiative that supports children affected by trauma

Waupaca County, WI Waupaca County 

Department of Health and 

Human Services 

Beginning in 2012, the Department of Health and Human Services has 

worked to transition into a trauma-informed agency by incorporating 

trauma-informed care into its operations. The agency’s operating 

principles include partnering with clients, promoting safety, and earning 

clients’ trust. The agency has become more family-friendly and is more 

focused on preventing children from entering the child welfare system, 

according to an agency official. Since becoming trauma-informed, it was 

reported that staff have had less secondary stress and there has been a 

decrease in staff turnover.

Source: GAO analysis of county child welfare, local education, and other county agency official interviews and county agency documents. | GAO-19-388
Appendix III: GAO Contact and Staff 

Acknowledgments

Page 39 GAO-19-388 Children Affected By Trauma

Kathryn Larin, (202) 512-7215 or larink@gao.gov

In addition to the contact named above, Elizabeth Morrison (Assistant 

Director), Ramona L. Burton (Analyst-In-Charge), Isabella Guyott, and 

Robin Marion made significant contributions to this report. Also 

contributing to this report were Luqman Abdullah, Susan Aschoff, Sarah 

Cornetto, Kelsey Kreider, Hannah S. Locke, Jean McSween, Mimi 

Nguyen, Stacy Ouellette, Michelle Rosenberg, Almeta Spencer, Daren K. 

Sweeney, Shelia L. Thorpe, and Carolyn Yocom.

Appendix III: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(102538)
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