Trauma or adverse childhood experiences 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 cope and can cause stress reactions in children, including feelings of intense fear, terror, and helplessness. 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. 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 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. While all children can be affected by trauma, trauma is common among children who enter the child welfare system. 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 approaches are better able to address children’s safety, permanency, and well-being needs. 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. 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 well- being, 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. A trauma- informed 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 contributes to their classroom behavior. Specific elements of a trauma- informed 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 trauma- informed learning environment. 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. See table 1 for examples of treatments. 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. 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 trauma- informed approach. 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. 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 and with students, as well as better relations between students and increased parent engagement. 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. 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 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), 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. Wisconsin officials also said they received Education’s School Climate Transformation Grant, which was used to create the state’s trauma-sensitive schools initiative. Washington officials credited SAMHSA’s Mental Health Transformation Grant with driving the state’s initial trauma-informed work, including its guide about trauma in schools. 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. 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. 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 trauma- informed programming. Two states reported using the Substance Abuse and Mental Health Block Grants. (See table 2 for additional grants states reported using to support 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 trauma- sensitive 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. 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. 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 identification of trauma-related needs of children and families. 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. 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. 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. 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 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.) 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. For additional 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 parents 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. 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. 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. Similarly, North Carolina’s state child welfare agency, in partnership with a nonprofit organization, trains clinicians in four trauma- focused, 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 trauma- focused 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. Children and youth are screened within 30 days of placement in foster care if officials expect them to remain in 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. 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. 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 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. 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. 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. Officials in all six selected states spoke of the importance of having engaged leadership in establishing and sustaining support for children affected by trauma. 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 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. 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 systems- wide change. 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. 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 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. 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 multi- dimensional approach to STS, which includes both prevention and intervention. This could include strategies such as establishing self- care groups, helping workers maintain work- life balance, and training organizational leaders on STS. 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). 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. 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, 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. 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. GAO has previously reported on difficulties finding specialty care for children. For example, in 2017 we found that limited access to mental health services was a challenge for several selected states due to a variety of factors, including insufficient numbers of providers in certain specialties, such as child psychiatrists. 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, evidence- based therapies, and university officials in Massachusetts described an initiative to make trained clinicians more accessible. (See text box.) 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, evidence- based 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. 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 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 Medicaid- related challenges, state Medicaid officials offered a different perspective on perceived Medicaid challenges and cited alternative ways to support children affected by trauma. 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. 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 and confidentiality laws and regulations, though the reasons they cited for these difficulties varied. 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. 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 officials in a fourth state, said that incompatibility among various systems made data sharing very difficult or impossible. 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 multi- agency partnership, including child welfare, school districts, public health, and others. Those officials also said they use a universal release-of- information which includes all partner agencies, enabling them to share data at multi-agency meetings. 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. 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 community and relationship building. 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. 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. 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 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. 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. 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. 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.

Summary: 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. 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 in-person 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 trauma-informed 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.