Treatment Starts with Assessment. Assessment Starts with Engagement.
NCA’s new Standards for Accredited Members call for an initial standardized mental health assessment and periodic re-assessment of children which serve to inform treatment. Every discussion about assessment (or screening) must be prefaced by a definition of what we are screening or assessing. Good practice dictates, and the Standards require, an assessment of other potential traumatic or abusive events, as well as resulting symptoms. Multiple traumas may influence the treatment approach and prognosis. The symptoms, not the abuse, are what must be treated.
While specific requirements related to the assessment are articulated in the Standards (the “science”), everything—everything—everything begins with engagement. An artfully executed assessment can not only identify treatment needs, but also serve to engage caregivers. When we involve the child and the caregiver(s), we start to understand their concerns. Then, the need for treatment can be framed from their perspective.
When caregivers are introduced to the assessment, consider a medical analogy: few informed patients would be comfortable with a surgeon initiating a surgical procedure without her/his examination of X-rays, MRIs, or sonograms (i.e., assessment). And, before seeing the surgeon, your family physician is likely to do a brief exam and conduct lab work (screening). Unfortunately, common practice in the world of mental health for abused children heretofore often has been to start therapy with only an interview (or history) of the client.
Within this context, here are a few additional guidelines to consider as you implement this important new standard:
- Explain the rationale to your multidisciplinary team. The assessment is a clinical procedure to address the needs of the child and family. It may or may not contribute to the “case.” Space does not allow for a complete discussion, but the following principle should guide everyone’s decision-making: “What would you want for your daughter or grandson?”
- Anticipate and address competing messages from others. Caregivers return home from the CAC and interact in their circle of social influence where everyone in their life suddenly becomes an expert on child abuse. The advice may be well-intentioned, and it most certainly will be generous and delivered with authority. Unfortunately, the advice often is not sound (e.g., “She won’t remember it. Move on.”)
- Invite non-offending fathers. Be sure that fathers are “on board” with treatment by obtaining their input in the assessment. They can either make meaningful contributions or undercut the process. Invite them. Speaking as a father and grandfather, “We’re not all rascals.”
- Use measures with children and parents; measures that are reliable, valid, and normed, and measures which are assessing multiple and relevant domains (or symptoms) common to child abuse. For some, your eyes just glazed over because this is the “science” part. Space does not allow for a full explanation, but consider this: The lab work that your physician requires periodically has these same qualities, and is NOT free. It is merely good practice.
- See #4 above. Sometimes you “get what you pay for.” No patient says, “I want you to test my blood for cancer cells, but I want that free test…even if it is less than adequate.”
- Assessing for post-traumatic stress is imperative, but not sufficient. PTSD symptoms occur frequently, but so do sexualized behaviors and thoughts of suicide or self-harm. Most free assessment measures and screeners currently available in the public domain do not assess these important symptoms. There is one new set of screening measures which do screen for PTSD, sexualized behavior, and thoughts of self-harm.1
- Provide feedback of the screening or assessment to children and their families. In therapy, we call it “psychoeducation.” When done well, assessment feedback enhances engagement and “jumpstarts” the therapy process.
- If you utilize an information integration tool, remember that those findings and conclusions are only as good as the reliable and valid information obtained directly from children and families.
- When seeking training on assessment/screening, remember that any new skill (e.g., therapy) requires demonstration, practice, and feedback. This basic behavioral principle has been incorporated in the world of therapy training and implementation, but many would have you believe that a mere webinar, lunch-and-learn, or a three-hour workshop will render you sufficiently trained in assessment. Nonsense!
- Finally, for those who want to be on the cutting edge, graph your findings for families, track symptoms over time, develop local norms, use these data for program evaluation and for demonstrating to funders that you are making a difference, and follow-up after discharge—families will appreciate you for it!
1The new screening tools are reliable, valid, and normed and are authored by John Briere and published by PAR, Inc. They are available to CACs nationwide at a price below typical retail. Contact Darla DeCarlo at firstname.lastname@example.org for more information.