ࡱ> 1 bjbjvv .ddH+89l.a e#{#{#{#V$b$<$ -------$0U3-%V$V$%%-{#{#k.)))%X{#{#-)%-)),T,{#`Hl%" ,-.0.(,,%5%V%5T,%5T,D%%)%%%%%--'%%%.%%%%%5%%%%%%%%% : TRAUMA SCREENING CHECKLIST (AGES 6-18)Michigan Department of Health and Human ServicesComplete and score the checklist according to instructions on the attached Trauma Screening Checklist Instruction Guide. Reference the attached Trauma Screening Checklist Definitions, if needed. When completed, refer to the Childrens Services Agency Trauma Protocol/Trauma Screening Best Practices Guide for further case planning based on results.Childs NameDate of BirthSex FORMTEXT       FORMTEXT       FORMTEXT      Person ID (Child)Case ID FORMTEXT       FORMTEXT      Parent/Caregiver NameDate FORMTEXT       FORMTEXT      County/AgencyCompleted by FORMTEXT       FORMCHECKBOX  Foster Care FORMCHECKBOX  CPSThis checklist completed based on an interview with  FORMCHECKBOX  Child FORMCHECKBOX  Parent/CaregiverSECTION 1 CHECK EACH ITEM WHERE THE TRAUMA IS KNOWN OR SUSPECTED. Note: Endorsing exposure items does not necessarily mean substantiation of the childs experience; it is for screening purposes only.Are you aware or do you suspect the child has ever experienced or been exposed to any of the following types of trauma? FORMCHECKBOX  Physical abuse FORMCHECKBOX  Prenatal exposure to alcohol/drugs or maternal stress during pregnancy FORMCHECKBOX  Neglectful home environment FORMCHECKBOX  Emotional abuse FORMCHECKBOX  Lengthy or multiple separations from parent FORMCHECKBOX  Exposure to domestic violence FORMCHECKBOX  Placement outside of home (foster care, kinship care, residential) FORMCHECKBOX  Exposure to other chronic violence FORMCHECKBOX  Sexual abuse or exposure FORMCHECKBOX  Loss of significant people, places, etc. FORMCHECKBOX  Parental substance abuse FORMCHECKBOX  Frequent/multiple moves; homelessness FORMCHECKBOX  Impaired parenting (mental illness) FORMCHECKBOX  Other (indicate) FORMTEXT       FORMCHECKBOX  Exposure to drug activity aside from parental useSECTIONS 2 5: CHECK EACH BEHAVIOR THAT HAS BEEN OBSERVED IN THE LAST 180 DAYS.SECTION 2Does the child show any of the following behaviors? FORMCHECKBOX  Aggression towards self; self-harm FORMCHECKBOX  Oppositional and/or defiant behavior FORMCHECKBOX  Excessive aggression or violence towards others FORMCHECKBOX  Sexual behaviors not typical for age FORMCHECKBOX  Explosive behavior (going from 0-100 instantly) FORMCHECKBOX  Difficulty with sleeping, eating, or toileting FORMCHECKBOX  Hyperactivity, distractibility, inattention FORMCHECKBOX  Social/developmental delays in comparison to peers FORMCHECKBOX  Excessively shy FORMCHECKBOX  Other (indicate) FORMTEXT      SECTION 3Does the child exhibit any of the following emotions/moods? FORMCHECKBOX  Excessive mood swings FORMCHECKBOX  Flat affect, very withdrawn, seems emotionally numb or zoned out FORMCHECKBOX  Frequent, intense anger FORMCHECKBOX  Chronic sadness, doesnt seem to enjoy any activities, depressed mood FORMCHECKBOX  Other (indicate) FORMTEXT      SECTION 4Does the child have any of the following difficulties in school? FORMCHECKBOX  Low or failing grades FORMCHECKBOX  Difficulty with authority/frequent behavior referrals FORMCHECKBOX  Attention and/or memory problems FORMCHECKBOX  Other (indicate) FORMTEXT       FORMCHECKBOX  Sudden change in performanceSECTION 5Does the child have any of the following relational/attachment difficulties? FORMCHECKBOX  Lack of eye contact, or avoids contact FORMCHECKBOX  Does not seek adult help when hurt or frightened FORMCHECKBOX  Lack of appropriate boundaries in relationships FORMCHECKBOX  Other (indicate) FORMTEXT      TOTAL ENDORSEMENTS (add all marked checkboxes) FORMTEXT      Henry, Black-Pond & Richardson (2010), rev: 3/16 Western Michigan University Southwest Michigan Childrens Trauma Assessment Center (CTAC) TRAUMA SCREENING CHECKLIST (AGES 6-18)TRAUMA SCREENING CHECKLIST INSTRUCTION GUIDEPURPOSE Caseworkers who complete the screen should have a basic understanding of trauma, its symptoms, and its potential impact to a childs functioning. A completed Trauma Screening Checklist provides information for workers to recognize trauma, its impact, and assists with case planning and building resiliency. The Trauma Screening Checklist is not intended to be used to make a clinical diagnosis. The Trauma Screening Checklist can be used as a tool to monitor progress and document changes in mood, behavior, attachment and school functioning with each completion of the screen.ADMINISTRATION AND SCORING The Trauma Screening Checklist should be administered to the child and the parent/caregiver. An interview of the child should depend on their intellectual, developmental, and emotional capability and their successful completion of a forensic interview. The parent should be interviewed if possible. If the parent is not available, or if the permanency plan is not reunification, the foster parent or caregiver should be interviewed. Prior to interviewing, build rapport with the child and/or parent/caregiver. Conduct separate interviews in a conversational manner with the child and parent/caregiver. For guidance, utilize the Tips for Administration below. Complete the Trauma Screening Checklist based on: the completed interview, the review of past records, and any contacts with collateral sources. Traumas identified in Section 1 are known or suspected, and do not have to be substantiated. Consult with your supervisor if you are uncertain about whether to check a particular item. Refer to the Trauma Screening Checklist Definitions for definitions of traumatic events and/or behaviors. Sections 2-5 should be completed based on the past 180 days. Determine total score of all sections combined. Each check mark is an endorsement and yields a score of 1. If the score on the childs completed Trauma Screening Checklist differs from the score on the parent/caregiver completed Trauma Screening Checklist, utilize the Trauma Screening Checklist with the higher score for case planning and making referrals. Refer to the Childrens Services Agency Trauma Protocol, which includes the Trauma Screening Best Practices Guide, to determine how to proceed. Upload completed Trauma Screening Checklist into the Person Overview section of MiSACWIS. Label Trauma Screening Checklist, followed by the date it was administered. Rescreening is required within 180 days of the initial screening and prior to case closure. Additional screenings are recommended following significant changes within the childs life (placement change, goal change, traumatic event, etc.) and can be completed with supervisory discretion to assist with further assessment or case planning as needed. TRAUMA SCREENING CHECKLIST (AGES 6-18)TIPS FOR ADMINISTRATION OF TRAUMA SCREENING CHECKLISTWith a Child/YouthWith a Parent/CaregiverBuild rapport with the child by reminding him/her that he/she knows themselves best, which is why you want to learn all you can directly from him/her.Build rapport with the parent/caregiver by assuring him/her that you understand he/she knows their child best, which is why you want to learn all you can directly from them.Utilize MiTEAM competencies and skills, strength-based, solution-focused interviewing strategies to elicit information.Utilize MiTEAM competencies and skills, strength-based, solution-focused interviewing strategies to elicit information. Recognize and validate the parent/caregivers support for the well-being of the child.Empower the child by valuing their own perceptions of his/her experiences. Educate the child, in an age appropriate manner, on the impact. Explain that trauma is something that was done to him/her or something he/she experienced (not something he/she caused). Normalize reactions to traumatic events the child has experienced.To enhance engagement, normalize the parent/caregiver reaction to stress and/or self-blame. Educate the parent/caregiver on reactions to trauma. Explore past traumatic events experienced by the child, potentially linking the childs experiences with the parent/caregiver past trauma to create empathy and understanding for the child. Frame the childs challenging behaviors as the possible impact of traumatic events.Summarize the results of the Trauma Screening Checklist. Explain that the results will be used to plan for his/her safety and effective services. Generate hopefulness for his/her future.Summarize the results of the Trauma Screening Checklist. Explain that the results will be used to plan for the childs safety and effective services. Generate hopefulness for the childs future.TRAUMA SCREENING CHECKLIST DEFINITIONS (AGES 6-18)SECTION 1: TYPES OF POTENTIALLY TRAUMATIC EVENTSTypeWorking DefinitionPhysical abuseThe child experienced an actual or attempted infliction of physical pain such as hitting, slapping, burns, and/or bruising by a parent, caregiver or adult.Suspected neglectful home environmentThe child experienced an absence of such things as food, clothing, or shelter, left alone for long periods of time relative to age, or left for extended periods of time to care for siblings; parent/caregiver failure to protect from known or suspected threat of harm, and/or absence of needed medical care.Emotional abuseThe child experienced verbal abuse (insults, debasement, threats of violence), emotional abuse (bullying, terrorizing, coercive control), belittling and/or humiliating interactions, purposefully shaming the child, or exploitation by the parent/ caregiver.Exposure to domestic violenceThe child experienced exposure (either actually witnessing, hearing, or being in the home) to emotional abuse, actual/ attempted physical or sexual assault, or aggressive control perpetrated between a parent/caregiver and another adult in the childs home environment.Exposure to other chronic violenceThe child experienced or witnessed extreme violence or threats of violence in the community such as neighborhood or gang violence, or the child experienced exposure to school violence or severe bullying.Sexual abuse or exposureThe child experienced an actual or attempted sexual contact such as fondling, genital contact by a parent/caregiver and/or another adult and/or a much older youth, and/or exposure to age-inappropriate sexual material or environment.Parental substance abuseParental substance use resulting in an inability to care for childs developmental needs on a routine basis; illegal substance use resulting in disruption of response to childs needs being met in a developmentally appropriate manner.Impaired parenting (mental illness)As the result of parent/caregiver mental illness, cognitive delays, or their own unresolved trauma, parent/caregiver behavior is erratic and/or unpredictable, or the parent/ caregiver does not have the capacity and therefore fails to meet the basic needs of child.Exposure to drug activity aside from parental useParent/Caregiver operating and/or distributing drug growing/ manufacturing operation within the home. May include frequent and chronic traffic in and out of the home secondary to substance abuse and/or criminal drug activity.Prenatal exposure to alcohol/drugs or maternal stress during pregnancyChild was prenatally exposed to alcohol/drugs as indicated by the mothers disclosure and/or documented legal action, and/or mother/child testing positive at birth for alcohol/drugs. Mother experienced chronic exposure to domestic violence during pregnancy and/or significant overwhelming relational distress.Lengthy or multiple separations from parent or primary caregiverTwo or more abrupt, unexplained, and/or indefinite separations from a parent, primary caregiver, or sibling due to circumstances beyond the childs control. These separations may or may not have been related to the childs entry into foster care.Placement outside of the home (foster care, kinship care, residential, hospitalization)The child has been involuntarily placed in a hospital (medical/psychiatric) or foster care separating him/her from the care of his/her parents with only supervised access to his/her caregivers. Child has experienced multiple hospitalizations or intrusive medical procedures impacting the childs developmental trajectory.Loss of significant people, places, etc.The child experienced an expected loss of someone close to them, or witnessed homicide, suicide, motor vehicle accident, drug overdose or experienced significant losses due to natural disaster/events. Significant primary relationship(s) may no longer be available.Frequent/multiple moves; homelessnessThe child experienced homelessness, couch-surfing alone or with parents between friends/relatives residences and/or lived in an emergency shelter for an extended amount of time.SECTIONS 2 5: BEHAVIORS, MOODS, ATTACHMENT/SCHOOL ISSUESThe section on behaviors (B), emotions/moods (M), and attachment (A) (under age 6 or school (S) is written in common terms. Variation in how front-line workers may interpret items is acceptable. If the child is displaying behaviors or concerns not listed, please write them in the other field on the checklist.Behavior/Mood/Attachment/SchoolWorking DefinitionExcessive aggression or violence towards others (B) (Ages 0-18)Excessive behaviors that cause psychological or physical harm to another individual/or surroundings.Excessive aggression or violence towards self/self-harm (B) (Ages 0-18)Child may bite, bang head, pull own hair, hit self, or intentionally put self in harms way (i.e. running into traffic or other unsafe situations). Includes cutting behaviors.Explosive behavior (going from 0-100 instantly) (B) (Ages 0-18)Episodes of impulsive, aggressive, violent behavior or angry verbal outbursts in which the reaction is grossly out of proportion to the situation. Also includes excessively prolonged episodes from which it is difficult for child to become calm again.Hyperactivity, distractibility, inattention (B) (Ages 0-18)Child may have increased arousal and/or difficulty with concentration and task completion, e.g. child may struggle completing schoolwork or have difficulty forming strong peer relationships.Excessively shy (B) (Ages 0-18)Child may cling to parent/caregiver, avoid eye contact or refuse to speak even after allowed a period of time that is developmentally appropriate to become familiar with a new person or situation.Oppositional and/or defiant behavior (B) (Ages 0-18)Child/youth may behave in negative or hostile ways, frequently argue and refuse to comply with rules, become physically or verbally aggressive, destroy property, steal, break the law, start fires or run away.Sexual behaviors not typical for childs age (B) (Ages 0-18)Attempts to insert objects in another childs vagina and/or rectum and/or perform oral sex, or attempts to insert objects in animals. Simulates sex through humping of stuffed animals, pillows, and/or live animals may also occur. Hypersexualized play is repetitive and may continue without some intervention. Verbalizes sexual acts in a coercive, threating or seductive behavior that is repetitive and does not respond to redirection. Difficulty sleeping, eating or toileting (B) (Ages 0-18)May have nightmares, trouble falling asleep, wake up frequently, thrash in sleep, wake easily, be an excessively picky eater, fail to gain weight, hoard or hide food, refuse to eat, only eat certain foods at certain times.Excessive mood swings (M) (Ages 0-18)Extreme changes from being happy to angry to sad, back to happy within short periods of time with no apparent environmental changes.Frequent, intense anger (M) (Ages 0-18)Quick to anger, anger out of proportion to event, extreme anger, may destroy property when in throes of outburst.Chronic sadness, doesnt seem to enjoy any activities, depressed mood (M) Ages 0-18)Low energy, lethargic, hard to engage, no joy or enjoyment.Flat affect, very withdrawn, seems emotionally numb or zoned out (M) (Ages 0-18)Facial expression doesnt change to reflect changes in emotional content of the conversation.Low or failing grades (S) (Ages 6-18)Consistently low or failing grades, may be because of failure to turn work in, not understanding the material, or excessive absenteeism.Attention or memory problems (S) (Ages 6-18)Easily forgets material, difficulty remembering what he/she read or heard in school, difficulty retaining information to process it (e.g. cant remember larger chunks of information when copying from board); inability to focus on task even it that task is interesting to the child, easily distracted by things in the environment.Sudden changes in performance (S) (Ages 6-18)Child is able to be successful in completing assignments, understanding material but then regresses and is unable to complete assignments and/or understand material within very short time.Difficulty with authority (S) (Ages 6-18)!%   $ & ( 2 4 6 8 L N P Z \ ` " 6 8 F 􏇏|jhOUjhOUhOj8h Ujh UmHnHujh Ujh UjfhoWUjhoWUjhUjhoWUhoWjhoWUh hh40'(YZ k` $Ifgd ?kdV$$Ifl4y,y,4 lalf4yt4 $Ifgd ?kd$$Ifl4y,y,4 lalf4yt4 $Ifgd4  6 ^ PGGG $IfgdoWekd$$Ifl4F<Z!y,<      4 lalf4yt4 $Ifgd4?kd$$Ifl4y,y,4 lalf4yt4^ ` =4 $IfgdRkdV$$Ifl40<y,<=4 lalf4yt $Ifgdekd$$Ifl4F<Z!y,<      4 lalf4yt4   H p G>> $Ifgdi9Rkd$$Ifl40Z!y,Z! 4 lalf4yti9 $Ifgdi9Rkd$$Ifl40<y,<=4 lalf4yt $IfgdF H J ^ ` n       , R T U c d e l m { | } Y Z [ {tjhh5\ h|xhhh h 5\ h5\j6 hUj hUhoWjhoWUhh4j4hOUjhOUjhOUmHnHujVhOUjhOUjhOUhO)p r   PG>> $Ifgdi9 $Ifgdi9Rkd$$Ifl40T!y,T!% 4 lalf4yti9 $Ifgdi9Rkdf$$Ifl40Z!y,Z! 4 lalf4yti9  S T l PGG $Ifgd?kdX $$Ifl4y,y,4 lalf4yt $Ifgd4ekd$$Ifl4FT!(y,T!t    4 lalf4yti9 Z [ _T x$Ifgdb?kd> $$Ifl48y,y,4 lalf4ytjv: <<$Ifgdjv:Rkd $$Ifl40(y,(Q'4 lalf4ytV[ OP^_` !fguvw{jFhUjMhUjThUjhUjhUhbjhbUjxhUj hUj hUj hUjhUhih5\h0 NO}~RRkd $$Ifl40<y,<`=4 lalf4yt'n$If^`gd $Ifgd?kd $$Ifl4y,y,4 lalf4ytb~eP?$If^`gdbRkd`$$Ifl40<y,<=4 lalf4yt'n $IfgdRkd $$Ifl40<y,< =4 lalf4yt'nefPRkd$$Ifl40<y,< =4 lalf4yt'n $IfgdRkd$$Ifl40<y,<`=4 lalf4yt'n &(*>@RT^`|~<>Z\^$%𥡖|u hAo5\ hb5\jhUjhUjhoWUhoWjhoWUjhUjhUj"hUh jhUjhUjhUhbjhbUh.^<PC $If]gdbRkd$$Ifl40<y,<=4 lalf4yt'n $IfgdRkd.$$Ifl40<y,<=4 lalf4yt'n}r ($Ifgd'nxkdr$$Ifl4\<d+y,<(&4 lalf4yt'n $Ifgdnoyc?kd$$Ifl4y,y,4 lalf4ytc] $IfgdiRkd$$Ifl40<y,<=4 lalf4yt'n%*+IJmoyz+,-^_mno46RTVǼDZǦǛǐDžzjhHUjhHUj,hHUj8hHUjhHUjhHUj\hHUhHjhHUhihb5\hbhhb5\ hc]5\ h5\ hb5\0yztkk $IfgdH?kd$$Ifl4y,y,4 lalf4yti x$Ifgdi?kd$$Ifl4y,y,4 lalf4ytc]^2PRkd$$Ifl40<y,<=4 lalf4yt'n $IfgdHRkdD$$Ifl40<y,<=4 lalf4yt'n24:<PC $If]gdHRkd|$$Ifl40<y,<=4 lalf4yt'n $IfgdHRkd$$Ifl40<y,<=4 lalf4yt'n<>Z\^3ADESTUlm{|}FGUVujH%hHUj$hHUj#hHUj"hHUjn"hHUhihH5\hhH5\ hH5\jhHUjphHUjhHUhHjhHUjhHU.}xkdN $$Ifl4\<d+y,<(4 lalf4ytH $IfgdHCcX x$IfgdH?kd!$$Ifl4y,y,4 lalf4ytc] $IfgdHRkd!$$Ifl40<y,<=4 lalf4ytiCDlRRkdV#$$Ifl40<y,<`=4 lalf4yt'n$If^`gdH $IfgdH?kd"$$Ifl4y,y,4 lalf4ytc]Fi $If]gdH $IfgdH$If^`gdHRkdO$$$Ifl40<y,< =4 lalf4yt'nVWijtu ,. 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Parent/Caregiver and child do not seem to respond to each others gaze for purposes of redirection, acknowledgement, permission, etc.Overly friendly with strangers; lack of appropriate stranger anxiety; lack of appropriate boundaries in relationships (A) (Ages 0-18)Exhibits over familiarity, will hold hands/touch, sit on lap, ask intrusive questions, and attend to new person rather than observing parent/caregiver interaction and cues with a new person.Doesnt seek comfort when hurt or frightened; shakes it off, or doesnt seem to feel it (A) (Ages 0-18)When getting hurt, the child seems to either not feel the pain or brushes it off quickly, does not seek adult comfort for pain or fear when it would be age-expected to do so. The child does not allow parent/caregiver or adult to soothe when hurt or sad. Avoids touch, such as rubbing the back or putting on a Band-Aid, avoids being comforted.The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.     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