Jill Smialek and Dr. Jeff Kretschmar discuss the Cuyahoga County Defending Childhood Initative, which  seeks to address violence against children in one of the country’s most violent areas – Cuyahoga County, Ohio. Their unique approach includes the creation of an integrated, county-wide screening, assessment, and service system for children ages 0-18 who have experienced violence and trauma. The initative is part of the Department of Justice’s Defending Childhood Demonstration Program, which funded eight sites across the country to  respond to the problem of children’s exposure to violence. The Center for Court Innovation has produced a report on the Cuyahoga County Defending Childhood Initative, a series of reports on five other sites, and a report that condenses lessons learned across the sites. 

The following is a transcript

AVNI MAJITHIA-SEJPAL: Hi, I’m Avni Majithia-SejpaL, senior writer at the Center for Court Innovation. Welcome to another episode of our New Thinking Podcast. Today, we’re here to talk about the Cuyahoga County Defending Childhood Initiative. Cuyahoga County, in Ohio, which includes the Cleveland Metropolitan Area, was one of eight sites across the country to be funded by the Department of Justice to address and raise awareness about children’s exposure to violence. We, at the Center for Court Innovation, have just released our process evaluation on six of those sites, which includes individual reports on each site and a report that condenses lessons learned across them. Today, from Cuyahoga County, we’re talking to Jill Smialek, manager of the Family Justice Center and of the Witness Victim’s Service Center, and to Dr. Jeff Kretschmar, research assistant professor at the Mandel School of Applied Social Sciences at Case Western Reserve University, and senior research developer at the Gun Center for Violence Prevention, Research, and Education. Jill and Jeff, welcome to our podcast.

DR. JEFF KRETSCHMAR: Thanks, Avni.

JILL SMIALEK: Thank you.

MAJITHIA-SEJPAL: I want to start by talking about violence. I understand that the county, and Cleveland in particular, has one of the highest violent crime rates in the country. What kinds of violence are kids exposed to?

KRETSCHMAR: You’re right that the kids in Cuyahoga County witness and experience pretty high rates of violence. The kinds of violence they’re experiencing or witnessing are similar to other kids in other communities. We have a lot of kids saying that they are hit and attacked. They witness a lot of shootings. There’s lots of verbal abuse, physical abuse. Our kids report high rates of bullying. I will say that of the kids who have been in our Defending Childhood system and who have been assessed for violence exposure, 96% of those kids report at least one past year victimization and 87% report as least two past year victimizations. Those numbers are really, really high.

SMIALEK: We also know that a lot of children who are coming through the Defending Childhood system have witnessed domestic violence in their homes. From our most recent report, it looks like about 50% of our cases are kids who are dealing with domestic violence in the home.

MAJITHIA-SEJPAL: The Defending Childhood initiative created a streamlined county-wide screening assessment and service system up to the age of eighteen who have exhibited symptoms of exposure to violence or trauma. Can you walk us through that process?

SMIALEK: When we were first starting the Defending Childhood initiative, we wanted to make sure that we were implementing something that was not a new program, not a standalone program, but rather something that was embedded within the very robust social service menu, or environment that we have here in Cuyahoga County. We made the determination that we would work with our agencies and organizations that were already serving a large proportion of kids who were exposed to violence but at the same time, not necessarily focusing on that as the number one issue. We determined that we would work with our Children and Family Services, Juvenile Court, and a number of our community based mental health service providers. We worked with Jeff and others to develop a screening tool. We used that screening tool in those existing agencies. They screen very quickly for trauma symptoms and trauma behaviors. Then, once they reach a specific threshold, they move on to a central intake and assessment agency where they receive a full blown, roughly four-hour mental health assessment.

From there, the mental health professional makes the determination as to any diagnoses that may apply and also makes a decision as to an appropriate therapeutic intervention. From there, the child is referred into services.

MAJITHIA-SEJPAL: Jeff, do you want to talk about the tool that you developed?

KRETSCHMAR: Sure. Very early on in the process, when we were first awarded the grant, one of the things that we quickly discovered that while there was some screening going on for violence exposure and trauma in our child-serving systems, it wasn’t consistent, it wasn’t uniform, and a lot of times, when kids were screened, nothing happened as a result of those scores or that information. They knew that kids were exposed but they didn’t really have much unique services to put these kids into. What we thought was it would be really beneficial if our entire system used the same screening tool and had some training on how to use it. Then, that tool, the results of the information from that tool, could then be used to refer children to fuller assessments and then if necessary, into trauma-focused CBT or other trauma informed services designed specifically for cases like this.

We first thought to use an existing tool that would look at trauma and violence exposure but confine any that were really short and free and that would span kids from zero to eighteen. We created our own. We came up with two screeners. One’s for the younger kids, zero to seven. One is for the older kids, eight and older. We ask them or their caregiver about what kind of violence they’ve seen and what trauma symptoms are also co-occurring at that time. If kids score a certain level in that screener, they are referred in for a fuller assessment, to really get a handle on what they’re experiencing and if that’s had some mental health consequences for them.

The worker who’s administering the screening, regardless of the score on the screener, can also decide to refer that child for additional assessment if they feel like they need it.

MAJITHIA-SEJPAL: I understand that research was integral to the initiative from the very beginning of the planning process. How did you and your colleagues go about this research? What were some of your insights?

KRETSCHMAR: The most important thing we learned in the beginning was that there was just a lack of uniform screening for childhood exposure to violence and trauma. We put a lot of effort into the development of the screener. We took information from existing screeners, took data that we had collected previously on thousands and thousands of kids who have been exposed to violence and trauma, and identified the questions that we could ask that best predicted how kids would answer a much longer assessment. We were able to create these very short screeners. There are about fifteen questions, they take on average four, five minutes, and essentially what we’re finding out is that these screeners are really good at predicting who really has seen a lot of violence, who is experiencing trauma associated with that violence. I think we’re probably close, at this point, to twenty thousand kids who have been screened since July of 2012.

A lot of our research effort has focused on understanding what the kids in our community were seeing and experiencing, figuring out how best to measure that in a consistent and uniform way, and then understanding after the screening what needs to happen. What does a full assessment need to look like? What are the best treatments for these kids? These kids, as you said, we’re talking about zero to eighteen. What might work in terms of a therapy for an eight year old might not be appropriate for a seventeen year old.

MAJITHIA-SEJPAL: That leads me to another question. Given that you address the needs of children and teenagers in such a wide age range, zero through eighteen, how did you adapt your methods to different age groups, and specifically to the youngest children?

SMIALEK: I think in addition to the screening methods that we use, we made sure when we were selecting the various evidence-based treatment modalities, that we were encompassing some or selecting some that were appropriate for younger children. One of those that we selected was PCIT, the Parent-Child Interactive Therapy, which we know is especially effective for younger children, and we also are able to use trauma-focused cognitive behavioral therapy for younger children.

We also recognize that this is a really tough area. It’s hard to find an appropriate way to intervene with children who are so young, because of the age that they’re in in development. Here in Cuyahoga County, in addition to Defending Childhood, we have a number of social service agencies and initiatives at the large scale level that deal with child well-being. One of those is an initiative that’s dedicated to early childhood mental health. We do have the ability to refer into one of the early childhood mental health services, which are separate and apart from Defending Childhood but again, I think it kind of illustrates how we have fit Defending Childhood into the existing system and the existing infrastructure that we have in Cuyahoga County so that if we come across a child who we can’t fit into PCIT or TFCBT, we know that we have this additional referral source that we can tap into.

MAJITHIA-SEJPAL: How did you adapt and make use of evidence-based and promising practice into–

SMIALEK: we worked a lot with a number of community based partners who have far more expertise than I do and that anybody in my office has. When we were planning for the Defending Childhood initiative, there was a sub-committee that was put together to specifically look at various services or various trauma modalities that would be appropriate for Defending Childhood. We tapped into their brain power, their experience, their expertise, in order to come up with some options that really made sense. We reviewed a number of different programs. We looked at not just therapies, but also some community based group interventions, like the Families and Schools Together program, to make sure that we were making smart decisions that would lead to good outcomes for us.

KRETSCHMAR: In terms of the tools, we did a lot of work in establishing the screeners. Then, in the assessment process, we’re using validated assessments, using validated and previously used questionnaires like the Child Behavior Checklist, the Trauma Symptom Checklist for Children, to make sure we’re really measuring what we need to measure to best be able to then refer kids into the appropriate services for them.

MAJITHIA-SEJPAL: In addition to providing direct services, you also focused on creating an infrastructure that would span the entire county. Can you talk a little bit about that?

SMIALEK: What we wanted to do was ensure that whatever we started was first of all, taken to scale, because as you said earlier, we have a lot of crime in Cuyahoga County, and particularly in the city of Cleveland. I think that we are very well aware of the number of kids who are exposed to violence. We want to be able to make a difference for as many of those children as possible. If we’re going to take it to scale given the resources that we have, we knew that we had to work with what’s already in place. It just made sense, as we were thinking through how to make the biggest impact with the amount of resources that we had, how exactly would we do that. The answer to that was to build on top of what we already have so that we can sustain it long term and make the biggest difference possible.

MAJITHIA-SEJPAL: What are some of the lessons for other counties that want to make changes on the level of infrastructure?

SMIALEK: I think there are several that kind Cuyahoga County can bring to the table. The first is just to make sure that you take your time and do a thoughtful and thorough planning process. I think that starts with doing a full environmental scan of the groups that are already in the neighborhood or in the county or in the community, both groups who are interested in this issue, and who have the desire to be at the table, and bringing them in and making sure that they have a relevant and meaningful role to play while they’re engaged with the process.

I also think probably one of the most important lessons that we learned here locally is that planning takes time and over time, things change. You have to make a promise to one another that you will be flexible because the plan you write today, you may need to implement it a little differently tomorrow when you’re finally ready to implement.

KRETSCHMAR: Something else that we knew but was confirmed is that while you can have service providers and county employees and research folks at the table, we’re talking about a program for and about kids. You need to have the involvement of the kids. You need to understand what they’re experiencing, what their comfort level is with what we’re planning. If you don’t have it, we can have a really, really great plan but if it’s not something that kids and families are comfortable with, then it’s not going to work. Having that level of consumer involvement in the planning process is really important. Also important is from day one, planning for sustainability of whatever it is you want to implement, so thinking out a year or two years or three years ahead and say, “How are we going to make this sustainable?” Which goes back to an earlier question around why we also focused on system issues in our project is because if we can change the system, that’s a sustainable change. It doesn’t necessarily cost anything to change the system like we’ve started to change it, but it can be really lasting.

MAJITHIA-SEJPAL: That’s really interesting. Thanks so much for taking the time to talk to me.

KRETSCHMAR: Sure.

MAJITHIA-SEJPAL: I’m Avni Majithia-Sejpal, from the Center for Court Innovation and I’ve been speaking to Jill Smialek and Dr. Jeff Kretschmar about The Cuyahoga County Defending Childhood Initiative. To read our report on the initiative, as well as our multi-site report, you can visit our website at www.courtinnovation.org. Thanks very much for listening.