The Impact of Domestic Violence on Children's Functioning: Care Planning Approaches to Foster Trauma-Informed Care Shannon Stewart, Yasmin Garad, Natalia Lapshini

1. The Impact of Domestic Violence on
Children’s Functioning: Care Planning
Approaches to
Foster Trauma-Informed Care
www.interrai.org
Shannon L. Stewart, Yasmin Garad, Natalia Lapshina

2. Children’s Mental Health in Ontario
• Clinicians, educators and school personnel want
to play a crucial role in the identification of
students struggling
 One in five students experiences mental health issues
 Yet only about 25% receive the treatment needed
 50-75% of adult mental health issues persist from
school-age years
• Highly predictive of
 Impaired social and emotional functioning
 Poor academic achievement
 School absenteeism
 Substance abuse
 Academic failure and drop out in both elementary and
secondary schools

3. Impacts of Trauma
• Children who experience domestic violence and abuse are at a higher risk
of experiencing:
 physical health issues
 mental health problems
 social skills deficits
 academic underachievement and school dropout
 underemployment
 poverty
 pre/postnatal exposure to drugs, alcohol, and toxins
 parental substance abuse
• Placement instability exacerbates this risk for mental and physical health,
and socio-emotional problems

4. The interRAI Trauma-Informed Care Project
Gain a comprehensive understanding
of the mental health dynamics of
individuals exposed to DVA
Improve outcomes and enhance early
intervention for mental health,
behavioural and socio-emotional
problems
Improve understanding
Early intervention
Strengthen capacity at community
level to address the health of victims
of DVA using trauma- informed care
Enhance multi-agency collaboration
and improve continuity of care to
better meet the needs of clients who
have experienced DVA
Strengthen Capacity
Multi-agency Collaboration
Project
Objectives
www.interrai.org

5. interRAI
interRAI is an international collaborative to improve the quality of life of vulnerable
persons through a seamless comprehensive assessment system.
Our consortium strives to promote evidence-informed clinical practice and policy decision
making through the collection and interpretation of high-quality data about the characteristics
and outcomes of persons served across a variety of health, school and social services
settings

8. How do interRAI instruments help children,
youth, and their families?
• Improving early identification of mental health and
substance use across service sectors
• Enhancing access to mental health care services
• Improve transitions
• Contributing to increased evidence-informed care
planning to improve the functionality of mental
health services across multiple service sectors

9. Lifespan Approach
Through the use of an integrated suite of setting- and sector-specific
assessments, the child/youth suite delivers comprehensive information about
children and youth that can support them from birth through to adulthood and
beyond.

10. interRAI Child and Youth Suite
School Community HospitalJusticeHome

11. Examples of Manuals in Children and Youth
Instruments

12. What sets interRAI Instruments Apart?
One assessment…multiple applications

13. CAPs
• Collaborative Action Plans are documents containing current evidence-informed approaches to guide
interventions in target areas.
• Case finding methodology
• CAPs target to those who may benefit from an intervention
• Enable service providers to use time efficiently
• Decision-support tools to inform interactions between service providers and individuals with identified
needs
• A triggered CAP will highlight child or youth needs and appropriate interventions in that area.
Judgement is required to determine clinician ability and availability.
• 29 ChYMH CAPs available; 30 ChYMH-DD CAPs; 17 0-3 CAPs; 29 Youth Justice CAPS
Example:

14. Safety
CAPs
Services
and
Supports
CAPs
Functional
Status
CAPs
Family Life
and Social
Integration
CAPs
Health
Promotion
CAPs
interRAI
ChYMH
Collaborative
Action Plans
(CAPs)
Functional Status CAPs
Communication, Life Skills
Family Life and Social Integration CAPs
Attachment, Caregiver Distress, Interpersonal
Conflict, Parenting, Social and Peer Relationships
Safety CAPs
Control Interventions, Criminality Prevention, Harm to Others
Hazardous Fire Involvement, Sexual Behaviour, Suicidality
and Purposeful Self-Harm, Traumatic LifeEvents
Services and Supports CAPs
Education, Informal Support, Readmission,
Support Systems for Discharge,Transitions
Health Promotion CAPs
Caffeine Use, Gambling, Medication Adherence,
Medication Review, Physical Activity, Sleep
Disturbance, Strengths, Substance Use, Tobaccoand
Nicotine Use, Video Gaming, Weight Management
www.interrai.org

15. Using the results
Results of interRAI Assessment Youth Profile
=
47
Support
referrals
Track
change
Support
planning
Assist triage
decisions

16. Implementation of trauma informed care using the interRAI Child and Youth Mental
Health instrument (ChYMH) Collaborative Action Plans (CAPs)
www.interrai.org
The interRAI Trauma-Informed Care Project
Training staff at participating agencies
on the use of the interRAI ChYMH
CAPs using a trauma-informed lens
Assessing the impact of implementing
interRAI ChYMH Collaborative Action
Plans from a trauma-informed
perspective

17. Goals of the Current Project
• Determine the needs of children who have been exposed to domestic violence (DV)
• Identify specific developmental, behavioural, and emotional problems of this sub-
population
• Engage diverse team of knowledge-users, research, and decision-makers
• Strengthen the delivery of mental health care for children and youth

18. Participants
• Recruited from over 70 schools,
secure custody sites and mental health
facilities in Ontario, Canada
• English-speaking children and
youth
• N = 8924
• No DV trauma n= 4764
• DV trauma n= 4160
No DV
trauma
DV trauma
Age (M, SD) 11.56 (3.59) 12.54 (3.50)
Gender
Males (%) 61.4 54.6
Females
(%)
38.6 45.4

19. Child and Youth Mental Health Instrument
• Comprehensive assessment system
• Approximately 60-90 minutes for
completion
• Semi-structure interview of individual
needs
• Well established reliability and validity
of psychometric properties
• A wide range of domains are possible
needs are evaluated including:
 Substance Abuse
 Social Relationships
 Environmental Issues
 Medical Issues
• Applications are included to support
decisions related to care planning and
outcome measurement

20. Measures
Domestic Violence Trauma - 6 questions:
Victim of: sexual abuse, physical abuse,
emotional abuse; witness of domestic
violence; physical neglect, emotional neglect
Dichotomized 0 = Never, 1= Present in last 3
days- 1 year ago
Combined into a cumulative trauma
variable (range: 0-6)
Dichotomized into 0= no DV trauma, 1 = yes
Medical diagnosis: asthma, diabetes,
epilepsy, FASD, traumatic brain injury,
migraines
Family factors: family dysfunction,
caregiver distress, communication with the
child, frequent disruptions in care
Peer relationships: victim of bullying
Externalizing / internalizing symptoms
scales
Disruptive and Aggressive Behaviour
scale

21. Poly-Victimization and Types of trauma
0.0
10.0
20.0
30.0
40.0
50.0
60.0
None 1
trauma
type
2
trauma
types
3
trauma
types
4
trauma
types
5
trauma
types
6
trauma
types
52.9
16.3
10.6
7.6
3.8 2.8
1.0
Percent
0
10
20
30
40
50
60
70
WDV Emotional
abuse
Physical
abuse
Emotional
neglect
Sexual
abuse
Physical
neglect
62.4
59.8
40
27.7
22.1
19.4
Percent

22. Externalizing and Internalizing Problems
0.0
5.0
10.0
15.0
DABS Internalizing
symptoms
Externalizing
symptoms
4.1
9.2
3.8
5.6
11.1
5.6
MeanScore
No DV trauma DV trauma

23. Family Factors
0.0
20.0
40.0
60.0
80.0
100.0
Caregiver distress Effective
communication
Disruptions in care
28.1
97.3
3.4
57.8
91.1
28.3
Percent
No DV trauma DV trauma
0.0
0.5
1.0
1.5
2.0
2.5
No DV trauma DV trauma
MeanFamilyDysfunction
Family functioning

24. Medical Conditions
0.0
2.0
4.0
6.0
8.0
10.0
12.0
Diabetes Epilepsy FASD Migraine Traumatic
brain
injury
Asthma
No DV trauma 0.7 1.2 0.8 1.4 0.6 7.5
DV trauma 0.6 1.6 3.1 2.4 0.7 10.5
Percent
No DV trauma DV trauma

25. 0.0
10.0
20.0
30.0
40.0
50.0
60.0
No DV trauma DV Trauma
35.6
57.6
Percent
Victim of Bullying

26. History of Needs Met (yes)
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Physical needs met Safety needs met
Percent
No DV trauma DV Trauma

27. Summary of Results
• 25.8% of children and youth who had witnessed DV have experienced multiple forms
of trauma
• Children and youth who had experienced DV trauma were less likely to have their
basic needs met in early childhood
• Compared to clinically referred children who did not experience DV trauma, those who
have experienced DV trauma:
 Experience more internalizing, externalizing, disruptive, and aggressive behaviours
 Have more problems with family functioning, are less effective communication with parents, experience
higher caregiver distress, and more disruptions in care
 Experience more medical conditions such as asthma, epilepsy, Fetal Alcohol Syndrome
 Experience more bullying by peers

28. How do youth in secure custody compare to
inpatient and outpatient youth with respect
to trauma?
N= 755 youth
Age 16 to 19 (M = 16.76, SD = .81)
Subsample
Case Type:
Secure Custody/Detention N = 90 (11.9%)
Inpatient N = 75 (9.9%)
Outpatient N = 590 (78.1%)
All youth were recruited from facilities in Ontario, Canada

29. Measures
Traumatic Life Events
Abuse: Victim of: sexual violence, physical abuse, emotional abuse, bullying
Family Factors: Parental addiction, change of legal custodian, abandoned by
parent, witness of domestic violence,
Neighbourhood Factors: Victim of crime, lived in a violent neighbourhood
Dichotomized 0 = Never, 1= in last 3 days- 1 year ago
Scales:
Social Disengagement (0-16)
Depressive Symptoms Scale (0-36)
Anxiety (0-28)
Aggressive Behaviour (0-16)
Hyperactive/Distractible (0-16)
Disruptive Behaviour (0-12)
29

30. Traumatic Experiences: Abuse
30
0.0
10.0
20.0
30.0
40.0
50.0
60.0
Victim of Sexual
Violence
Physical Abuse Emotional
Abuse
Victim of
Bullying
Percent
Trauma Type
YJ
Inpatient
Outpatient

31. Traumatic Experiences: Family Factors
31
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
Percent
Trauma Type
YJ
Inpatient
Outpatient

32. Traumatic Events: Neighbourhood Factors
32
0.0
10.0
20.0
30.0
40.0
50.0
60.0
Violent Neighborhood
Victim of Crime
Percent
Trauma Type
YJ
Inpatient
Outpatient

33. Internalizing Problems:
Anxiety, Social Disengagement and Depressive
Symptoms
33
0
2
4
6
8
10
12
Anxiety
Social
Disangagement Depression
MeanScore
Intermalizing Symptoms
YJ
Inpatient
Outpatient

34. Disruptive Behaviour Problems
34
0
0.5
1
1.5
2
2.5
3
YJ
Inpatient
Outpatient
MeanScore
Disruptive Behaviour Symptoms

35. Hyperactivity and Distractibility
35
0
1
2
3
4
5
6
7
8
YJ
Inpatient
Outpatient
Mean-Distractibility/Hyperactivity
Case Type
Males
Femailes

36. Aggressive Behaviour
36
0
0.5
1
1.5
2
2.5
3
YJ
Inpatient
Outpatient
Mean-AggressiveBehaviour
Case Type
Males
Femailes

37. Care Planning:
Trauma
37
0
5
10
15
20
25
30
35
40
Reduce the impact of prior
traumatic life events
Address immediate safety
concerns
Percent
Trauma CAP
YJ
Inpatient
Outpatient

38. Care Planning:
Harm to Others and Self-Harm
38
0
5
10
15
20
25
30
Moderate risk of
harm to others
High risk of harm
to others
Percent
Risk of Harm to Others CAP
0
5
10
15
20
25
30
35
Moderate
risk of harm
to self
High risk of
harm to self
Percent
Suicidality and Purposeful Self-Harm CAP
YJ
Inpatient
Outpatient

39. Care Planning: Interpersonal Conflict
39
0
5
10
15
20
25
30
35
40
45
50
Reduce conflict within a
specific domain
Reduce widespread conflict
Percent
Interpersonal Conflict CAP
YJ
Inpatient
Outpatient

40. Care Planning: Substance and Tobacco Use
40
0
20
40
60
80
100
YJ Inpatient Outpatient
Percent
Substance Use CAP
0
5
10
15
20
25
30
35
40
45
50
Reduce or
cease daily
tobacco use
Prevent
long-term
tobacco use
Percent
Tobacco Use CAP
YJ
Inpatient
Outpatient

41. Care Planning – Other CAPs
41
0
10
20
30
40
50
60
70
Percent
Triggered CAPs
YJ
Inpatient
Outpatient

42. Conclusions: Comparison of Patient
Groups
• Trauma rates were found to be higher for the YJ group.
• Females experienced higher rates of sexual violence and emotional abuse compared to
males.
• Females reported higher depression and anxiety compared to males.
• Males reported higher externalizing behaviours than females.
• YJ group reported lower levels of depression and anxiety than the two patient groups.
• Evidence for differentiated patterns of gender differences for aggression between youth who
live in the community and youth either detained in the YJ system or within inpatient mental
health care.
• No gender differences were found for distractibility and hyperactivity in the YJ group.
• Youth involved in the justice system have complex psychosocial issues that require unique
interventions.
• Current study highlights a need for further research into implementation of trauma-informed
care within the justice system.

43. Dr. Shannon L. Stewart, Associate Professor
Director of Clinical Training
Faculty of Education, Western University
International InterRAI Child and Youth Lead
interRAI Fellow
sstewa24@uwo.ca