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Service Delivery Innovation Profile

Home-Based Crisis Intervention Reduces Trauma Symptoms and Behavior Problems Among Children Who Witness Violence


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Snapshot

Summary

The Summit County Children Who Witness Violence program was a collaborative effort sponsored by Akron Children's Hospital that was designed to decrease the traumatic impact of witnessing violence for children under the age of 18 through the use of home-based trauma services. The two-pronged program consisted of initial crisis intervention and assessment combined with ongoing trauma support services, including individual counseling for the child, parent, and family. All services were voluntary, confidential, and free of charge to the consumer. The program significantly reduced trauma symptoms and behavior problems among participating children and families. The program was discontinued on December 31, 2011 due to loss of funding.

Evidence Rating (What is this?)

Moderate: The evidence consists of a 5-year formal evaluation of participating children and their families, conducted by Kent State University, Institute for the Study and Prevention of Violence. The evaluation measured key outcomes, including trauma symptoms and behavior problems, at three distinct points in time—during the crisis, at intake into ongoing services, and at discharge from ongoing services.
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Developing Organizations

Akron's Children Hospital
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Date First Implemented

2002
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Patient Population

Vulnerable Populations > Childrenend pp

Problem Addressed

Domestic violence negatively affects the development of children of all ages, often leading to physical and mental health problems. Those children who witness violence, moreover, sometimes recreate the violent, abusive behavior they have seen at some point in the future. Although early intervention can help minimize the impact, many children who witness violence do not get such intervention and support.
  • Many children affected: It is estimated that 15.5 million American children live in families in which domestic violence had occurred at least once in the previous year, with approximately 7 million children being exposed to severe domestic violence.1
  • Risk of health problems and future violence: A child who witnesses violence is at higher risk for many health problems, including difficulties with sleeping or eating, depression, aggressiveness, anxiety, difficulties with relationships, and problems with concentration and school performance.2  Furthermore, exposure to physical abuse during childhood doubles the risk of future victimization among women and the risk of future perpetration of abuse by men.3
  • Lack of available services to help: Before the implementation of this program, organizations in Summit County were not providing immediate or ongoing crisis intervention services to children who witness domestic violence. Traumatized children were only seen if referred to a mental health agency with exacerbated trauma symptoms, and even then these traditional mental health providers often did not recognize the signs of trauma.

What They Did

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Description of the Innovative Activity

The Summit County Children Who Witness Violence program offered voluntary, confidential, and free home-based crisis intervention and round-the-clock trauma support services for Summit County children (from newborns to age 17 years) who witnessed violence. The goal of the program was to identify children as close to the exposure as possible, assess their need for specific services, and link them to those services, thereby decreasing the long-term impact from the trauma. The program was discontinued on December 31, 2011 due to loss of funding. Key elements of the program were as follows:
  • Identification of at-risk children: Children entered the program in one of two ways—a traditional referral or immediate response to a crisis.
    • Referral: A referral source called the program office and provided information on the child being referred. Typical referral sources included law-enforcement officers, local schools and social service agencies, the local battered women's shelter and Victim Assistance Program, Summit County Children's Services, Akron Children's Hospital, the Developing Options for Violent Emergencies Unit (which provides specialized medical treatment to victims of sexual assaults and domestic violence), and the Summit County Prosecutors Office's Strategic At-risk Family Education Program. Program staff contacted the family, explained the program services, and scheduled an appointment. 
    • Immediate response to crisis: Anyone who was in a position to know or otherwise strongly believed that a child was witnessing violence could call a hotline number that was staffed 24 hours a day, 7 days a week. Program staff dispatched a crisis intervention team to the home or to a safe location within 30 minutes of the referral. Law enforcement and medical professionals typically used this method.
  • Initial assessment and crisis resolution: A team of two Crisis Intervention Specialists, who are available 24 hours a day/7 days a week, met with the family three to five times (for approximately 60 to 90 minutes per session) to assess the situation, resolve the crisis, and develop interventions designed to help reduce and manage the child's distress. While the specialists may have met with the family more often (especially if a death occurred as a result of the violence), the typical five-session approach consisted of the following:
    • Initial visit: The first visit focused on gathering information regarding the precipitating incident and past experiences of violence; educating the caregiver about trauma and program services; obtaining signatures for a variety of forms; and meeting and giving the child a teddy bear, termed a "care bear." All children, even teenagers, receive a "care bear," as even older children were found to enjoy and take comfort from receiving the bear.
    • Second visit: The second visit consisted of trust building between the specialist team and the child, including the use of a variety of "ice-breaking" techniques such as coloring mandalas and coloring books, playing various board games, and completing worksheets that allowed the child to discuss their likes, dislikes, and wishes. The child was introduced to Ready, Set, Relax, a progressive muscle relaxation and breathing exercise program designed to reduce distress. The specialist team observed the child for trauma symptoms and began to assess the need for ongoing support.
    • Third visit: The third visit began or continued with the assessment process and relaxation techniques. The specialist team also often introduced art and play interventions.
    • Fourth visit: The fourth visit concluded the assessment process. The child continued to receive relaxation training and art and play interventions, and the specialists recommended ongoing support services as needed. 
    • Fifth visit: The fifth visit served as a transition meeting for those children who were referred for ongoing trauma support services (see next section). The ongoing service provider attended this meeting as well, thus assuring a seamless transition to the next level of care.
  • Ongoing trauma support services: Children and families in need of ongoing trauma support could receive parenting skills training, individual child counseling, and/or family counseling in their homes from local social service agencies and other trauma services providers. These providers met with the children and/or families one or two times a week for 1 to 2 hours over a period of 3 to 6 months. During these sessions, they used a variety of techniques, including cognitive-behavioral therapy, play therapy, and education.
  • Continued services beyond Children Who Witness Violence: When children and/or families needed services outside of the scope of the program or required hours of counseling over the program's approved amount, the agency transitioned the client into their standard services, which were not covered by program funding. All agencies accepted Medicaid and private insurance and had sliding fee scales based on income for those without insurance coverage.
  • Community-based education and training: The program sponsored ongoing training, education, and awareness sessions for area professionals and the public at large, including conferences on topics related to trauma, interpersonal violence, and juvenile violence or crime. Training sessions varied in length from 10 minutes to a full day. Law-enforcement training typically occurred in 10- to 15-minute increments over the course of 3 days during role call. In addition, the Akron Police Department incorporated the program's training into its police academy coursework.

Context of the Innovation

Akron Children's Hospital is the largest pediatric care provider in northeast Ohio, performing more surgeries than any hospital in the area and caring for more than 450,000 patients every year. In 2000, Betty Montgomery, former Ohio Attorney General, announced she would distribute more than $5 million in federal funds to 69 domestic violence programs across the state. She also provided each of the state's pediatric hospitals with $30,000 to plan and possibly develop a program to serve children who are exposed to violence. In 2002, after accepting the planning money, Akron Children's Hospital's Adolescent Services Department and 28 community partners launched the Children Who Witness Violence program.

Did It Work?

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Results

A comprehensive, 5-year evaluation of more than 800 children and their families who participated in the program found that it significantly reduced trauma symptoms and behavior problems.
  • Reduced trauma and fewer behavior problems: Longitudinal results found significant decreases in trauma symptoms and behavior problems, as measured by the Trauma Symptom Checklist for Children and Revised Behavioral Problem Checklist. There were also significant decreases in levels of emotional distress among young children, as measured by the Pediatric Emotional Distress Symptoms.
  • One in four reach goals: Roughly one in four children reached their treatment goals by the time they were discharged from the crisis intervention service sessions.

Evidence Rating (What is this?)

Moderate: The evidence consists of a 5-year formal evaluation of participating children and their families, conducted by Kent State University, Institute for the Study and Prevention of Violence. The evaluation measured key outcomes, including trauma symptoms and behavior problems, at three distinct points in time—during the crisis, at intake into ongoing services, and at discharge from ongoing services.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Formation of steering committee: Akron Children's Hospital put together a steering committee consisting of representatives from 13 different organizations, including child protective services, law enforcement, justice, youth-serving organizations (e.g., schools), and victim-services organizations. The committee's charter was to "prevent the short- and long-term negative impact on children who witness violence." To that end, the committee developed a plan laying out a recommended course for the community to address this emerging issue. The committee met for 2 years to plan the program and then for 1 year after implementation.
  • Application for funding grant: After the committee finalized its plans for this program, the Children's Hospital Medical Center in Akron applied for and was awarded in August 2002 a $500,000 4-year grant from The Robert Wood Johnson Foundation Local Initiative Funding Partners program.
  • Formation of managerial group: The program created a managerial group consisting of the program supervisor and one administrative member from each collaborating organization. This group was charged with solving programmatic problems, issues, and concerns. The group met once a week for the first 4 years and then met afterwards if a major issue arose.

Resources Used and Skills Needed

  • Staffing: The program had a full-time coordinator and secretary. Local agencies that were under contract with the program provided other services.
  • Costs: The program's annual budget was approximately $300,000, the bulk of which was used to pay the  subcontract agencies that provided crisis intervention and ongoing support services. Other costs included salary and fringe benefits for the coordinator and secretary, cell phone rental, training, travel, translation services, office supplies, and therapeutic materials for the children (e.g., the bears).
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Funding Sources

The Robert Wood Johnson Foundation Local Initiative Funding Partners; City of Akron; Summit County Department of Job and Family Services
As noted, the initial funding for the program came from The Robert Wood Johnson Foundation Local Initiative Funding Partners, along with matching funds from local foundations. The program received partial funding from local foundations, with remaining funding coming from the City of Akron (through a community block development grant) and the Summit County Department of Job and Family Services. Funding was discontinued as of September 30, 2011; as a result, the program was discontinued on December 31, 2011.end fs

Tools and Other Resources

The program used many materials from the National Institute for Trauma and Loss in Children (http://www.starrtraining.org/trauma-and-children), including the following publications:
  • Brave Bart: A Story for Traumatized and Grieving Children
  • Handbook of Trauma Interventions: Zero to Three
  • Early Childhood Grief
  • Helping Children Feel Safe Program
  • I Feel Better Now!
  • Ready...Set...R.E.L.A.X.
  • SITCAP
  • Trauma Debriefing Handbook for Schools and Agencies
  • Trauma Intervention Program
  • What Color Is Your Hurt?
The program also used the following materials:
  • Seasonal Mandalas by Wolfgang Hund
  • Manadala Patterns by Wolfgang Hund
  • When Something Terrible Happens by Marge Heegaard
  • I Saw it Happen by Wendy Deaton
  • Someone I Love Died by Wendy Deaton

Adoption Considerations

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Getting Started with This Innovation

  • Conduct extensive planning: Engage in and meticulously document program planning. Main program components to consider include the following: definition of services, goals, objectives, methods, responsible parties and staff, target population, therapeutic modality to be utilized, measurements, and measurement tools.
  • Define roles for partnering agencies: Develop clear-cut roles for each collaborative partner. Document roles in the form of a Memorandum of Understanding or a contract during the planning stage. The Children Who Witness Violence project did not do this during the planning stage, which later created confusion and controversy once funding was received and actual implementation began. Partner roles ended up being discussed and negotiated during the implementation process, which slowed the implementation process.
  • Obtain buy-in early: Spend time up front getting the buy-in of key partners. This process includes explaining how program successes and problems may threaten collaborative partners (e.g., by creating "turf" issues).
  • Provide clear and unified leadership: Ensure that all managerial and administrative staff provide a unified message to front-line staff (those providing services) and collaborating partners. A clear chain of command and line of communication must be in place to avoid confusion among the collaborative partners and the staff. 

Sustaining This Innovation

Cultivate relationships with referral agencies: Spend time educating and maintaining the support of key referral sources and other community-based organizations. Referral sources must believe in the quality of program services and the reliability and professionalism of the staff, while community organizations need to trust and have confidence in the program.

Spreading This Innovation

Program leaders provided technical support to several other communities that were interested in establishing similar programs.

Additional Considerations

Leaders of the Children Who Witness Violence program were also involved in the Summit County Domestic Violence Coalition and the Ohio Domestic Violence Network, a statewide coalition of domestic violence programs, supportive agencies, and concerned individuals organizing to reduce and ultimately eliminate domestic violence. Program personnel were also contributing members to an Ohio Department of Mental Health task force to establish a unified childhood trauma screening and assessment protocol for Ohio mental health organizations.

More Information

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Contact the Innovator

Melissa Peace
Manager
Akron Children's Hospital
One Perkins Square
Akron, OH 44308-1062
Phone: (330) 543-3571
Fax: (303) 543-3717
E-mail: mpeace@chmca.org

Innovator Disclosures

Ms. Peace has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Cunningham L, Mirakhur A, Flannery D. Summit County Children Who Witness Violence Program, Final Evaluation Report. Kent State University: Institute for the Study and Prevention of Violence; April 2007. (Report Available upon request from innovator.)

Footnotes

1 McDonald R, Jouriles EN, Ramisetty-Mikler S, et al. Estimating the number of American children living in partner-violent families. J Fam Psychol. 2006;20(1):137-42. [PubMed]
2 National Center for Children Exposed to Violence. Domestic violence Web site. 2006.
3 Whitfield, CL, Anda RF, Dube SR, et al. Violent childhood experiences and the risk of intimate partner violence in adults: assessment in a large health maintenance organization. J Interpers Violence. 2003;18(2):166-85.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: June 23, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 19, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.