Trauma-Responsive Employment Services: The Healthy Workers, Healthy Wisconsin Project

By providing training and access to employment opportunities, job programs help individuals obtain the skills and social connections necessary to achieve sustainable employment.1 The structure and function of these programs vary, though many serve low-income adults with limited education and job training. Despite their public appeal, most job programs in the US struggle to sustain impact over time, as gains in employment and income among program participants seldom last more than six months.2

There are several reasons why these programs often do not produce long-term benefit. First, job programs rely on a pool of low-skilled positions into which they place participants for training and development. However, the availability of low-skilled jobs is shrinking due to automation and out-sourcing.3 Second, employment service participants of color often face systematic discrimination when attempting to land employment, undermining their efforts to attain economic self-sufficiency.4 Finally, personal health challenges and risk factor profiles sometimes sabotage low-income job seekers’ attempts to sustain long-term employment. For instance, studies have shown that these job seekers endure stress and trauma at much higher rates than the general population; in addition, their experiences of adversity impair physical and mental health, which exacerbates problems with work.5,6 To address the health and employment effects of trauma, innovative trauma-responsive employment service programs have begun to emerge.

In order to enhance the well-being of their trauma-affected clients and increase the chances that clients will obtain and sustain meaningful employment, these programs integrate key components of trauma-informed care (TIC). They combine, for instance, hallmark TIC principles such as empowerment and peer support7 with emerging TIC practices such as trauma screening, referral to services, and use of evidence-based trauma interventions.8 Results from a few published research studies suggest that such programs promote positive long-term outcomes:

  • A welfare-to-work program, serving low-income mothers of young children, introduced several key trauma-informed components to their menu of services: financial empowerment training and the well-validated peer support Sanctuary Model®. The program helped to reduce participants’ depression symptoms while increasing income-benefits that endured well after services ended.9
  • An innovative supported employment program, serving military veterans with post-traumatic stress disorder, provided immediate and extensive mental health referral services along with case management services. An additional key program component, rapid job placement, aimed to facilitate self-empowerment and self-efficacy. Evaluation results indicated that the program increased participants’ earnings over a long period.10

Healthy Workers, Healthy Wisconsin

In 2017, Community Advocates Public Policy Institute partnered with the Institute for Child and Family Well-Being to launch Healthy Workers, Healthy Wisconsin (HWHW), a five-year project designed to increase low-income job seekers’ access to trauma-responsive employment services. Funded by the Wisconsin Partnership Program and Bader Philanthropies, HWHW integrates trauma-responsive practices within various employment service programs located in Southeast Wisconsin. Types of participating programs include welfare-to-work, non-traditional transitional jobs, and prison reentry. At the heart of the initiative, which runs through 2021, is a protocol titled trauma screening, brief intervention and referral to treatment or T-SBIRT.


The T-SBIRT protocol is a brief, standardized intervention that integrates trauma-informed care principles and practices into its structure. By directly addressing trauma exposure and its effects, T-SBIRT works to remove critical barriers to health care access. Within employment services, the protocol requires approximately 30 minutes to complete and consists of a number of steps including the following.

  • Screening for healthcare access, trauma exposure and trauma symptoms
  • Probing for helpful and unhelpful stress coping skills
  • Enhancing motivation for help seeking behavior
  • Referral to health, mental health, behavioral health and/or social services

Evident in the structure of T-SBIRT are hallmark TIC principles and practices such as screening and assessment, a focus on stress coping, client empowerment through motivational interviewing, and referral to treatment and other services (see issue brief in Trauma Responsive Practices). In fact, T-SBIRT providers work closely with referral partner agencies that offer well-validated services, including trauma-specific mental health treatments that reduce PTSD symptoms. Participating employment service agencies also collaborate closely with their employer partners to enhance the trauma-informed nature of stability employment. As such, T-SBIRT and HWHW rely heavily on interagency collaborations, another critical feature of TIC.

HWHW Results

A recent study of HWHW showed that it is feasible to implement T-SBIRT within employment services.11 Several non-traditional stability or temporary jobs programs were the subjects of the study. Expanding the range of programs and number of participants, the authors have conducted ongoing analyses of HWHW data. Results suggest that the protocol was acceptable or tolerable to the 186 project participants. Fully 94.1% of the sample reported feeling the same or better after completing T-SBIRT services, consistent with other research showing that respondents typically experience little to no distress when discussing past trauma exposure in the context of a well-conducted interview (see Asking Sensitive Questions Issue Brief).

Moreover, T-SBIRT addressed common problems among participants, meaning that was suitable for the client group. For instance, 96.6% experienced significant trauma in their lives, and 55% screened positive for post-traumatic stress disorder. Other mental health problems appeared to plague a relatively large portion of the study sample. Over forty percent screened positive for depression, and nearly half endorsed problems with anxiety. An additional barrier to health and well-being that T-SBIRT targets is access to healthcare, and over one-third or 37.7% of the participants indicated that they had no regular place to go for healthcare.

Designed ultimately to facilitate referrals to outside health-related services, T-SBIRT appeared to function as intended with employment service recipients. Nearly three-quarters of the study sample accepted a referral to any type of service. Over half accepted a referral to mental health care, which is surprisingly good news given the stigma that such services carry among low-income groups.12 Finally, over one-quarter of the project participants accepted a referral to primary healthcare services.

Conclusion and Future Directions

As evidenced by the feasibility study results, T-SBIRT shows promise as an efficient, user-friendly tool that employment service providers can implement in non-clinical settings to connect clients to appropriate services such as primary and mental healthcare. If shown to produce meaningful health and employment outcomes, T-SBIRT will have significant implications, not only for individual at-risk job seekers, but also for their families and entire communities suffering from the interrelated cycles of poverty, unemployment, poor health, and untreated trauma.

Currently, ICFW is conducting an impact study to explore whether completion of T-SBIRT within employment services is associated with improved health and employment outcomes. Focus groups with program participants have also been completed in order to assess program satisfaction and explore recommended improvements. In addition, HWHW administrators continue to search for trauma-focused mental health referral partners given the high demand for yet limited supply of such services. Program administrators are additionally involved in collective efforts to define trauma-informed employment practices.

Finally, the ultimate goal of HWHW is to stimulate policy change such that state-run employment services become more trauma-responsive. Implementing T-SBIRT along with other HWHW recommendations will potentially promote more responsive and effective employment services. Therefore, Community Advocates Public Policy Institute in tandem with the Institute for Child and Family Well-Being is disseminating results of the HWHW initiative to policy makers and the public at-large.


1 Harper-Anderson, E. (2008). Measuring the connection between workforce development and economic development: Examining the role of sectors for local outcomes. Economic Development Quarterly, 22, 119-135.
2 Redcross, C., Millenky, M., Rudd, T., & Levshin, V. (2011). More than a job: Final results from the evaluation of the center for employment opportunities (CEO) transitional jobs program. OPRE Report, 18. Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.
3 Autor, D. H., & Dorn, D. (2013). The Growth of low-skill service jobs and the polarization of the US labor market. American Economic Review, 103, 1553–1597.
4 Levine M. V. (2012). Race and male employment in the wake of the Great Recession: Black male employment rates in Milwaukee and the nation’s largest metro areas, 2010. Milwaukee, WI: University of Wisconsin-Milwaukee, Center for Economic Development.
5 Cambron, C., Gringeri, C., & Vogel-Ferguson, M. B. (2015). Adverse childhood experiences, depression and mental health barriers to work among low-income women. Social Work in Public Health, 30, 504-515.
6 Topitzes, J., Pate, D. J., Berman, N. D., & Medina- Kirchner, C. (2016). Adverse childhood experiences, health, and employment: A study of men seeking job services. Child Abuse & Neglect, 61, 23-34.
7 Substance Abuse and Mental Health Services Administration (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Author.
8 Lang, J. M., Campbell, K., Shanley, P., Crusto, C. A., & Connell, C. M. (2016). Building capacity for trauma-informed care in the child welfare system: Initial results of a statewide implementation. Child Maltreatment, 21, 113-124.
9 Booshehri, L. G., Dugan, J., Patel, F., Bloom, S., & Chilton, M. (2018). Trauma-informed Temporary Assistance for Needy Families (TANF): A Randomized Controlled Trial with a Two-Generation Impact. Journal of Child and Family Studies, 27, 1594-1604.
10 Davis, L. L., Kyriakides, T. C., Suris, A. M., Ottomanelli, L. A., Mueller, L., Parker, P. E., … & Drake, R. E. (2018). Effect of evidence-based supported employment vs transitional work on achieving steady work among veterans with posttraumatic stress disorder: a randomized clinical trial. JAMA Psychiatry, 75, 316-324.
11 Topitzes, J., Mersky, J. P., Mueller, D. J., Bacalso, E., & Williams, C. (2019). Implementing Trauma Screening, Brief Intervention, and Referral to Treatment (T-SBIRT) within Employment Services: A Feasibility Trial. American Journal of Community Psychology, 64, 298-309.
12 Thornicroft, G., Mehta, N., Clement, S., Evans- Lacko, S., Doherty, M., Rose, D., … & Henderson, C. (2016). Evidence for effective interventions to reduce mental-health-related stigma and discrimination. The Lancet, 387(10023), 1123-1132.


“A recent study of HWHW showed that it is feasible to implement T-SBIRT within employment services.11

Trauma Screening, Brief Intervention, and Referral to Treatment (T-SBIRT)

Trauma-Informed Care

It is estimated that over 70% of the population worldwide has experienced a traumatic event.1 Based on rapidly expanding insights into the scope and consequences of trauma exposure, trauma-informed care has become an ascendant service framework. As evidence to this effect, the Substance Abuse and Mental Health Service Administration (SAMHSA) has articulated general guidelines2 for implementing trauma-informed care across multiple service sectors such as:

• Physical, Mental and Behavioral Health
• Child Welfare
• Workforce Development
• Juvenile and Criminal Justice

Building on SAMHSA’s guidance, practitioners and researchers have begun to translate the principles of trauma-informed care into trauma-informed practices.3 For instance, Berliner and Kolko (2016) write that trauma-informed care should incorporate the following strategies: “screening for trauma exposure, assessing trauma impact, and increasing access to trauma-specific treatment (p. 170).” Consistent with these recommendations, Dr. James Topitzes of the Institute for Child and Family Well-being developed a Trauma Screening, Brief Intervention, and Referral to Treatment (T-SBIRT) protocol that is designed to identify trauma exposure and symptoms among adults and refer them to trauma-focused treatment as needed.

T-SBIRT Overview

The original SBIRT model addresses alcohol and drug misuse through a brief, universal approach. Most commonly delivered within healthcare settings, SBIRT has been shown to reduce drinking and drug use among risky substance users.4,5 It applies motivational interviewing principles to encourage behavior change and provides the conceptual foundation for T-SBIRT.

Like SBIRT, T-SBIRT draws on the public health ethic of delivering widespread and minimally burdensome screening and referral services to improve population health. It is client-centered and brief, requiring approximately ten minutes to complete. Due to its brevity and uncomplicated design, it can be readily integrated into various service settings such as primary and specialty healthcare centers, behavioral and mental health treatment clinics, child welfare and social service agencies, and criminal justice facilities. Professionals from case managers to clinicians can conduct T-SBIRT sessions with the proper training and technical assistance.

While the structure of T-SBIRT is similar to SBIRT, it has two distinct
purposes: (1) to help clients generate insight into the extent and effects of their trauma exposure, and (2) to enhance their motivation to engage in behavioral or mental health services. The steps of T-SBIRT consist of the following motivational interviewing elements: seeking permission to share information, providing information and education, asking open-ended questions, reflecting and summarizing responses, and reinforcing statements reflecting motivation to change.

T-SBIRT Feasibility Study

A recent study demonstrated that it was feasible to implement T-SBIRT in primary care community clinics.6 Clinic administrators agreed to the study because they: a) recognized the corrosive influence of trauma on patient health and well-being, and b) were dedicated to offering integrated and trauma-informed healthcare services. The study gathered data on more than one hundred adults (N=112) that lived in central city neighborhoods and qualified for clinic services due to low-income status. Of the full sample of study participants, 53.7% were African American, 36.1% were Latino/a, and 5.6% were White. Participants’ ages ranged from 18 to 74, with an average of 41.4 years, and just over 40% were female.

Prior to their primary care physician visit, study participants received SBIRT and T-SBIRT services from a mental or behavioral health specialist. Feasibility data emerged from integrity checklists that service providers completed during sessions and from treatment acceptability surveys that clients completed after sessions. Results showed that T-SBIRT is a highly promising approach according to five different indicators of feasibility:6

a) Suitability: 96% of sample endorsed exposure to at least one lifetime traumatic event; 56% of sample generated a positive PC-PTSD screening result

b) Acceptability: 3.00 or ‘very acceptable’ was the average overall patient rating of T-SBIRT

c) Compliance: 100% of patients who were offered T-SBIRT accepted and completed services

d) Fidelity: 97% of all T-SBIRT integrity checklist steps were completed by providers

e) Outcomes: 63% of sample accepted a mental/behavioral health referral at session’s end

Each of the results summarized above meets or exceeds published standards for feasibility.10 For instance, rates of model fidelity over 80% are considered to be excellent. The study’s observed rate of referral acceptance is also higher than acceptance rates of other brief health referral services.5,11 Based on these encouraging results, T-SBIRT is now being implemented and tested in additional community-based settings.

Future Directions

The Institute for Child and Family Well-being recently launched a new initiative with funding from the Wisconsin Partnership Program to implement T-SBIRT within workforce development programs. Research has shown that adults seeking job services face multiple barriers to employment due in part to their history of trauma exposure.12 Addressing trauma with T-SBIRT while also promoting job placement may therefore improve program outcomes.

Additionally, the Institute has joined forces with the Central Racine County Health Department in Wisconsin to combine T-SBIRT with universal home visiting services. With funding from the Racine County government and the United Way of Racine County, the project aims to implement T-SBIRT with women once they return home from the hospital after giving birth. This approach has the potential to increase community-wide access to trauma-informed mental health services during a particularly sensitive period for mothers and their infants.

By introducing trauma-related screening and referral practices within universal home visiting services, T-SBIRT has the potential to coordinate care across Racine area service providers. As such, it is actively supporting intersystem collaboration and communication,13 a key implementation driver of trauma-informed care, and it is helping to translate trauma-informed care principles into practice.


1 Benjet, C., Bromet, E., Karam, E. G., Kessler, R. C., McLaughlin, K. A., Ruscio, A. M., … & Alonso, J. (2016). The epidemiology of traumatic event exposure worldwide: Results from the World Mental Health Survey Consortium. Psychological Medicine, 46(2), 327-343.
2 Substance Abuse and Mental Health Services Administration (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS publication number (SMA) 14-4884. Rockville, MD: U.S. Department of Health and Human Service, Substance Abuse and Mental Health Services Administration.
3 Berliner, L., & Kolko, D. J. (2016). Trauma informed care: A commentary and critique. Child Maltreatment, 21(2), 168-172.
4 Babor, T. F., McRee, B. G., Kassebaum, P. A., Grimaldi, P. L., Ahmed, K., & Bray, J. (2007). Screening, Brief Intervention, and Referral to Treatment (SBIRT) toward a public health approach to the management of substance abuse. Substance Abuse, 28(3), 7-30.
5 Madras, B. K., Compton, W. M., Avula, D., Stegbauer, T., Stein, J. B., & Clark, H. W. (2009). Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites:
comparison at intake and 6 months later. Drug and Alcohol Dependence, 99(1), 280-295.
6 Topitzes, J., Berger, L., Otto-Salaj, L., Mersky, J. P., Weeks, F., & Ford, J. D. (2017). Complementing SBIRT for alcohol misuse with SBIRT for trauma: A feasibility study. Journal of Social Work Practice in the Addictions, 17
(1-2), 188-215.
7 Carlson, E. B., Smith, S. R., Palmieri, P. A., Dalenberg, C., Ruzek, J. I., Kimerling, R., Burling, T. A., & Spain, D. A. (2011). Development and validation of a brief self-
report measure of trauma exposure: the Trauma History Screen. Psychological Assessment, 23, 463-477.
8 Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D. S., Shaw-Hegwer, J., … Sheikh, J. I. (2003). The primary care PTSD screen (PC-PTSD): Development and operating characteristics. Primary Care Psychiatry, 9, 9-14.
9 National Center for PTSD (2016). Understanding PTSD and PTSD treatment. Washington, DC: National Center for PTSD.
10 Bowen, D. J., Kreuter, M., Spring, B., Cofta-Woerpel, L., Linnan, L., Weiner, D., … & Fernandez, M. (2009). How we design feasibility studies. American Journal of Preventive Medicine, 36, 452-457.
11 Chan, Y. F., Huang, H., Sieu N., & Unützer, J. (2013). Substance screening and referral for substance abuse treatment in integrated mental health care program. Psychiatric Services 64(1), 88-90.
12 Topitzes, J., Pate, D. J., Berman, N. D., & Kirchner-
Medina, C. (2016). Adverse childhood experiences, health, and employment: A study of men seeking job services. Child Abuse & Neglect, 61, 23-34.
13 Lang, J. M., Campbell, K., & Vanderploeg, J. J. (2015). Impact: Advancing trauma-informed systems for children. Farmington, CT: Child Health and Development Institute of Connectict.



“While the structure of T-SBIRT is similar to SBIRT, it has two distinct purposes: (1) to help clients generate insight into the extent and effects of their trauma exposure, and (2) to enhance their motivation to engage in behavioral or mental health services.”


T-SBIRT protocol

When delivering T-SBIRT, service providers complete the protocol with their clients in the following sequence:

1. Make a brief statement about known connections between stress, trauma and poor life outcomes.

2. Ask permission to screen for and discuss issues of stress and trauma.

3. Ask about sources of current life stressors using open-ended questions.

4. Screen for exposure to traumatic events using the Trauma History Screen7 or other validated tool.

5. Assess for current symptoms with the Primary Care Post-Traumatic Stress Disorder (PC-PTSD) screen.8

6. Ask about “positive” and “unhelpful” strategies used to cope with trauma memories and symptoms.

7. Inform clients that it can be difficult to eliminate substance misuse or other unhelpful coping strategies without simultaneously addressing trauma.

8. Gauge and enhance motivation to pursue behavioral or mental health services.

9. Make a referral to treatment when indicated following best referral practices.

10. Offer an educational booklet on post-traumatic stress, published by the federal government.9

11. Implement an evidence-based calming exercise if necessary.

Supporting Safe, Stable, and Healthy Housing

Housing provides a foundation for health, well-being and prosperity. However, many families in the child welfare system lack reliable access to an affordable home. In this issue brief we highlight how housing is linked to child safety, permanence and well-being, and call for child welfare practices that promote safe, stable, and healthy housing.

Inadequate Housing Undermines Safety, Permanence, and Well-being

The root causes of child abuse and neglect are complex, with poverty, substance use and mental illness counting among the many known risks to child safety. Although inadequate housing has received less attention, studies have shown that overcrowding, eviction and homelessness are associated with an increased risk of abuse and neglect.1,2 Corresponding evidence suggests that providing assistance with housing and other concrete needs (e.g., clothing; furniture) may reduce the risk of abuse and neglect.3

Along with its threats to child safety, poor housing jeopardizes family preservation and child permanency goals. Among families that are referred to child protective services, those with a history of housing instability and homelessness are at a greater risk of having a child removed from their care.4 Housing problems can present barriers to family reunification as well.4,5 In sum, inadequate housing may contribute to entering the child welfare system and difficulty exiting the system.

Unsafe, unstable, and unhealthy housing also comes at a significant cost to child well-being. The effects of inadequate housing can be insidious, meaning that the immediate consequences are imperceptible, yet the long-term consequences are dire. For example, exposure to unsafe physical conditions such as the presence of toxic hazards (e.g., lead, asbestos) can, over time, lead to respiratory diseases, reduced brain volume, and intellectual impairment.6,7 Similarly, housing instability and homelessness is a source of significant family stress, which, in turn, impairs children’s neurobiology, immune system functioning, as well as cognitive and social-emotional development.8

Poverty, Housing Instability, and Child Welfare System Involvement in Milwaukee

Like many other cities across the country, Milwaukee faces a housing crisis. As shown in the figure below, a startling percentage of city residents are regularly evicted or forced to move. The figure also reveals that housing instability is unevenly distributed among racial and ethnic groups — differences that are associated with disparities in income and wealth as well as a lack of affordable housing stock. According to the most recent U.S. Census data, the poverty rate in Milwaukee for blacks was about 40%, for Hispanics it was nearly 32%, and for non-Hispanic whites it was less than 15%. The crisis in Milwaukee also stems from a shortage of affordable housing for low-income families, reflecting a nationwide trend where “the majority of poor renting families spend at least half of their income on housing costs.”9

Matthew Desmond’s Milwaukee Area Renters Study found that a significant percentage of rental property occupants had been evicted as adults, and another significant proportion had been forced to move in the past two years.

For families in the child welfare system, especially those with children placed in out-of-home care, problems with poverty and insecure housing are particularly acute. For example, one study in Milwaukee by Courtney et al.5 showed that, compared to families receiving voluntary in-home services, families with a child in out-of-home care were almost twice as likely to have been evicted and almost three times as likely to have been homeless in the prior year. Supporting these findings, recent data collected by Children’s Hospital of Wisconsin (see figure below) demonstrate that children who are placed in foster care in Milwaukee often come from families who have a history of overcrowding, eviction, and homelessness.

Source: Children’s Hospital of Wisconsin Well-being Assessments

Addressing Housing Needs in the Child Welfare System through Evidence-Based Service Planning

Because many families in the child welfare system present with complex needs, including barriers to housing, comprehensive service plans are often prepared. Increasingly, however, the field is moving toward an evidence-based service planning (EBSP) approach,11 which recognizes the following: (a) child welfare systems have limited resources, (b) clients  can be overwhelmed by demanding case plans, and (c) targeted, brief services can be as effective, if not more so, than comprehensive, long-lasting services. The EBSP approach also acknowledges that child welfare systems have an ethical responsibility to prefer practices with a record of effectiveness over unproven practices, and that the most basic and exigent family needs should be addressed first. Thus, child welfare agencies have an obligation to use, whenever possible, evidence-based and evidence-informed assessment, referral, and case management practices.

Assessment, Referral, and Case Management Practices

Child welfare systems are required to collect extensive data to document their performance on indicators of child safety, permanence, and well-being. While considerable child-level information is typically collected, robust assessments of family needs and strengths are often lacking. Recognizing this information gap, the well-being unit at Children’s Hospital of Wisconsin launched a new initiative in 2015 whereby child and parent well-being assessments are completed with all families that have a child placed in out-of-home care in Milwaukee. Information on housing and other family needs is collected at multiple time points in order to enhance initial risk assessments, service planning, and progress monitoring.

Once an initial assessment is completed, however, child welfare agencies typically are unable to provide intensive, concrete forms of housing assistance. At minimum, child welfare agencies should have a prepared resource guide that staff can use to facilitate referrals to local sources of housing support. However, a single referral may not be enough to ensure that families receive the support they need. When they seek housing support, families often face a lengthy intake, search and application process, and housing programs may not have the capacity to engage families for the time necessary to help them secure a stable residence.

Therefore, child welfare agencies may need to collaborate with systems and organizations that specialize in housing and other basic needs. Supportive housing programs are emerging that facilitate cross-system coordination of housing support and other community services such as trauma-informed mental health and substance use services.12 Similarly, the Family Unification Program, sponsored by the U.S. Department of Housing and Urban Development, promotes coordination between child welfare agencies and housing authorities to increase access to subsidized housing.13 Expanding the scope of child welfare case management to include enhanced communication and even co-location with housing support programs could improve the likelihood of a successful transition to a safe, stable, and healthy home.


1 Warren, E. J., & Font, S. A. (2015). Housing insecurity, maternal stress, and child maltreatment: An application of the family stress model. Social Service Review, 89(1), 9-39.
2Culhane, J., Webb, D., Grim, S., Metraux, S., & Culhane, D. (2003). Prevalence of child welfare services involvement among homeless and low-income mothers: A five-year birth cohort study. Journal of Sociology & Social Welfare, 30(3), 79–95.
3Ryan, J. P., & Schuerman, J. R. (2004). Matching family problems with specific family preservation services: A study of service effectiveness. Children and Youth Services Review, 26, 347–372.
4Pelton, L. H. (2015). The continuing role of material factors in child maltreatment and placement. Child Abuse & Neglect, 41, 30-39.
5Courtney, M. E., McMurtry, S. L., & Zinn, A. (2004). Housing problems experienced by recipients of child welfare services. Child Welfare, 83(5), 393-422.
6Weitzman, M., Baten, A., Rosenthal, D. G., Hoshino, R., Tohn, E., & Jacobs, D. E. (2013). Housing and child health. Current Problems in Pediatric and Adolescent Health Care, 43(8), 187-224.
7Cecil, K. M., Brubaker, C. J., Adler, C. M., Dietrich, K. N., Altaye, M., Egelhoff, J. C., … & Lanphear, B. P. (2008). Decreased brain volume in adults with childhood lead exposure. PLoS Med, 5(5), e112.
8Thompson, R. A. (2014). Stress and child development. The Future of Children, 24(1), 41-59.
9Desmond, M. (2015). Unaffordable America: Poverty, housing, and eviction. Fast Focus, Institute for Research on Poverty, 22.
10Desmond, M., & Shollenberger, T. (2015). Forced displacement from rental housing: Prevalence and neighborhood consequences. Demography, 52(5), 1751-1772.
11Berliner, L., Fitzgerald, M. M., Dorsey, S., Chaffin, M., Ondersma, S. J., & Wilson, C. (2015). Report of the APSAC task force on evidence-based service planning guidelines for child welfare. Child Maltreatment, 20(1), 6-16.
12Farrell, A. F., Britner, P. A., Guzzardo, M., & Goodrich, S. (2010). Supportive housing for families in child welfare: Client characteristics and their outcomes at discharge. Children and Youth Services Review, 32(2), 145-154.
13Fowler, P. J., Henry, D. B., Schoeny, M., Landsverk, J., Chavira, D., & Taylor, J. J. (2013). Inadequate housing among families under investigation for child abuse and neglect: Prevalence from a national probability sample. American Journal of Community Psychology, 52(1-2), 106-114.


“The majority of poor renting families spend at least half of their income on housing costs.”

Assessing Well-Being in Child Welfare

Why Does Assessing Well-Being Matter?

Most children and adolescents that enter the child welfare system have been exposed to multiple adverse childhood experiences (ACEs), including abuse and neglect. As a result, they often present with neurobiological, cognitive, and social-emotional deficits that are likely to undermine their long-term health and well-being in the absence of effective services.1,2 Unfortunately, evidence-based interventions are implemented infrequently in child welfare settings.3

Child developmental screenings coupled with clinical and functional assessment practices are critical first steps in the intervention process.4 In addition, gathering information related to family and community assets can help to reinforce multidimensional and age-appropriate child assessments.5 This issue brief describes a strengths-based and family-focused approach to assessment and intervention that has been developed by Children’s Hospital of Wisconsin to promote the well-being of children and adolescents in the child welfare system.

Child-Well-Being: A National Movement

There is widespread agreement that the child welfare system should work to ensure that children live in a safe and stable environment. For several decades these goals have been codified in federal legislation including the Child Abuse and Prevention and Treatment Act in 1974 (P.L. 93-247), which set minimum standards for abuse and neglect and supplied funding to the states for its prevention, assessment, investigation, and treatment. Subsequently, the Adoption Assistance and Child Welfare Act (1980; P.L. 96-272) provided states with economic incentives for family preservation services to keep families together while minimizing the length of time and number of placements that children experience in out-of-home care.

It was not until the passage of the 1997 Adoption and Safe Families Act (P.L. 105–89) that federal child welfare statutes began to prioritize child well-being. Despite this welcome shift, the field has been slow to integrate this goal into child welfare practice and policy, due in part to a lack of consensus on how to define and measure well-being or whether it should stand alongside safety and permanency as a statutory goal of child welfare.6 There are signs, however, that the movement toward well-being is beginning to gain traction. For example, in 2012 the Administration for Children, Youth and Families (ACYF) issued a memorandum titled Promoting Social and Emotional Well-Being for Children and Youth Receiving Child Welfare Services7 that highlighted the impact of ACEs and toxic stress on child development. Among its recommendations, ACYF called for the routine use of trauma screenings and functional assessments to measure child well-being along with the implementation of validated interventions to promote well-being.

The Well-Being Assessment Program: Children’s Hospital of Wisconsin

Children’s Hospital of Wisconsin has re­sponded to the call for improved screen­ing and assessment practices in child welfare by designing and implementing a Well-Being Assessment program that is integrated and coordinated with prevention and intervention services. The program is based on three basic assumptions about well-being. First, assessments should attempt to understand the whole child. Therefore, to assess well-being it is important to measure child development and functioning across multiple domains (e.g., physical; cognitive; social-emotional). Second, assessing well-being requires evaluating the child in context. For this reason, any assessment of child well-being is incomplete without information about the child’s family and home environment. Third, well-being is a crucial focal point for child welfare systems to address, one that is linked to long-term child outcomes that extend past a child’s time in foster care.

The Well-Being Assessment program is designed so that immediately after children are placed in foster care they are assessed for exposure to adversity and trauma as well as their physical and psychosocial development and functioning. Assessors also gather comprehensive parent/caregiver data, including information about mental health, substance use, intimate partner violence (IPV), economic security, and housing stability. In addition, the Childhood Experiences Survey is used to assess parents’ exposure to ACEs, which can be used to help them acknowledge their own resilience and motivate them to interrupt intergenerational cycles of trauma. The table below illustrates that many adults who are reported to child protective services have ACE histories that place them at risk of many physical health, mental health, and behavioral health problems.

Complementing an assessment of family risk, the program also collects data on protective factors such as family functioning, social and concrete support, nurturing and attachment, and knowledge of parenting/child development.


Compared to respondents in the original ACE study,8 parents assessed by Children’s Hospital of Wisconsin (CHW) Well-Being team are more than three times as likely to report four or more ACEs. High ACE scores have been shown to significantly increase the risk of many health-related problems, including alcohol and drug abuse, depression, obesity, heart disease, and cancer.

Using Evidence to Inform Practice

The Well-being Assessment program fulfills essential functions that facilitate evidence-based practice. The assessment process presents an opportunity to support each family’s active engagement in services. While completing structured assessments over the course of several meetings in the home, Children’s assessors use motivational interviewing techniques9 to build rapport and enhance clients’ intrinsic motivation to participate in services and work toward achieving their goals. Assessment results are reviewed with the family, case manager, and other team members to identify shared goals and service priorities. In addition, initial assessments help to gauge child and family baseline functioning and inform service recommendations. Case management personnel use the data to direct clients to validated interventions at Children’s such as Parent-Child Interaction Therapy and Trauma-Focused Cognitive Behavioral Therapy as well as other services and supports in the community that promote safety, permanency, and well-being. The assessment program also gathers baseline data on child and parent/caregiver functioning, which sets the stage for monitoring family progress over time and evaluating service effectiveness.

Pushing the Envelope: The Post-Reunification Pilot Project

The child welfare field currently lacks knowledge related to how families function after a child returns home from foster care. Child welfare agencies rarely gather data to measure child and family progress after reunification occurs. To address this gap, the Institute for Child and Family Well-Being recently launched The Post-Reunification Pilot Project that aims to gather information that can be used to provide families with post-reunification support. Children’s Well-Being Assessment program now continues the assessment process after a child returns home from foster care to track their well-being over time and provide timely support to their family. Ultimately, the collection of post-reunification data is expected to generate information that can support real-time decision making and increase the likelihood that children remain in a safe, stable home environment that promotes their well-being.


1Anda et al., (2006). The enduring effects of abuse and related adverse experiences in childhood. European Archives of Psychiatry and Clinical Neuroscience, 256(3), 174-186.
2Schore, A. N. (2003) Early relational trauma, disorganized attachment, and the development of a predisposition to violence. In M. F. Solomon and D. J. Siegel (Eds.), Healing trauma: Attachment, mind, body, and brain. New York, NY: Norton.
3Chaffin, M. & Friedrich, B. (2004). Evidence-based treatments in child abuse and neglect. Child and Family Service Review, 26(11), 1097-1113. McCue-Horwitz, S., Chamberlain, P., Landsverk, J. & Mullican, C. (2010). Improving the mental health of children in child welfare through the implementation of evidence-based parenting interventions. Administration and Policy in Mental Health and Mental Health Services Research. 37, 27-39.
4Children’s Bureau (2014). Screening, assessing, monitoring outcomes and Using Evidence-Based Interventions to Improve the Well-Being of Children in Child Welfare.
5Ungar, M. (2004). The importance of parents and other caregivers to the resilience of high-risk adolescents. Family process, 43(1), 23-41.
6Wulczyn, F. (Ed.). (2005). Beyond common sense: Child welfare, child well-being, and the evidence for policy reform. Transaction Publishers.
7US Department of Health and Human Services. (2012). Information memorandum: Promoting social and emotional well-being for children and youth receiving child welfare services. ACYF-CB-IM-12-04). Washington, DC: Author.
8Felitti et al., (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14, 245–258.
9Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change. Guilford Press.


“Children’s Hospital of Wisconsin has re­sponded to the call for improved screen­ing and assessment practices in child welfare by designing and implementing a Well-Being Assessment program that is integrated and coordinated with prevention and intervention services.”

Asking Sensitive Questions

Human service providers ask clients questions to understand their backgrounds, identify their strengths and needs, and build rapport. Many clients have been exposed to significant adversities and traumatic events that undermine their health and well-being. Yet, service providers often have reservations about asking clients to disclose their personal histories. There are some good reasons for these concerns, but evidence suggests that they are often unfounded. This issue brief summarizes what research tells us about asking sensitive questions.

Concerns About Asking

There are several reasons why service providers may express reservations about asking their clients to disclose personal and sensitive information, including:

Will it harm my client?
Some providers may worry that asking questions about adversity and trauma could cause distress or discomfort by prompting clients to relive past experiences.

Will it hinder our relationship?
Providers could be concerned that the client may interpret the questions as intrusive or judgmental. As a result, client-worker rapport might be disrupted or damaged, which could lead to avoidance behaviors or even program dropout.

So what?
Some providers may be aware that they lack the time, training, or resources required to meet the complex needs of clients with histories of adversity and trauma. Others may feel that they can’t change the past, and that they should focus on their clients’ current circumstances and goals.

What We Know About Asking Sensitive Questions

All of these concerns are understandable. Helping professionals are committed to avoiding harm and promoting well-being. In order to do so, they need to establish and maintain healthy working relationships with their clients.

Yet there is little evidence to suggest that asking questions about adversity and trauma is harmful to clients or detrimental to client-worker rapport. In fact, based on a substantial body of research, we have learned that:

  • Major adverse reactions to sensitive questions are less common than many professionals anticipate.1,2
  • The vast majority of clients can respond to sensitive questions without significant distress.3,4
  • Clients with a trauma history are more likely than clients without a trauma history to report discomfort with sensitive questions. However, clients with a trauma history also appear to be more likely to report that it is helpful to be asked these kinds of questions.4,5
  • Clients who report discomfort with sensitive questions often say it is important to ask these kinds of questions, either because it is a valuable experience for them or because they can help others by sharing their experiences.6
  • Some discomfort with sensitive questions is normative and even potentially therapeutic.7


Out of more than 1,200 women that have completed the Childhood Experiences Survey, nearly 80% reported no discomfort or only slight discomfort with the questions.

New Research Findings

Data collected from Wisconsin’s Family Foundations Home Visiting (FFHV) program reinforces these conclusions. Since 2014, FFHV programs have used the Childhood Experiences Survey (CES) to ask their clients about their history of adverse childhood experiences (ACEs). A final item in the CES asks clients how uncomfortable they felt answering questions about ACEs. As the figure (page 2) shows, out of more than 1,200 women that have completed the CES, nearly 80% reported no discomfort or only slight discomfort with the questions. About 10% felt very or extremely uncomfortable.

It is also likely that clients are experiencing some discomfort when they refuse to answer a sensitive question. Overall, rates of refusal on CES questions are very low (1.4%). Clients were more likely to refuse to answer a question about their sexual abuse history (5%) than any other item (1-2%), which is not surprising given the very personal nature of the subject. Refusal rates varied across FFHV programs statewide. In some agencies, no clients refused any CES item, while in other agencies the refusal rates were up to 5%. This suggests that client perceptions of sensitive questions may be influenced by the professionals who ask the questions. We also found statistically significant differences in refusal rates by client race and ethnicity, with higher refusal rates among American Indian (2.4%) and African American women (1.8%) than among Latina (1.1%) and Caucasian women (0.8%). Thus, perceptions of sensitive questions also may vary by client demographic group and cultural context.

Practice Implications

Safety first.
Client discomfort with sensitive material can be mitigated by professionals who are able to establish a safe and supportive environment. In this regard, home visiting can be an optimal context for asking sensitive questions. A skilled home visiting professional is able to develop a strong relationship with clients built on respect, trust, and unconditional positive regard.

Discomfort is a two-way street.
Professionals can influence a client’s level of discomfort with sensitive questions depending on when, where, and how they ask the questions. Professionals need to monitor their approach to sensitive topics and reactions to client disclosure.

“We may underestimate resilience. Out of concern and empathy for their clients, human service professionals may actually overemphasize survivors’ vulnerability by avoiding their traumatic histories.”

Discomfort is not necessarily a bad sign.
In fact, it is possible that “a moderate level of activation is often a good sign, indicating that the client is not in a highly avoidant or numbed state.”8

We may underestimate resilience.
Out of concern and empathy for their clients, human service professionals may actually overemphasize survivors’ vulnerability by avoiding their trauma histories.9

We may be asking the wrong question.
For professionals that serve disadvantaged and oppressed populations, adversity and trauma are nearly universal client concerns. We also know that, in the absence of appropriate support and intervention, adverse and traumatic experiences often continue to undermine health and well-being over the life course. Therefore, in addition considering what might happen if they ask clients sensitive and personal questions, professionals should consider: What happens if I don’t ask?

Recommended Approaches

Recommended approaches to administering the Childhood Experiences Survey:

  • Prepare client for sensitive nature of questions.
  • Clarify goals of the questions: to reducethe negative effects of exposure to early adversity.
  • Set aside enough time to talk as needed.
  • Don’t ask the questions too early or too late in the service term.
  • Ensure privacy of the respondent at time of survey administration.
  • Give client a copy of the survey.
  • Record responses or ask respondent if she wants to circle responses.
  • Acknowledge adversity or trauma if it has been disclosed previously.


1Langhinrichsen-Rohling, J., Arata, C., O’Brien, N., Bowers, D., & Klibert, J. (2006). Sensitive research with adolescents: Just how upsetting are self-report surveys anyway? Violence and Victims, 21, 425-444.
2Walker, E. A., Newman, E., Koss, M., & Bernstein, D. (1997). Does the study of victimization revictimize the victims? General Hospital Psychiatry, 19, 403-410.
3Black, M. C., Kresnow, M., Simon, T. R., Arias, I., & Shelley, G. (2006). Telephone survey respondents’ reactions to questions regarding interpersonal violence. Violence and Victims, 21, 445-459.
4Edwards, K. M., Kearns, M. C., Calhoun, K. S., Gidycz C. Z. (2009). College women’s reaction to sexual assault research participation: Is it distressing? Psychology of Women Quarterly, 33, 225–234.
5Decker, S. E., Naugle, A. E., Carter-Visscher, R., Bell, K., & Seifert, A. (2011). Ethical issues in research on sensitive topics: Participants’ experiences of distress and benefit. Journal of Empirical Research on Human Research Ethics, 6, 55-64.
6Campbell, R., & Adams, A. E. (2009). Why do rape survivors volunteer for face-to-face interviews? A meta-study of victims’ reasons for and concerns about research participation. Journal of Interpersonal Violence, 24, 395-405.
7Schwerdtfeger, K. L. (2009). The appraisal of quantitative and qualitative trauma-focused research procedures among pregnant participants. Journal of Empirical Research on Human Research Ethics, 4, 39-51.
8Briere, J. N., & Scott, C. (2014). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment (p. 72). Sage Publications.
9Becker-Blease, K. A., & Freyd, J. J. (2006). Research participants telling the truth about their lives: the ethics of asking and not asking about abuse. American Psychologist, 61(3), 218-226.


So What?

Intended benefits of assessing and addressing childhood adversity and trauma include helping clients to:

Acknowledge exposure to adversity and trauma.

Recognize and enhance their own resilience.

Explore and alter negative effects of adversity and trauma on current functioning.

Improve personal health and well-being.

Understand potential implications for social relationships. For parents, this may focus on the need to prevent the intergenerational transmission of adversity and trauma.

Engaging Families in Home Visiting

Why Does Family Engagement Matter?

Home visiting programs provide support and services to enhance the health and well-being of children and their caregivers, particularly in vulnerable and economically disadvantaged populations. Research indicates that home visiting services can promote maternal and child health, nurturing home environments, and gains in child development.1

But success hinges on the extent to which families engage in services. Most evidence-based programs make services available to families for multiple years, but the majority of clients receive services for a year or less.2 Compounding this problem, the families who may benefit most from home visiting are also the ones who may be hardest to reach, enroll, and retain. Moreover, evidence from home visiting and other service sectors suggests that participation alone is a poor predictor of client outcomes.3

One reason this might be the case is that there is a difference between program participation and engagement: Participation refers to signs of client and program activity, such as enrollment, number and frequency of visits, and service completion. Engagement reflects the quality of client attitudes toward, emotional investment in, and behaviors related to their services and service providers.4

It may be that participation is a necessary but not sufficient condition for success. This issue brief presents what we know about participation and engagement based on the available literature and new findings from Wisconsin’s Family Foundation Home Visiting (FFHV) program.

Initiating Program Participation

For many programs, outreach periods can last several weeks and even months. Most families that accept services, however, do so within a shorter period of time. For families that accepted services from one of Wisconsin’s FFHV programs since January 2015, the median time spent in recruitment was 15 days. Over three-fourths (77%) of families that received services enrolled within the first 30 days of outreach.

Many potential clients decline voluntary services because they feel they do not need them. Results from the FFHV evaluation indicate that over half (56%) of individuals who declined to enroll reported they did not need services or they already had adequate support. Yet, programs often do not receive a definitive answer from clients regarding their intent to enroll in or decline services. Programs may find that “passive” refusals are more common than active refusals. A passive refusal is when a client agrees to services but is never available for a visit. One review of Healthy Families America (HFA) programs reported that only 5-10% of clients refused services outright, but 20-30% of individuals that accepted services did not complete a single visit.5

Sustaining Program Participation

Although guidelines for optimal service duration vary, many program models recommend that families receive services for multiple years. However, studies consistently show that a large majority do not receive services for that long.

On the other hand, the expected length of service according to model standards may not be a good gauge of program success. Some families may leave services early because they have achieved their goals. In fact, there is surprisingly little evidence that the intended length or actual length of a program is associated with client outcomes.6 It is unclear why this is the case, but it may be partly because families begin to benefit within the first few visits. The Durham Connects model illustrates this point.

  • Durham Connects
    Durham Connects is a brief model that consists of 4 to 7 in-person or telephone contacts. Results from a randomized trial show that, compared to a control group, families that received Durham Connects had significantly higher scores in positive parenting behavior, home environment quality, and fewer emergency room visits.7

    STEP 1: Birthing visit
    The Durham model begins during a birthing hospital visit when a family can schedule up to 3 home visits with the nurse that occur between 3 and 8 weeks of infant age.

    STEP 2: Home visits
    Visits include information sharing (“teachings”) and assessments for health and psychosocial risk factors. High-risk families are connected to additional community services and maternal and infant health care.

It is also possible that the frequency of visits is as important, if not more so, than the length of services. Research indicates that more frequent visits increase the likelihood of positive outcomes such as increased gestational age8 and enhanced maternal behavior.9Yet, research also suggests that only about half of families receive the minimum number of recommended visits.10

In response to this challenge, the FFHV program launched a continuous quality improvement (CQI) effort in 2015 to improve the rate of completed home visits. Programs focused on communicating the expectations of visit frequency with families, rescheduling visits immediately, and sharing monthly tracking data with staff. Within nine months of launching the CQI initiative, the percent of families that received at least three-fourths of their expected visits increased from 59% to over 70% of families.


Half of clients that enroll in an FFHV program exit services within the first nine months. These rates are consistent with studies of other home visiting programs.

Engaging Families

Sustained participation is linked to, but also distinct from, family engagement. Engagement is a dynamic, interpersonal process that changes based on interactions between clients and home visitors over time. One concept that captures this evolving relationship is called therapeutic alliance.

Therapeutic alliance refers to the strength of the bond between a client and service provider as well as their agreement on goals and tasks. The FFHV evaluation team developed a brief measure of therapeutic alliance, the Brief Alliance Assessment (BAA), which is designed to match the strengths-based and family-focused orientation of home visiting.  Client and home visitor reports are gathered separately and compared to assess their agreement.

Early results from the BAA indicate that both client and staff perceptions of alliance are overwhelmingly positive. For instance, one indicator of mutual bond is trust. Preliminary results indicate that 94% of clients and 88% of home visitors either agreed or strongly agreed that they trusted each other. Goal and task alignment also appears strong, as 96% of clients and 88% of staff report agreement or strong agreement on “what we should focus on when we meet.” Interestingly, compared to staff, clients reported higher average ratings of alliance. This may be a good sign. It could reflect that home visitors need to maintain appropriate professional boundaries. It is also possible that home visitors may have an even stronger connection with families than they realize.


1Kendrick, D., et al. (2000). Does home visiting improve parenting and the quality of the home environment? Archives of Disease in Childhood, 82, 443-451.
2Gomby, D. S., Culross, P. L., & Behrman, R. E. (1999). Home visiting: Recent program evaluations: Analysis and recommendations. The Future of Children, 4-26.
3Korfmacher, J., et al. (2008, August). Parent involvement in early childhood home visiting. In Child & Youth Care Forum (Vol. 37, No. 4, pp. 171-196). Springer US.
4Staudt, M. (2007). Treatment engagement with caregivers of at-risk children: Gaps in
research and conceptualization. J of Child & Family Studies, 16, 183-196.
5Daro, D. A., & Harding, K. A. (1999). Healthy Families America: Using research to enhance practice. The Future of Children, 152-176.
6Sweet, M. A., & Appelbaum, M. I. (2004).
Is home visiting an effective strategy? Child Development, 75, 1435-1456.
7Dodge, K., et al. (2014). Implementation and randomized controlled trial evaluation of universal postnatal nurse home visiting. Am J of Public Health, 104, S136-S143.
8Goyal, N., et al. (2013). Dosage effect of prenatal home visiting on pregnancy outcomes in at-risk, first-time mothers. Pediatrics, 132 (Supplement 2), S118-S125.
9Nievar, M. A., Van Egeren, L. A., & Pollard, S. (2010). A meta-analysis of home visiting programs. Infant Mental Health Journal, 31, 499-520.
10Duggan, A., et al. (2000). Hawaii’s healthy start program of home visiting for at-risk families. Pediatrics, 105 (Supplement 2), 250-259.


8 Factors that Influence Participation and Engagement

The perceived benefit of services and initial motivation to enroll are key predictors of participation. Clients with lower levels of initial interest are less likely to sustain participation.

Specific Needs
Families of infants with health risks (e.g., low birth weight) are more likely to express interest, enroll, and remain in services.

Family Instability
Frequent moves, intermittent phone service, and family crises can cause families to miss services or leave the program entirely.

Although half of primary caregivers living below the poverty line in the U.S. are employed, home visiting clients who work receive less visits and are enrolled in services for shorter periods of time than unemployed clients.

Early Outreach
Recruiting families early in pregnancy may increase the likelihood of enrolling and sustaining services.

Staff Characteristics
Home visitors with more experience and lower caseloads have lower rates of client dropouts.

Staff Turnover
Families are more likely to drop out of services early if their home visitor leaves.

Frequent, high-quality supervision may promote staff retention and help home visitors improve case planning and services.