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Journal of Child & Adolescent Trauma logoLink to Journal of Child & Adolescent Trauma
. 2021 May 14;15(1):65–74. doi: 10.1007/s40653-021-00357-x

Trauma-Informed Intervention with Children: Integrating the CANS Assessment with the ARC Framework in a Clinical Setting

Jiyoung K Tabone 1,✉, Carrie W Rishel 1, Helen P Hartnett 1, Kathy F Szafran 2
PMCID: PMC8837714  PMID: 35222776

Abstract

Ongoing trauma-focused assessment is critical to developing trauma-informed treatment plans. The current study examines the clinical benefits of utilizing the Child and Adolescent Needs and Strengths (CANS) assessment to guide intervention based on the Attachment, Self-Regulation, and Competency (ARC) model to address children’s trauma related symptoms in a rural state. WV CANS was developed by adapting the language of original CANS to be culturally specific to the state’s unique situation and culture in consultation with the original CANS developer. This study included the data from children who received mental health services under WV CANS-ARC mapping from 2017 to 2019. Children’s trauma-related symptoms are assessed using the WV CANS at intake and every 90 days to identify any changes in their symptoms. In order to examine the changes of traumatic symptoms over time, the study was limited to children who have at least three time points, with a total of 362 children used for the current analyses using Multilevel modeling with SAS PROC MIXED. The study found that children’s trauma related symptoms significantly decreased in all ARC outcome domains over time after adjusting for basic demographic variables. The current study contributes to the evidence on treatment for children’s trauma-related symptoms, especially with the application of the CANS-ARC mapping in a real-world clinical setting. The findings have significant implications for clinicians in integrating the assessment and treatment process using CANS-ARC mapping and for cross-system collaboration with continuity of care serving children who have experienced trauma.

Keywords: Trauma-informed intervention, CANS, ARC, Trauma assessment, children’s trauma

Introduction

The high prevalence of childhood exposure to trauma has been clearly demonstrated. A nationally representative sample of U.S. youth found that more than two-thirds reported exposure to at least one significant trauma by age 16 and more than one-third reported exposure to multiple traumatic events (Copeland et al., 2007). Exposure to trauma and its long-term consequences have been examined through Adverse Childhood Experiences (ACE) studies. The original ACE framework included 10 specific adverse life events including emotional abuse, sexual abuse, physical abuse, domestic violence, parental separation or divorce, mental illness in the household, household substance abuse, criminal household member, emotional neglect, and physical neglect (Felitti et al., 1998). More recent studies have expanded the original ACE framework to include other types of trauma such as school and community violence, sibling and peer victimization, natural disaster, traumatic loss and others (Finkelhor et al., 2013; Greeson et al., 2014). Regardless of which types of trauma are examined, a strong link between trauma exposure in childhood and negative adolescent and adult outcomes has been clearly established.

Effect of Trauma on Children’s Development

Exposure to trauma in childhood increases likelihood of negative health outcomes including mental health problems (Cicchetti, 2016; Taillieu et al., 2016; Trauelsen et al., 2015), increased substance use (Anda et al., 2008; DeBellis, 2002; Ducci et al., 2009; O’Connell et al., 2007; Mills et al., 2005), physical health disorders (Bellis et al., 2014; Danese & Tan, 2014; Suglia et al., 2018), sexual risk taking (Hillis et al., 2001), and youth violence (Fox et al., 2015). A dose-response effect has been repeatedly demonstrated, with greater number of traumatic events or circumstances associated with worse outcomes (Flaherty et al., 2013; Greeson et al. 2014). For example, a study examining the relationship between ACEs and substance use illustrates that each ACE increased the likelihood for early initiation of drug use by two to four-fold (Dube et al., 2003). Another study of a diverse sample of over 14,000 children found that the greater the number of trauma types experienced in childhood, the greater the severity of child behavior problems (Greeson et al., 2014).

Trauma experienced in childhood may be especially damaging in its impact on the primary attachment system (Arvidson et al., 2011). Young children’s sense of safety and understanding of themselves and the world revolves around their relationship with an attachment figure (Bowlby, 1969). Exposure to trauma in childhood may damage children’s belief and trust in the caregiver’s ability to protect them (Lieberman et al., 2011). To mitigate exposure to trauma and help children build the resilience needed to thrive, Bath (2008) proposed three pillars of trauma-informed care: safety, connection and self-regulation. Children who have experienced trauma feel inherently unsafe. Establishing a sense of safety is a necessary foundation for further intervention and is dependent on the development of the second pillar of trauma-informed care, connection. Building positive connections with adults helps children restructure negative emotions associated with trauma and learn to develop positive emotional responses to caring adults in their lives. Finally, learning self-regulation skills allows children to manage their emotions and impulses in a way that promotes positive experiences in educational, social, and other settings (Bath, 2008). For example, a recent study suggests that of children who have experienced trauma, those who demonstrate the ability to self-regulate have better educational outcomes (e.g. stronger school engagement and less likelihood of repeating a grade) than those who do not display self-regulation skills (Bethell et al., 2014).

Trauma-informed interventions aimed at addressing attachment, connection, and self-regulation have been shown to be effective in multiple studies. For example, a trust-based relational intervention based on Bath’s (2008) three pillars of care was shown to decrease child behavioral problems and trauma symptoms, whereas scores in a match-sample control group did not change (Purvis et al., 2015). Another specific model, the Attachment, Self-Regulation, and Competency (ARC) framework, is grounded in attachment theory and focuses on building resilience in children who have experienced trauma through three core domains of intervention: attachment, self-regulation, and competency (Blaustein & Kinniburgh, 2010). Studies have shown that interventions based on the ARC framework are effective at both the individual level, with a reduction in child behavior problems (Bartlett et al., 2018), and at the classroom level, with improvement in the broader classroom environment (Rishel et al., 2019; Tabone et al., 2020).

The ARC Framework

The ARC framework provides a flexible structure to guide providers in trauma-informed intervention with children. The model is applicable for work with children from early childhood to young adulthood and their caregiving support systems. The flexibility of ARC allows for adaptation to various settings, including outpatient clinics, schools, and residential treatment centers (Hodgdon et al., 2013). The National Child Traumatic Stress Network (NCTSN) identifies the ARC framework as an effective intervention for trauma (see https://www.nctsn.org/treatments-and-practices/treatments-that-work).

The ARC framework centers on three core domains that are impacted by exposure to trauma (See Fig. 1). Within these three domains of attachment, self-regulation, and competency are 10 building blocks of intervention. The attachment domain targets factors needed to build a healthy and safe attachment system that can buffer the impact of traumatic stressors. The blocks include caregiver affect management, attunement, consistent response, and routines and rituals. The self-regulation domain targets a child’s awareness and understanding of his or her internal experience, as well as the ability to modulate that experience and safely share that experience with others. The blocks include affect identification, modulation, and affect expression. The competency domain targets the child’s ability to build the skills needed for healthy development and functioning such as social connection, community involvement, and academic engagement. The blocks include executive functions, self-development and identity, and trauma experience integration (Arvidson et al., 2011; Blaustein & Kinniburgh, 2010). The individual building blocks represent specific intervention targets and, as a whole, provide an organizational framework to guide the development and implementation of intervention approaches that address the comprehensive nature of trauma (Rishel et al., 2019).

Fig. 1.

Fig. 1

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Attachment, Self-Regulation, Competency (ARC). Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005, Reprinted with permission

Integrating Trauma-Informed Assessment and Treatment

Trauma-focused comprehensive assessment is critical to developing trauma-informed treatment plans. However, there are multiple challenges to using traditional assessment information in practice. A single diagnosis (i.e., Posttraumatic Stress Disorder) cannot fully capture the range of difficulties that children exposed to trauma experience and, as a result, children may be mislabeled or receive multiple diagnoses, which are not necessarily connected to their traumas (Kisiel et al., 2017). Studies indicate that many children with traumatic experiences exhibit a broad range of debilitating responses that fall outside typical PTSD symptom clusters (Cook et al., 2005; Pynoons et al., 1996). There is typically not sufficient trauma-related information gathered on areas of children’s needs and strengths, and assessments are often disconnected from treatment plans (Kisiel et al., 2009a and b). It is also important to reassess children over time because their mental health symptoms and responses to trauma may change with ongoing development and changing life circumstances (Margolin & Gordis, 2000). These challenges illustrate the need to apply ongoing trauma-focused comprehensive assessment strategies to guide intervention for children and families.

The Child and Adolescent Needs and Strengths (CANS) Assessment Tool

The Child and Adolescent Needs and Strengths (CANS) tool assesses children’s exposure to potentially traumatic experiences and level of traumatic stress symptoms, as well as considering strengths. The CANS measures children’s trauma history and trauma-related mental health symptoms in connection with children’s other needs and strengths in planning for intervention and services. Throughout the assessment process, clinicians engage children and family members and they work collaboratively to determine an appropriate course for treatment and service planning. The CANS also recognizes that children may change with regard to their needs, strengths, readiness and ability to engage in different aspects of trauma-focused treatment or services over time. The CANS can be used for both initial and continuing engagement and psychoeducation about the effect of trauma with children and caregivers and can help highlight changes that will guide ongoing intervention and treatment planning. When implementing the CANS, clinicians can review comprehensive trauma-focused assessment information with clients, use the tool as a basis for collaborative treatment planning with children and caregivers, and track clients’ changes over time to adjust treatment plans as necessary (Kisiel & Fehrenbach, 2015; Villa et al., 2015).

Integrating the CANS Assessment and the ARC Framework

The CANS assessment tool has been previously integrated with trauma-focused Evidence-Based-Practices (EBPs) including ARC, Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS), and Trauma-Focused Cognitive Behavior Therapy (TF-CBT) across different samples. This work illustrates that integrating the CANS assessment with trauma-focused intervention results in comprehensive treatment utilization and has a significant impact on reducing trauma related symptoms (Villa et al., 2015). Specifically, the CANS assessment was first integrated with the ARC model (CANS-ARC mapping) at the Center for Child Trauma Assessment, Services & Intervention (CCTASI, http://cctasi.northwestern.edu/), Northwestern University, in collaboration with one of ARC developers, Margaret Blaustein. In the CANS-ARC mapping, each ARC building block was defined (or mapped) by measurable CANS items (Villa et al., 2015). The CANS items were connected to the ARC building blocks based on their relevance to the block. In this model, assessment information measured by the CANS can be easily translated into the ARC framework in order for clinicians to identify areas that need further improvement and to integrate their assessment and treatment processes. Clinicians can translate CANS assessment scores into ARC competencies using the CANS-ARC mapping template and create graphs and reports based on assessment and treatment building blocks to promote clients’ understanding and progress. In a pilot study of the CANS-ARC mapping, clinicians report the mapping process was very comprehensive and provided a helpful model to connect assessment and treatment. Results of the study indicate that application of the CANS-ARC mapping process significantly reduced trauma related symptoms in child welfare sample (Villa et al., 2015). The CANS-ARC mapping showed promising preliminary results with extensive potential applications to many different settings. The current study seeks to expand on this previous work to examine the use of the CANS-ARC mapping in a clinical setting in a rural state.

Background and Context of the Current Study

West Virginia is a rural state that has experienced a rapid increase in substance abuse and addiction and has the highest reported rate of opioid-related overdose mortality. About 52.4% of children in West Virginia experience at least one adverse childhood experience (ACE), including parental opioid overdose fatalities (Adverse Childhood Experiences Coalition of West Virginia, 2018). The ACEs Coalition of West Virginia has identified a link between opioid addiction and childhood traumatic experiences and emphasizes the importance of early intervention efforts to help children and families (Rishel et al., 2019). Application of the CANS-ARC mapping approach could have significant implications in a state where there are high ACEs scores and limited resources. There is a clear need for an integrated information tool that connects trauma-informed assessment to the clinical treatment process.

Crittenton Services has been serving West Virginia for more than a century, providing both residential and community-based outpatient mental health services. Crittenton Services is a major mental health clinic in the Northern “panhandle” of West Virginia that serves 23 counties through 5 outpatient offices and a residential facility. Crittenton, a member of the ACEs Coalition of West Virginia, began to engage with national leaders in ACEs research and trauma-informed treatment in 2010. In 2012, the National Crittenton Foundation (TNCF), a national advocacy group that supports 28 independent Crittenton organizations across the country, partnered with Dr. Felitti (the author of the original ACE study) to participate in a study of ACEs within treatment populations. West Virginia respondents to this study scored substantially higher as compared to the national Crittenton population, indicating greater trauma exposure. Specifically, 65% of West Virginia Crittenton respondents reported 6 or more ACEs as compared to 45% of national Crittenton respondents (Crittenton Services, Inc., 2018). In a broader non-clinical study, the National Survey of Children’s Health (NSCH) found 26% of West Virginia children have experienced two or more ACEs as compared to the national average of 21.7% (Adverse Childhood Experiences Coalition of West Virginia, 2018).

In response to the high prevalence of trauma in the state and intensifying statewide crisis of opioid addiction, Crittenton Services of West Virginia, has participated in a number of state and national initiatives focused on trauma-informed services. Crittenton participated in developing the WV CANS with other private and public sectors including WV Department of Health and Human Resources, WV System of Care, WV Division of Juvenile Services, and WV Public/Private/Family Work Group which represents WV provider Agencies and family members. These collaborative efforts recognized West Virginia‘s unique situation and rural culture and adapted the language of original CANS items to be culturally specific to WV. The developers of the WV CANS also included additional subscales focused on trauma and pregnancy/parenting in consultation with Dr. John Lyons, who developed the original CANS. Crittenton also partnered with the Trauma Center at the Justice Resource Institute to integrate a trauma-informed treatment framework, the ARC model, into agency practice and environment. Then in 2015, Crittenton worked with the Center for Child Trauma Assessment and Service Planning (CCTASP) to apply the CANS-ARC mapping process to the WV CANS. As part of the on-going WV CANS-ARC mapping integration, all clinical staff attend a formal mapping training as well as complete a testing and certification process to assure fidelity and consistency in the administration and scoring of the assessment. During the training, staff learn how the WV CANS items were mapped onto each ARC building block, how to translate assessment information into treatment planning, and how to use the WV CANS-ARC mapping results as a tool to engage with families. Staff continue subsequent trainings on an individual basis during the course of formal supervision with their clinical supervisor, and Crittenton also holds yearly formal re-training sessions for all clinical staff. Table 1 presents the WV CANS-ARC integration describing the ARC domain blocks and their corresponding WV CANS items.

Table 1.

WV CANS-ARC Map describing ARC domain blocks and corresponding WV CANS items

ARC Attachment Domain
ARC Sub-domains Corresponding WV CANS items
Caregiver Affect Management Parent/caregiver understanding of impact of own behavior on child; ability to communicate; mental health; family stress, substance use; posttraumatic reactions
Attunement Attachment difficulties; knowledge of child’s needs; empathy with children
Consistent Response Discipline
Routines and Rituals Spiritual/religious; cultural stress; living situation; sleep, learning environment; organization; educational setting; school behavior; school attendance
ARC Self-Regulation Domain
ARC Sub-domains Corresponding WV CANS items
Affect Identification Avoidance; numbing; dissociation; somatization
Modulation Coping and savoring; attention/concentration; impulsivity; affective and/or physiological dysregulation; anger control; suicide risk; non-suicidal self-injury; other self-harm; substance use; eating disturbance; Danger to others; cruelty towards animals; fire setting; sexually abusive; sexualized behaviors; bullying runaway; intentional misbehavior
Affect Expression Family; interpersonal; social functioning; attachment difficulties
ARC Competency Domain
ARC Sub-domains Corresponding WV CANS items
Developmental Tasks Social functioning; daily functioning; recreational; school behavior; school achievement
Executive Functions Attention/concentration; impulsivity
Self & Identity Optimism; talent/interest; spiritual/religious; resilience; sexual development; identity
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Previous work has addressed use of the CANS as a critical aspect of trauma-informed assessment (Kisiel, et al., 2014), the CANS’ connection to treatment planning using EBPs models and use of the CANS to respond to changes in ongoing treatment needs (Villa et al., 2015). In particular, the CANS-ARC mapping has been recognized for its comprehensive utilization, had been shown to have conceptual and empirical support, and the Center for Child Trauma Assessment, Services & Intervention (CCTASI) has provided trainings of CANS-ARC mapping for clinicians. There are no studies to our knowledge, however, that have longitudinally examined the effectiveness of CANS-ARC mapping in actual clinical settings in rural areas. The current study examines the clinical benefits of utilizing the WV CANS assessment to guide intervention based on the ARC model to address children’s trauma related symptoms.

Methods

Sample

The study includes the data from children who were clients of Crittenton Services under WV CANS-ARC mapping from 2017 to 2019. Children are usually referred to Crittenton for behavioral issues from family or friends, schools, the state Department of Health and Human Resources (DHHR), pediatricians, or juvenile court. Children’s trauma-related symptoms are assessed using the WV CANS at intake and every 90 days to identify any changes in their symptoms, which then leads to adjustment in treatment plans as appropriate. In order to examine the changes of traumatic symptoms over time, the study was limited to children who have at least three time points (three sequential WV CANS assessments), with a total of 362 children used for the current analyses. Most children (86%) received services in an outpatient facility, with 11% receiving services in a residential facility, and 3% in school-based settings. Slightly more than half of the children were girls (53%), and majority of the sample were White (95%). Those who reported as non- white (5%) included African-American, Multi-race, and other. The average age of the children in the sample was 12 years (SD = 3.8). About 22% of children had both parents serving as guardians, 33% had single mother only, and 15% had relatives serving as their guardian(s). The rest of children (30%) were reported to have temporary state or court appointed guardianship and categorized as other.

Measures

The WV CANS was used to measure children’s trauma related symptoms at the beginning of services, 90 days, and 180 days after the first assessment. Like the original CANS, all WV CANS items were rated on a 0 to 3 scale. A score of 0 indicates no evidence of any trauma of this type; a 1 indicates a single indecent of trauma occurred or suspicious exists of this trauma type; a 2 indicates multiple incidents or a moderate degree of this trauma type; and a 3 indicates repeated and severe incidents of trauma with medical/physical consequences. WV CANS ratings are completed by clinicians, all of whom are trained to achieve high levels of reliability and fidelity and are certified through Center for Child Trauma Assessment and Service Planning, Northwestern University. Subsequent on-going supervision was also scheduled during clinical supervision meetings on regular basis. Previous research has demonstrated that the original CANS has adequate reliability and validity (Anderson et al., 2003; Epstein et al., 2009; Kisiel et al., 2009a and b; Leon et al., 2000; Leon et al., 1999; Lyons et al., 2002; Lyons et al., 2004; Park et al., 2009). The original CANS has been used by many states as a decision support tool and as a tool for quality and outcomes monitoring (Lyons & Weiner, 2009). Although WV CANS adapted the language of the original CANS to be culturally specific to WV, the majority of CANS language remained the same, and the current analysis did not use the subscales including pregnancy/parenting items. Dr. John Lyons consulted in the WV CANS’ adaptation process, but official assessments on WV CANS’ reliability and validity were not conducted. As described earlier, the WV CANS items were mapped to the ARC domains as part of the agency assessment process, and Chronbach’s alpha scores were calculated in the three ARC main domains.

Attachment

This ARC domain includes four sub-domains (four dimensions): caregiver affect management, attunement, consistent response, and routine and rituals. Caregiver affect management assesses ability of the caregiver to recognize and regulate emotional experience and includes 6 WV CANS items, parent/caregiver understanding of impact of own behavior on child, ability to communicate, mental health, family stress, substance use, and posttraumatic reactions, as described in Table 1. Attunement refers to the capacity of caregivers and children to accurately read each others’ cues and respond effectively and includes 3 WV CANS items, attachment difficulties, knowledge of child’s needs, and empathy with children. Consistent responses targets the caregiver’s ability to responds consistently and appropriately to a child’s behaviors, and there is one WV CANS item, discipline. Routines and rituals assess the ability of the caregiving systems to develop predictable routines in order to increase child’s perceived safety and help with self-regulation, and includes 9 WV CANS items, spiritual/religious, cultural stress, living situation, sleep, learning environment, organization, educational setting, school behavior, and school attendance. Each sub-domain was created by summing the relevant multiple items, and then these sub-domains were combined to measure the attachment domain (α = 0.70).

Self-Regulation

This ARC domain includes three sub-domains (three dimensions): affect identification, modulation, and affect expression. Affect identification supports children’s ability in building a vocabulary for their emotional experience and understanding the connection between emotions and precipitating events. This sub-domain is measured by 3 associated WV CANS items including avoidance, numbing, dissociation, and somatization were used to measure this. Modulation targets children’s ability to tune in to, tolerate, and sustain a connection to internal states, and children with traumatic experience often feel overwhelmed or constricted with few strategies to modulate arousal states. Modulation was measured using 20 WV CANS items including coping and savoring, attention/concentration, impulsivity, and affective and/or physiological dysregulation as described in Table 1. Affect Expression is connected to children’s ability to identify safe resources and communicate emotional experience. Sharing emotional experience is a key aspect to human relationships, and this sub-domain was measured using 4 WV CANS items, family, interpersonal, social functioning, and attachment difficulties. Each sub-domain was created by summing the relevant multiple items, and then these sub-domains were combined to measure the self-regulation domain (α = 0.60).

Competency

The third ARC domain includes three sub-domains (three dimensions): Developmental tasks, executive functions, and self & identity. Developmental tasks assess children’s developmental competencies across their developmental stages, and 5 WV CANS items were used for this sub-domain: social functioning, daily functioning, recreational, school behavior, and school achievement. Executive functions refer the child’s ability to effectively engage in problem solving, planning, and anticipation and were measured using 2 WV CANS items, attention/concentration and impulsivity. Self & Identity target the development of a sense of self that is unique and positive and incarnates experiences from the past and present. This sub-domain was measured 6 WV CANS items including optimism, talent/interest, spiritual/religious, resilience, sexual development, and identity. Each sub-domain was created by summing the relevant multiple items as described above, and then these sub-domains were combined to measure the competency domain (α = 0.57).

Controls

Basic demographic characteristics (e.g., gender, age, race, and guardianship) were used as controls. Because 95% of the sample were white, race was dichotomized (white vs. non-white). Female was coded as 1 (male as 0) and age was measured at the initial assessment as a continuous variable (years). Guardianship was categorized into four groups: both parents, single mother, relative, and other. Additionally, program settings (outpatient, residential, and school-based settings) where children received the services were adjusted for in the analyses.

Analysis

Multilevel modeling using SAS PROC MIXED is used to examine the treatment effects on three outcome domains repeatedly measured using the WV CANS. In longitudinal data, the multilevel model has two levels in which repeated observations (between-subject level) are nested within individuals (within-subject level). Trajectories are defined by intercept (level of trauma-related symptoms at the first data point) and slope (increasing or decreasing trends over time), and each individual’s trajectory is then characterized by its own intercept and slope parameters. Given that we have multiple trajectories, we can consider a mean trajectory (fixed effects) by pooling overall individuals with the individual variability (random effects) around the mean values. This allows an examination of how the mean trajectory of trauma related outcome changes over time in each domain after adjusting for basic demographic variables.

Results

The fixed effects indicated there were significant mean intercepts and significant mean slopes in all three outcome domains. After adjusting children’s gender, race, age, guardianship, and service programs, the initial values of trauma related symptoms were 8.99 in attachment, 12.54 in self-regulation, and 13.04 in competency domains respectively, and they are all significantly different from zero. Over time, these trauma symptoms showed significant decreases in the attachment (time = −0.48, p < .001), self-regulation (time = −0.34, p < .01), and competency (time = −0.39, p < .001) domains. The random effects revealed that there was significant individual variability in intercepts and slopes of three outcome domains as seen in Tables 2 and 3. The results of significant decreases in three domains are illustrated in Fig. 2.

Table 2.

Descriptive Data on the Sample

% (N) or M (SD)
Gender
Girls 53% (192)
Race
White 95% (318)
Age (years) 12.0 (3.8)
Guardianship
Both Parents 22.2% (216)
Single Mother Only 33.0% (321)
Relatives 14.5% (147)
Other 30.3% (294)
Program
Outpatients 85.4% (309)
Residential 11.3% (41)
School-based 3.3% (12)
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Table 3.

Results of Multilevel models of change for Traumatic Symptoms in ARC Outcome Domains

Attachment
Estimates (SE)		 Self-Regulation
Estimates (SE)		 Competency
Estimates (SE)
After controlling for age, race, gender, guardianship, and program:
Fixed effects
Intercepts 8.99 (1.43)*** 12.54 (1.25)*** 13.04 (1.01)***
Time −0.48 (0.13)*** −0.34 (0.13)** −0.39 (0.09)***
Random effects
Intercept 55.89 (5.27)** 50.15 (4.78)** 28.25 (2.65)**
Time 3.51 (0.48)** 3.69 (0.33)** 1.55 (0.22)**
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Fig. 2.

Fig. 2

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Trajectories of Traumatic Symptoms in ARC Outcome Domains

Discussion

The current study examined the effectiveness of the CANS-ARC mapping in a community based clinical setting. The ARC framework was integrated with the CANS in order to assess a broad range of children’s traumatic symptoms and directly connect to ongoing treatment planning and adjustment. The study showed promising results that children’s trauma related symptoms significantly decreased in all outcome domains over time after adjusting for children’s gender, race, age, guardianship, and service settings.

The findings are consistent with empirical evidence in support of the ARC model in treatment of traumatic symptoms in children (Arvidson et al., 2011; Bartlett et al., 2018; Blaustein et al., 2010; Hodgdon et al., 2013). However, the existing studies mainly used residential or child welfare samples and did not examine the effect longitudinally. Moreover, none of them used the CANS to capture extensive and wide-range traumatic symptoms and connect to ongoing treatment planning and adjustment. This study expands upon existing empirical evidence by using a community sample, examining longitudinal effects on traumatic symptoms, and integrating the CANS assessment with the ACR framework.

The study found that the ARC model has substantial benefits in reducing children’s trauma related symptoms as repeatedly measured by the WV CANS. Clinicians reported that integrating comprehensive trauma-focused assessment, the WV CANS, with the ARC intervention framework was beneficial to treatment. Specifically, clinicians noted that the mapping process translates trauma assessments (CANS) into the treatment components (ARC) and makes it easier to highlight children’s needs and adjust the treatment as needed over time. They also indicated that the CANS-ARC integration is helpful in sharing and explaining the information with children and their families. The study findings have both significant clinical and policy implications regarding the mapping model dissemination. There are multiple systems and agencies that use the CANS within and across states. Oftentimes, children with trauma symptoms are involved in more than one service system such as schools, mental health clinics, residential centers, courts, and/or the Department of Health and Human Resources (DHHR). The CANS-ARC mapping can support not only the connection between assessment and treatment but also the continuity of care and collaboration across service systems and other professionals serving the child.

There are some limitations that must be recognized in interpreting the findings of the study. First, the study did not use an experimental design or a comparison group, and this limits any causal or mediated causal inference. Future research should include a control or comparison group to address this issue. Second, the current study was limited to children with three time points (N = 362) for the purpose of longitudinal examination. There might be unmeasured bias between children with three time points and those with two or four time points. However significant reduction on trauma symptoms found in the present analysis with three time points remained the same with two and four time points, and it seems highly unlikely to have selection bias among children with different time points. Third, although clinicians receive ongoing training to the clinical use of the mapping model during regular clinical supervision time with their clinical supervisors, there may be a potential inter-rater reliability issue among clinicians who may have differed in their approach to administering the mapping model. Fourth, although the WV CANS was adapted from the original CANS with revised language sensitive to rural WV culture in consultation with Dr. John Lyons, the promising results of the WV CANS-ARC mapping may have limited generalizability in other states. Additionally, a clinician mentioned that the mapping model was especially beneficial with some children in a residential setting because they were focused on what they need to do to “get out.” The ability to show youth the visual charts with scores was very helpful for them to see their progress and areas they needed to work on in order to “finish” the program. It also gave the control back to the youth to work on improving those areas. Although the mapping model can be beneficial in a particular setting (e.g., residential program), it can be a confounding factor for the current analysis, and we controlled the service settings in our analysis. However, future research could examine different effects in varying clinical program settings. Another limitation is that the study includes a majority of one race and ethnicity, white, in rural areas, and more studies with ethnocultural diversity of clinical samples are required in the future. Lastly, the random effects of multilevel models revealed that there was significant individual variability in intercepts and slopes of three outcome domains. For the purpose of current study, we examined the mean trajectory of children over time. Future research should empirically investigate whether or not there are distinctive sub-group trajectories and assess the different extent of treatment effects on different sub-groups.

Conclusion

The study found that children’s traumatic symptoms significantly decrease over time through the application of the CANS-ARC mapping in a real-world clinical setting. The study expanded current evidence by integrating the ARC model to the CANS assessment that measures extensive and wide-range traumatic symptoms and effectively connects to ongoing treatment planning and adjustment over time in rural area. It has significant implications for clinicians in integrating the assessment and treatment process using CANS-ARC mapping and for cross-system collaboration with continuity of care serving children who have experienced trauma.

Acknowledgements

We express much gratitude to Crittenton West Virginia Staff, especially Beverly Petrelli, Veronica Reynolds, and Chandy Paul-Martin, for supporting our work.

Declarations

Conflict of Interest

The authors declare that they have no conflicts of interest.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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