Kids Are the Experts: Youth Perspectives on Healing After Abuse

In this episode of One in Ten, host Teresa Huizar speaks with Kristi Westphaln (UCLA School of Nursing) about integrating children’s voices into Children's Advocacy Center (CAC) outcome measurement and understanding what healing after abuse means to youth. Westphaln describes her work with the Canopy CAC and a scoping review showing CAC literature emphasizes programmatic measures (forensic interviews, prosecution) more than child perspectives, and how this aligned with the National Children’s Alliance Youth Feedback Survey pilot.

Time Stamps: 

Time. Topic 

00:00 Kids Are The Experts 

01:14 Kristi’s CAC Journey 

04:19 Why Youth Voices Matter 

08:03 Youth Survey Primer 

09:07 Three Healing Questions 

12:14 Who Joined The Study 

17:20 What Healing Means 

21:33 Talking And Support 

24:35 Pets Faith Justice 

31:12 What CACs Can Do 

37:14 Trauma Without The Word 

39:44 Key Takeaways And Thanks 

43:36 Closing And Where To Listen 

Resources:

Talk with me about it: Child and youth perspectives on healing after child abuse - ScienceDirect

Transcript

Teresa Huizar: 

Hi, I'm Teresa Huizar, your host of One in Ten. In today's episode, Kids Are the Experts: Youth Perspectives on Healing After Abuse, I speak with Dr. Kristi Westphaln, Assistant Professor at UCLA School of Nursing. Now, what really helps children heal from abuse? This is the central question of our work as child abuse professionals. Seeking the answers to that question and bringing the resources to achieve it are the daily work of multidisciplinary teams and clinical staff. 

And it's the core question at the heart of every parent's worry for their child who has experienced abuse. But what do we know about how children and youth conceive of their own recovery? What does healing mean to them? And what is the most important thing to them in their own healing journey? The answers might surprise you. I know you'll find this conversation as thought-provoking as I did. Please take a listen. 

Kristi, welcome to One in Ten.  

Kristi Westphaln: 

Thank you so much for having me, Teresa. I'm excited to be here.  

TH: 

Well, we're excited to have you here. Tell me a little bit about how you became interested in this topic around children's voices and the absence thereof in the literature around child abuse.  

KW: 

Is it okay if I give you a little bit of backstory on how I learned about CACs and how it leads into that?  

TH: 

Sure, of course. We're always glad to hear how people came in contact with CACs. 

KW:  

I didn't know about Children's Advocacy Centers throughout most of my career. I'm a pediatric nurse practitioner as well as a researcher. And when I moved to do my postdoc at Case Western Reserve University in Cleveland, Ohio, I had this amazing opportunity to jump on board with the Canopy Child Advocacy Center as it was starting to open. And as somebody who's always been inpatient and working with child protection, just being able to see the multidisciplinary team and kind of a new flavor was amazing. So from there, Jen Johnson, the executive director, welcomed me into the team and I got to be part of the data outcomes group for Canopy. And through that, we had a lot of really interesting conversations about data. I mean, we talked about the things that we measured, duration of time a case is open, or how many encounters folks would have with mental health services or victim advocates and satisfaction with caregiver services. But we often sat there going, hmm, are we asking kids?  

Is this really measuring experiences of kids and families as they navigate healing through child abuse and navigate their journey through the CAC system? And so from there, that led to a scoping review, which was published in Child Abuse and Neglect. And we got to present it at one of the NCA Leadership Conferences just to talk a little bit about what the literature said about how CACs were measuring things. And we found that there were a lot of programmatic things in the literature, in particular prosecution and forensic interviews, and a lot less of things looking from the perspective of kids and again parents. We had some caregiver satisfaction stuff, but that really got us interested about how to dig deeper because the literature just wasn't showing what kids had to say. And it was funny because at that same point, getting to meet with Caitlyn Loundsbury and then later on with Erin Casey, we had this amazing convergence of timing where the NCA was just about to launch the Outcome Measurement System Youth Feedback Survey. And that was kind of the first time the NCA was like ahead of the game in terms of, you know what, we're asking families, but let's see what kids have to say. And when that first like pilot of it happened, not only did kids show they wanted to engage with CACs, they had major things to say about it. 

From there, I know that was a long backstory, but I just I feel so grateful for being introduced to the CAC system through Canopy Center and how it evolved from Canopy to a couple other projects and then to have this amazing opportunity to actually align with the National Children's Alliance to actually involve children's voices in in this work. So that's the story.  

TH: 

Well, thanks for sharing about all of your work and how you came to Children's Advocacy Centers. I think though that you raise an important point that we were thinking about and had been thinking about a long time, which is, you know, how to hear from kids directly about their experience within Children's Advocacy Centers. We already knew that caregivers really had a very high opinion of the care their children received there. And we knew what MDT members had to say about it. But we knew that kids would also have their own perspectives and could identify things that maybe a caregiver or frankly any other adult would not necessarily have noticed. 

And it was interesting when we first started talking about having a youth feedback survey, we heard all kinds of cautions from people about that idea. You know, it could be damaging, it would be very difficult. The age is like I can't even tell you about all the whatabouts that we had to hear about. And it's not to say that those aren't legitimate things to pay attention to. 

But we were pretty determined that there was a way to ask kids safely about their experience at Children's Advocacy Centers. And we assumed that they had some valuable things to say about that. So I appreciate you participating in those early days and the fact that you wanted to do that right from the start.  

KW: 

I love that you called out some of those barriers because for me, I'm a child abuse researcher. I do also do a little bit of work in immigrant and refugee child health. And child voices are really, really underrepresented in the research. And you mentioned all of the gobbly gook of why. There are a lot of whys, right? People like to say, it's psychologically potentially harmful for children. Or there are concerns that there might be limitations in a child's ability to understand based on development or communication. I mean, I could tell you stories of navigating the consent process, right? Because if you want to work with youth that are in the system in foster care and not yet adopted, not only do you have to go through the red tape of working through the IRB, which is essential for human protections, but we also have to go to court, right? And get all those court approvals. So there are just barriers upon barriers that are there. But those of us that do this work and feel that it's vital, which it is, we figure out ways to kind of navigate it. I could go on and on with the list. I think the other one too is lack of parent and primary caregiver support of wanting to allow kids to be part of it. And then there's the design piece, right? Because it can sometimes be much easier to design questions and research in that adult perspective rather than sitting there and taking the time to kind of childproof it, child-friendly it, make it appealing and feasible for kids to engage in the work.  

TH: 

I also think there's just a fundamental misunderstanding of what kids know and understand that sometimes attends to these things in that we're asking children to come to a Children's Advocacy Center for the express purpose of talking about very difficult things that have happened to them and to describe that in some detail, right? 

And then when it comes to asking them about that, we're like, they couldn't possibly understand how they feel. It's these two things do not go together. If someone is can be asked about a series of abuse instances and their feelings and sensory details about that, then they definitely are capable of describing their own feelings, I think. I mean, it's all well-intentioned, this protectiveness about and carefulness about how you go about asking kids things in ways that are developmentally appropriate and safe. 

But I also think that if we're not careful, we'll protect ourselves out of having meaningful input from children in these services.  

KW: 

I agree. I always think of that quote, you know, nothing about us without us. That includes all of us. We should not be doing work without including those that we wish to serve through the work and taking the feedback, working together with the community and making sure that it makes sense, it's mindful, and it includes all voices. 

TH: 

So some of our listeners are not very familiar with the outcome measurement system. So I'm going to give them the 30-second primer, which is to say that it's a system of surveys that are intended to really touch all points in the system. So it asks multidisciplinary team members about their experience with the Children's Advocacy Center and what they like and don't like about that. It does the same with caregivers around a specific set of indicators. 

And then we developed this youth survey to do the same. And our plan is to further develop the outcome measurement system to include other surveys in the future as well. But this study is focused on the youth survey, which was really kind of at a pilot state at the time. We had not, I mean, we had deployed it, but not widely. and you all were a part essentially of that first wave of deployment of the youth survey, but you added three questions to it. So tell folks a little bit about kind of what it currently covers and the three questions you added, because I thought the three questions were really, really good and insightful.  

KW: 

Thank you for that. Yeah. I mean, anytime anyone's doing community engaged partnered research, I think it's extremely important that you sit down with everyone at the table and make sure that the questions that you're asking are truly asking what you're wanting. 

And so I had some fantastic conversations with Caitlin and some other folks at the NCA about all right, I know that the concept of healing can be, you know, challenging, but really when you look at the literature, there are a lot of retrospective studies that look at adults who experienced abuse when they were children and kind of putting the retrospectacles on and like thinking back. But there's not a lot out there that really asks kids in a closer time point while they're still children, how they feel and what's important to them and really what healing means to them. So we had this opportunity to kind of co-create these questions and there were three of them. And the age range of the children that could potentially answer the survey was variable. So we wanted to make sure that the questions included language that would be understandable to a younger child as well as to an older child. So the first question that we added was, and these are all open-ended short answer questions. And in the beginning, again, we were nervous because of the pilot, but the pilot showed kids have things to say. And if we don't ask, that's bad on us for not giving the opportunity. So this first question was, what does healing or feeling better after child abuse mean to you? And we spent a lot of time trying to figure out all right, healing would a seven-year-old, would an eight-year-old, you know, how to kind of balance that. And so after going back and forth with a bunch of different folks, including psychologists, social work, other folks from the NCA, myself, my clinical background as a pediatric nurse practitioner, and some of my colleagues in medicine, we came up with what does healing feeling better, having both of those together just to give it a little bit more broad ability for the kids to understand. 

The second question, I mean, we wanted to kind of get an idea of the concept, right? What did they say healing meant to them? But then understand what was the most important thing, right? So we asked, what's the most important thing for you to heal or feel better after child abuse? And then the third thing we really wanted to hone in on was what's the most important thing that centers and we put CAC's in parentheses with that question, because when I first wrote it, the earlier version just said CAC's, but then Caitlin was like, no, no, wait a minute. 

A lot of the places self-identify as center and the kids would know it as center versus a Child Advocacy Center. So I felt like that was a really good save. Go team. And then so again, what's the most important thing that centers or CACs like this can do to help you heal or feel better after child abuse? So that gave us the opportunity to look at more of a conceptual or more abstract understanding of healing and then kind of hone in what's most important to you. And then what can we as CACs do to really address what's most important to you? 

TH: 

So let's also talk a little bit about who were the kiddos that answered these questions. How many of them were there? How did you find them? What kinds of CACs did they come from? 

KW: 

Absolutely. So I should probably back up and talk about how we recruited Children's Advocacy Centers to join, because obviously we're adding three questions. Some centers may or may not have been on board or comfortable with that. So we wanted to be very mindful with the recruitment for that. 

So we had three modalities that we recruited participant CACs for this study. The first one was the 2021 NCA Leadership Conference, where we actually presented the results from the scoping review study. And that was a great way to segue: like, look, this is what we found. We need more child voices here. So we'd like to offer you the opportunity to engage with us further in another study that will allow us to learn more based on these findings. So that was our first type of recruitment. The second one was the NCA graciously hosted a recruitment webinar. And so CACs that were interested were able to hop on and learn more, ask questions and engage with the research team. And third, we also had an email that was disseminated a couple times from the NCA to various CACs across the country and it gave them the opportunity to opt in. And so when we heard from those that opted in, they essentially received the youth feedback form that was modified with the three questions. 

And from there we collected data from October 2021 until March 2023. So what are the sample characteristics? We had a total of sixty-one CACs across the country opt in, which was fantastic, very exciting. And the total number of responses were three thousand seven hundred and fifteen responses. Three thousand seven hundred and fifteen children that experienced abuse had things to share with us and they were open about it and they chose to share. And it's still, it's, you know, we were able to learn a lot from them. In terms of our CAC service locations, we had urban, rural, and suburban in terms of our breakdown for who decided to opt in. I think the most common respondents were our urban folks, followed by our rural and then our suburban. So it was like maybe 39% urban, 38% rural, and then 22% suburban. I was really excited about the rural, shout out to the rural CACs for engaging in the project.  

TH: 

That actually fairly well tracks with the distribution of CACs. So I think that you can have some confidence that, you know, this is what the overall sort of overarching look at CACs would look like. if it were done with a larger group with the same distribution. 

KW: 

We got a wide range of kids. I mean the youth feedback survey was not supposed to super be for younger kids, but our youngest kid was seven and our oldest kid was seventeen. And we were very mindful in analyzing our data to make sure that we did it within the entire sample context, but we also did subgroup analysis because I think it's important to account for developmental ages and stages and responses and what that can mean in terms of variation of how we respond to children and help based on their age. So our largest cohort of kids were our 13- to 17-year-olds, and they were about 62, 63% of the total sample, which is about 2,300 kids. I think our next largest group was our 10- to 12-year-old kiddos. They were about 29, 30% of the sample, and they were about 1,100 respondent responses. And then our youngest age group was our littles, our seven- to nine-year-olds. 

And they were about six, seven percent of the sample and two hundred and forty-five unique responses. We had English and Spanish too in there, which I was curious if there were more languages out there that were available, but that may have been a limitation at the time with the pilot. But the majority, 98% of the respondents were in English. We had about 1.311% that were in Spanish, but we were able to one of the research team members is bilingual. And so she was able to interpret all of those for us. So we were able to get, you know, multiple perspectives and not have to exclude anyone based upon language.  

TH: 

I think what's interesting to me about the sheer numbers of responses in that time, it really showed a true interest on the part of kids in telling us what they thought. And I had a conversation this last week with someone where I was explaining the survey and they're like, I don't know if kids will fill out a survey. And I was like, we've had some experience that says that they will, you know, and that they are often eager to have their feedback included and to believe that it's shaping the way that CACs will respond to future kids.  

KW: 

And I think now, more than ever, we truly need to be integrating children's voices in all aspects of care. When I've worked in primary care as a nurse practitioner, our primary care visits for our patients are sometimes 15 to 20 minutes and that's it. And kids aren't often given the mic. You go into the visit, it's so fast. We're on an assembly line and I would love to see things change and modify, but creating that space for kids to be able to speak to themselves is really important, not only for listening and engaging them, but acknowledging what's important for them for their health and their growth and their development.  

TH: 

Let's start with that first question about what does healing after child abuse mean to you? Talk a little bit about what you heard. I know that it varied a little bit based on the age of the participants, but what was significant and most important in terms of what that meant to them.  

KW: 

So I think overall this was probably the most nebulous question because it's the most abstract. And we know that kids develop mentally are still working on their abstract thinking as they progress through. I think for this question across all age ranges, a lot of the kids shared kind of these again, broad characterizations of, you know, they want to feel happy. They want to feel better, you know, feeling safe. And that I think the biggest thing out of all of this was even if they weren't able to clearly articulate the way, you know, maybe an older child would, they very much felt that healing is very important and just having the opportunity to acknowledge it and be part of the process is important. I think the other takeaway too is it's really abstract. There are a lot of theoretical models and frameworks out there again that were derived from adult-based data. 

And I think that there are opportunities for more work in this area to understand the abstract piece of these experiences through the lens of children. And I think art is really one of those spaces that could maybe help answer that a little bit better.  

TH: 

Well, actually, I want to maybe beg to differ a little. And then I think if you were to ask an adult what it would mean to heal after abuse, I'm not sure they would say things much differently. That they want to feel better, that they want physically to feel better, which some of the kids commented on the bodily aspect of physically feeling better or they wanted to feel safe. I think that while I hear what you're saying, that initially to some people it might sound vague, I really think this is the way we talk about our well-being, right? We talk about it in these very fundamental ways that are about not having a negative feeling. Basically, they were finding words that meant the opposite of the negative feeling that they had been feeling prior to coming to the CAC, it seemed to me. 

KW: 

Yeah. I'll also say full disclosure, I am all pediatrics. I have no experience with anything related to the adult population. But I found in working with kids, if they don't always have the words to express how they feel when they draw it, sometimes you learn a little bit more. And so that's one of the things that I had hoped from this project. I think it would be fantastic to be able to start some sort of opportunity to explore this question further using art therapy and art therapists to collaborate with just to see how different it might look if kids drew it instead of only had an open-ended question to kind of write off of.  

TH: 

An interesting idea. Well let me read two quotes that I thought were related to this and very interesting. One was “knowing the worst is over and I'm safe now.” And I have had so many kids say to me personally when I was the director of a center, “I feel safe now.” 

And this comes up in OMS surveys all the time. This issue of how unsafe they felt before and how safe they feel now, which I think is really instructive because it's not just physical safety, it's that psychological safety piece of it and what an enormous relief they often feel about not feeling that they're having to hold that secret. And in other words, to be happy with yourself and accept who you are as a person, which was a fairly sophisticated, I would say, understanding of what feeling better is, you know? So it's interesting that there is a part of this that is like, it's about feeling like a person again for these kids. And what must they have felt like before?  

KW: 

And I will say too, in looking at the data as well, there wasn't a lot of variation among age groups with these concepts. They were pretty similar across the board. And there were also, you know, there were kids that didn't know. 

And when I have somebody say I don't know, I don't take that as a non-answer. I take that as they genuinely don't know. And that's an opportunity for growth, right?  

TH: 

So depending on how long you've been abused, if that's your lifespan, you might not know what would make you feel better because you may never have actually felt better. So I think that there's just some very interesting nuances with this based on, you know, the experience that kids have had. Now let's turn to a little bit about, because I found this one pretty interesting. 

What's the most important thing for you to heal or feel better after child abuse? So, what did we learn about that?  

KW: 

Children are able to clearly articulate what is important to them. And we probably should be doing a better job of listening to that. Overall, talking about it was the overarching what the kids said. And I think there's a difference between talking about it and then having people listen to you. 

I think they're different concepts, but talking about it and having family overall were and maybe not necessarily your family by blood, but like the idea of people who support you continued to come up. Also, some of the younger kids were talking about having pets and having toys available to them. And the older children talked about again, friends and music and things that connected them. So again, in a world where we're talking about efficiency and we're talking about moving things quickly. I think what this says is kids want connection. They want support. They want to know that the trusted adults and the folks around them will allow them to talk about what it is that's going on in their lives, believe in them and support them through.  

TH: 

I think one of the interesting things about this is that often caregivers are very reluctant to let kids talk about it or feel like that might be damaging to them. It often even plays into their beliefs about whether or not kids should go to therapy. It's just like, let's forget it. Let's just forget it happened, put a lid on it, it'll go away. And of course, we know that's not actually what works. And so it's interesting to hear kids to say, I know that I need to talk about it in order to feel better. And I think providing not only safe spaces for that through therapy, but helping caregivers understand that this is something important to kids and how to listen and how to hear and what's healthy in that. 

And how to support that I think is going to be very important because as you say, they also note that the support of their family is critically important, which aligns with the literature on that and also with the older kids. And it was just unsurprising because of the developmental phase that they're in, but the support of friends, you know, that they're really looking to peer support as well.  

KW: 

I think part of this too, like you brought up a good point about like family members being able to cope, deal, and allow for space to talk about it. And, you know, adults experience child abuse as well. And sometimes there can be a past history in the family. And if we have to think about all these things from a family-centered perspective, yes, I mean this has happened to the child, but it's the whole family. So I think one of the things that I learned about when I was in the Canopy Center was, you know, at CACs it's not just the child. There are resources to help, you know, siblings and help family members also connected to services. And I think that's really important because sometimes for family members to allow the space for their children to talk to them. They also might need a little bit of support dealing with their stuff.  

TH:  

Unquestionably. I was interested in the pet piece. Like why? Not because we don't always, you know, we don't all love pets. You know, I was talking to a center director this week who was like, you know, our center doesn't yet have a facility dog and I'm kind of not sure about it. And then I was at another center who has four. 

And they're so beloved. And, you know, I always say if we want our social media likes to go up, all we have to do is post a picture of a facility dog. And it's like they're a celebrity, no matter what facility dog they are. But it's so interesting how consistent the stories are from CACs, the handlers themselves, the forensic interviewers, or wherever the dog is allowed to go to, if a child wants to interact with it. Obviously it's a consent-based system, but it's such a comfort. 

That's the interesting thing about it. I mean, they were talking about their own pets, presumably here, but it kind of resonated with me because I was like, that's really interesting because we know how kids respond to these facility dogs. They're so calmed by just having them present, even if the dog's asleep beside them. Like they're just so calmed by that.  

KW: 

Actually, there was a lot of those quotes about centers and that that had pets. And there were references to their own home pets. So I didn't want to out like, you know, because they mentioned in some of the quotes the name of the dog. And I'm like, I can't, you know, you know, they've got to keep everything, you know. We can't be saying the name of the dog. But they're absolutely in our data reflected that some of the kiddos that did have the opportunity to engage at CACs that already had a pet therapy component, they loved it. So word out there. 

I mean the the kids really, really enjoy having the pets.  

TH: 

And they gravitate to these facility dogs. And I think, you know, for the ones who need it and ask for it or at least are offered it and say yes, I think that it can be a surprising comfort that allows them to get through an otherwise challenging day. So let's talk a little bit about what didn't have strong endorsement from everyone, but for the folks who did, it seemed to be very important. 

 There were two different areas. And let's talk about the first one, which was faith, which was interesting that, you know, percentage-wise, it wasn't a huge percentage of kids that commented on it. Maybe because the questions were related to the center itself and these aren't religious centers. I don't know why it didn't come up more, but for the ones that did comment on it, it seemed very important to them.  

KW: 

We didn't get a lot of in-depth quotations, and my apologies, I don't have one to pull up now. 

I was very surprised. I thought there would have been more.  

TH: 

Interesting. I mean, maybe if it had seemed broader than sort of through the CAC, there would have been more. Because we certainly have had other researchers on who've done research paired with CACs where, you know, and as you're aware, kids bring it up in forensic interviews, they bring it up during victim advocacy, sometimes during therapy, they bring up these kinds of things. So maybe it's just the wording of the questions didn't necessarily lend itself to a kid's mind going there. 

But I did think that was interesting. But the other one was justice, which again, not tons of kids brought up, but for the ones who did, they seem to have very strong feelings about it.  

KW: 

I absolutely agree with that. The quotations associated with the kiddos that did speak to the desire for justice as being the most important thing to heal, they were strong words. And again, I don't have the quotes in front of me right now.  

TH: 

You know, why I tell you I was struck by that is I spent this last part of the week in Canada with their fantastic child and youth advocacy centers. And it was a symposium on justice. And of course, here in the US, you know, we did a lot of work in early years around system improvements on the justice side. And those were really important. I mean, improving forensic interviewing, improving multidisciplinary team investigations, improving the ability of child witnesses to testify in ways that are friendly to them, all those things. But also, most cases won't take that route, right? Most kids are not going to get criminal justice in the end. And so for Children's Advocacy Centers, I would say about 15 years ago or a little more, we sort of pivoted to say we've done a lot there. But now we're really going to focus on the healing aspect of this because we can see that many children will never get that justice that they're looking for. Not because the team isn't knocking themselves out trying and prosecutors aren't doing everything they can. 

But juries do what they do, judges do what they do. Sometimes you have corroborating evidence, sometimes you don't, like things out of the hands of kids, team members, everybody. So I'm just curious about, you know, what you think we should be doing for those kids for whom it is so important, you know, who are connecting it mentally to their ability to heal, you know, trying to pursue justice as much as we can. Is it giving them more voice in the decisions that are being made in terms of whether or not to carry their case forward and whether or not they testify and all of that. Is it more education about how the justice system works? Is it, I mean, more reality testing about the likelihood that that's going to be an eventuality for them? I can imagine a CAC seeing this and listening to this and going, gosh, I am just not sure what to do with that because we want to help these kids as much as we can, but some of this is outside our control. 

KW: 

Yeah. I think asking, because again, we're not at a point where we can just look at a child and know we have kind of broad ideas, but having a way to understand with our patients and our clients what is most important. I think there isn't always a lot of education and walkthrough for kids about what the justice system looks like. I mean, unless they're actually gonna end up going to court, there's really not a lot. I've seen a couple children's books out there and they've escaped me the names right now, that kind of walks kids through. But I think if you have a child, you know, that comes in and they really are expressing an interest in understanding the process, I think it's important to sit down with them and take the time to let them talk about this is important to me, this concept of justice. What does it mean for me? What does it look like? And have that conversation. I don't think that conversation happens enough. And again, we can't tell just by looking at someone who comes in the door, what is going to be important to them. So maybe having an opportunity to have them think about if they come into a visit, what are the things that they would like to address in that visit in advance?  

TH: 

You know, as it related to the third question, which is what was the most important thing that the CAC can do to help you heal or feel better after abuse? It was interesting to me as well. I mean, you've already mentioned people said talking about their abuse, being listened to, which as you point out is different than just being able to talk, you know, having someone who's really actively listening, receiving support. But it also sounded like there were some specific needs that the youngest kids talked about, which seemed to have to do with both comfort and needing breaks, maybe. You know, they seem to talk more about wanting access to games, toys, to stuffed animals, to other things. And I was thinking, is that because they need a distraction? Is that because they need a break? Is that because I mean what do you think that was about? 

KW: 

I think it's looking to things that are sources of comfort when they're maybe dealing with big feelings that they haven't quite figured out to how to process yet. Yeah. So a lot of younger kids, right? They have comfort objects, you know, games. Some of those things can help them process and cope with things a little bit more as they're trying, you know, figuring out where they are with their process and how they feel. I mean, the younger kids, all of the sample said that talking to them, you know, let me talk about it was important I mean for the younger ones, the next important thing was listening to them about it. So talking and listening, the games and toys were next. And then after that it gets into feeling safe, having that comfortable environment, having a personal touch, like knowing that I'm an individual person and having kind of that, you know, not just being cookie cutter, but like really addressing things about me that I like and that I like to do and incorporating that into the visit. 

TH: 

So let's talk about a a little bit about the CAC environment because early in our movement, a lot of attention was paid to the child friendly environment. And it was a huge distinguishing factor between CACs and all the horrible other places that kids had been interviewed or those kinds of things.  

KW: 

Or you mean just in the adult emergency department?  

TH: 

Right. Right. Right. Yeah. Or police stations or schools or just wherever that just wasn't appropriate for such a personal and difficult conversation.  

And then after everyone was in their beautifully decorated space, I think there was also a little bit of a pendulum swing into focus on other things and maybe kind of like l not less importance, but maybe less focus on that. And it seems to me that your findings kind of argue that we have to continue to maintain these very child friendly spaces.  

KW: 

I think it's multifactorial. 

I think it's from the first minute you walk in the door and the first person you come into contact with, you know, is open, is friendly. And for kids, seeing spaces that are colorful, that are bright, that are, you know, maybe have imagery that are trees or butterflies or things that speak to them that the place is safe. That is really important. That is really important. And kids are not little adults.  

TH: 

So they can't just set aside your sterile room and go, these are really nice people, you know. 

 They're taking it in from the moment they walk in. Does it feel safe, friendly, like a place I would want to be in, essentially?  

KW: 

It makes me think too of the difference walking into an adult hospital versus a children's hospital. I work at a children's hospital. I walk in the door, there's fish tanks, there's rainbows, there's Disney prints, and all those things can help kids see around them that the space is designed for them. They have familiar friends and cartoons and, you know, it just I think it adds to that extra layer of even though I'm going through some tough stuff, I'm safe here and the space is for me.  

TH: 

As you were talking, I was just thinking about a center that I recently saw that just illustrated this so beautifully. When I walked in, there's a bubble wall immediately and the wallpaper had trees and animals and just it was just, shout out to Toba Center in Winnipeg because it was stunning. And not over the top, just so warm that anyone who was walking in the door and a child of any age could walk in and feel immediately embraced by the surrounding. And I just thought this is what we want for all kids when they come to a Children's Advocacy Center, that whether the building is small or the building is large, or who's in the building or not in the building in terms of professionals, that in every space they're in, it feels warm and friendly to them. 

KW: 

And it may seem like a soft thing, but it is really truly important to invest in. The kids are telling us this is important. And again, they're telling us and it's important to listen.  

TH: 

Kristi, it was really interesting that, you know, when the youth surveys first came out and we started first getting the first wave of them. I read a bunch of the individual comments. So not a part of this study, but just read hundreds of comments because I was just curious about what kids would say, you know, because there was already a little open-ended thing at the bottom about is there anything else you want to tell us? You know, include it. Kids are so tuned into their physical environment. That was the sort of my first window into that. Not that I hadn't known it to some degree, but they would mention things like, it's too cold in the CAC, or it was too quiet in the CAC, because the air conditioner was probably set for adults, not little tiny bodies, or you know, there was no music playing or anything. So they walk in and it feels like out there in a library. And it was really great feedback. And I'm reminded why we encourage CACs to collect this information so that they can see it for their center, because those were such easy fixes to make kids more comfortable. Like that's something that you can read that and go, you know what? I'm going to walk over to the thermostat and fix this little problem right here now. So I love this about the feedback you get from kids. It's often very, very specific to their experience. You know, it's not generic, essentially. Or I love XYZ facility dog. Or, you know, like whatever. It's always very specific. All right. So let's just pivot for a minute and talk about the fact that of course kids don't say things like, I have trauma, or those words.  

KW: 

That was an interesting thing. I expected to see the word trauma before I even got into this data. 

And it was like markedly absent. But I think it makes sense. I mean trauma informed care, so important, right? Such an important framework to help everybody. But was it created by the kids and the people that have experienced those things? Or is it more of a framework to help us who are caring for them do a better job? So, I mean, it you know, on one end, I'm not surprised that the kids weren't saying it because I don't know if that would have necessarily we're asking about healing. We didn't really have it like trauma as part of the questions. But yeah, that was a really interesting finding for me.  

TH: 

I feel like that's an adult professional word anyway. Like even when you talk with, you know, civilians, people who are not in the child abuse intervention or prevention space, they'll talk about being hurt by something or even they might use traumatized, but you don't just hear a lot of trauma, I feel like, talk as much, although more now than you used to, but okay, here's where I was headed with this. Okay. What was so interesting to me though is that they described trauma symptoms. Other forms of distress. So they didn't use the word trauma, but they did were able to describe hypervigilance or other kinds of things. So talk about that a bit because, you know, it was a good reminder that maybe they don't know the adult word for something, but they're clearly tuned into the distress that they're feeling.  

KW: 

Yeah, actually you saying that makes me think of AI of all things, right? 

I mean, we don't have the exact word of trauma, but the context surrounding it is there and it's present in the symptomatology. And just because we aren't using the direct word of a diagnosis doesn't mean that kids or other folks aren't experiencing symptoms that are consistent with it. So I think that means, you know, we all we need again, it goes back to like listening and that delicate balance of what somebody maybe says directly to you versus digging deeper. 

And again, these kids were very open with us and shared these things. And we had a child psychologist actually on our team helping with analyzing the data, which I think really richened our ability to see the kind of the symptoms that the children had shared.  

TH: 

So child abuse professionals, as you know, are the audience for this podcast. And you get to wave your magic wand right now and tell them, you know, what you hope they take away from this. Like if you could change anything in the system or if you could change anything at CACs or if you had some recommendations based on this that they could take away from it, what would it be? Just, you know, the top three, maybe.  

KW:  

Oh, here we go. Yeah. So it's not rocket science here. I think, first of all, this is not any negative reflection on the trauma-informed care movement. But at times I kind of wish it was called healing informed care. Because using the language of trauma centers the lived experience in the trauma and I mean this study was all about healing and kids' perspectives on how to move forward. So I guess I would urge a healing framework and an asset-based framework and perspective versus more of a risk-based or centering the experience of life solely as being deemed trauma. I think we all try really hard right now to give space, but we live in a time and in a system where time is money and we're all under pressures to move things through. 

I mean, remember, it's a kid's life. It's a family's life. And sometimes those little touches that we have as clinicians, as advocates, at whoever whatever our role is in the system, there are things that we can do to ensure a more relational, safe experience with children and families than just have it be a checkbox fast food transaction. Even if things are tough, I think we still can hunker down, we can invest in these things and we can do these things for our patients and our families. I mean, I would love to see more research, even if it's hard, that captures the perspectives. And I'm careful when I use the language of survivor or victim because I think it's up to the individual how they define their experience and where they're at. And I think it's also something that's fluid and dynamic and changes. But I think we really need to when we design programs, when we implement programs, we always need to have our kids and our families as part of those conversations, not as an afterthought, but part of the design. I think we'll do better. 

Yeah, I think those are, I could go on and on, but those are things that I think about every day. As a nurse practitioner working on a child protection team and as a researcher that more than anything, I want to see a world with no child abuse in it.  

TH: 

Well, it's such a helpful reminder that we need to continue to find ways to bring child and youth voices into the equation and to really listen and take seriously what they're telling us that they need. So I so appreciate you coming and chatting with us about this.  

Is there anything else that I should have asked you and didn't, or anything else that you wanted to make sure we talked about today?  

KW:  

I'd like to give a shout out to my co-authors on this study. So I'm really proud of the fact that this work was so multidisciplinary. We had medical lens, Dr. Miriam Statz, Dr. Sarah Ronus, both Sarah is a pediatrician at university hospitals at Rainbow Babies, and Miriam is doing her pediatric emergency medicine fellowship right now. 

Our social work, our representation from Erin Casey, psychology, Bridget Vasquez, who is also my sister-in-law, which is fun. And then the nursing lens for me. So I just I am so grateful to all of my collaborators, especially Erin, and really, really grateful for Lolly McDavid, the child abuse pediatrician that introduced me to Jen Johnson at the Canopy Center. I just I feel like my passion to want to continue to do research and collaborate with CACs has just been, I mean. 

I can't even, I'm so grateful and I'm eager to do more and just wanna acknowledge and thank all those folks that that helped bring that into my life.  

TH: Wonderful. We'll look forward to future partnership, Kristi, and come back and visit us at one in ten anytime. Thank you so much.  

KW: 

Thank you, Teresa. 

TH: 

Thanks for joining us on One in Ten. If you like this episode, please rate it wherever you listen or watch. And for more information about this or any of our other episodes, please visit our podcast website at oneintenpodcast.org.