1. Introduce a new tool into the CANS battery
Family Assessment of Needs and Strengths – Trauma Exposure and Adaptation (FANS-TEA)
Laurel Kiser
Vickie Beck
Kay Connors & John Lyons
Sarah Gardner
Fred Strieder

2. Acknowledgements
Substance Abuse and Mental Health Services Administration (NCTSI Category II)
In developing the FANS-TEA, we build off of several existing versions of the CANS:
the CANS-TEA (Kisiel, Lyons, Saxe, Blaustein & Ellis, 2002)
Several of the trauma items were developed or adapted based collaborations with Cassandra Kisiel, Ph.D., Glenn Saxe, M.D., Margaret Blaustein, Ph.D., and Heidi Ellis, Ph.D., with the SAMHSA-funded National Child Traumatic Stress Network.
the Family Advocacy and Support Tool (FAST)
Additionally, we want to acknowledge the work of all those individuals who made contributions to development of the CANS family of instruments.
Specific acknowledgment of the CANS TEA and the FAST

3. Families with Complex Adaptations to Trauma
Too many families are exposed to accumulated traumatic circumstances.
Complex adaptations to trauma in families are defined by the intensity, duration, chronicity, or “toxicity” of the accumulated trauma, and by the nature of the family’s response.
Those families whose strengths have been overwhelmed by their accumulated traumatic stressors exhibit distress and disrupted family functioning.
The family is one example of a “trauma membrane,” the protective environment surrounding a trauma survivor (Lindy, 1985; Nelson Goff & Schwerdtfeger, 2004; Rozensky et al., 1993). In the best of circumstances, the family provides extra support, structure and coping when a family member is traumatized. We all know that a family that rallies around a trauma survivor promotes a healthy reaction and bonadaptation. For those in distress and seeking treatment, family support leads to better outcomes.
However, under conditions of chronic, multiple or complex trauma exposures, the family may lose the ability to serve its protective function. Repeated exposures can lead to severe and chronic reactions in multiple family members with effects that ripple throughout the family unit and create “trauma-organized systems”. Understanding the context in which families experience trauma and the common clinical characteristics of families are critical to (1) adequately assessing their responses and (2) staging and sequencing appropriate services to meet families’ needs and optimize positive outcomes.

4. Families with Complex Adaptations to Trauma
Exposure to multiple traumas within a traumatic context
Systemic response
Multiple family members experiencing trauma-related distress
Multiple family subsystems negatively impacted
Family resources are insufficient to support needs
Family unit trauma-related distress
Family maladaptation with risk of becoming a trauma-organized system
First, complex family trauma occurs when families are exposed to multiple traumas within a traumatic context.
Second, such exposures result in a complicated systemic response that involves individual distress, alterations in the functioning of multiple subsystems within the family, family unit distress and gradual impairment in the family’s ability to carry out its basic functions.

5. Traumatic Context Family Unit
Child Response
Adult/
Parental
Response
Intergenerational Response
Sibling Relations
Adult Intimate Relations
Parenting Practices & Quality
Parent-Child Relations
The FANS-TEA is structured around the conceptual framework of families with complex adaptations to traumas. It is designed to measure needs and strengths of a family system that has been exposed to trauma as illustrated in the Figure.
Describe traumatic context, individual responses, subsystem reciprocal responses, and family unit response.
Although the question format is consistent methodologically with the CANS, the FANS-TEA is structured somewhat differently than other CANS instruments.
The first section includes items intended to describe a family's exposure to trauma and other stressors.
The second section includes items intended to describe the family as a unit.
Each additional section includes items addressing the subsystems of the family starting with individual family members.
Traumatic Context
Individual
and
Family
Outcomes
Family
Unit
Time Acute and longer-term effects
Individual development
Family life cycle
Adapted from Kiser & Black, 2005 5

6. Purposes
To document the range of strengths and needs exhibited by families affected by trauma,
To describe the contextual factors and systems that can support a family’s adaptation to trauma, and
To assist in the management and planning of services for families with exposure and adaptation to traumatic experiences.
In the trauma field, individual models of empirically supported assessment and treatment dominate, yet all members of the family are impacted by experiences of trauma;
Clinicians and child service system staff need tools to assist –
in understanding the impact of trauma not just on individual family members but on the entire family system
and in designing adequate service and treatment plans that effectively address the needs of these families.

7. Administration Completed by a trained clinician
Information is typically gathered during 1-3 sessions with the family.
Clinician may use the Family Trauma Treatment Interview (FTTI) for structuring the conversation with the family.
Clinician completes the FANS-TEA using the information collected.
We are currently developing guidelines for administration of the FANS TEA:
The FANS TEA is designed to be completed by a trained clinician or staff member following an interview with the family. Best practice would involve an interview with all family members present which would include information gathering and structured opportunities for observation of family interaction.
Information used to complete the FANS-TEA is typically gathered during 1-3 sessions with the family. The clinician completes the FANS-TEA using the information gathered and checking back with the family if additional information is needed or if the clinician needs clarification prior to rating certain items.
For clinicians or staff who might want a structured approach for carrying out this conversation with the family, we have developed a prototype trauma-informed bio-psycho-social-spiritual family interview to guide the information gathering process.
So let’s explore the FANS TEA.

8. I. THE FAMILY TRAUMATIC CONTEXT
In this section, we would like you to think about the experiences that your family has had regarding trauma and stressors. These traumas and stressors could have occurred to any member of the family or to the whole family together.
Complex adaptations to trauma in families occur when families are exposed to multiple traumas within a traumatic context. Families living in within a traumatic context often contend with exposure to multiple traumas, associated secondary stressors, and experience their environments as containing on-going dangers and traumatic reminders. They live in a context marked by uncertainty and uncontrollability. One example of a traumatic context is urban poverty.
Understanding the context in which families experience trauma is critical to
adequately assessing their responses and
staging and sequencing appropriate services to meet families’ needs and optimize positive outcomes.
Ratings of traumatic exposures and stressors are based on a rating scale developed for the CANS TEA and adapted for the FANS TEA.
Ratings on the items in this section reflect the family's trauma and stressor history.
The traumas and stressors could have occurred to any member of the family or to the whole family together.
For Family Traumatic Context, use the following categories/action levels:
0 indicates a dimension where there is no evidence of any trauma/stress of this type.
1 indicates a dimension where a single incident of trauma occurred or suspicion exists of trauma experiences; or mild stressor
2 indicates a dimension on which the family has experienced multiple traumas or a moderate degree of trauma/stressor.
3 indicates a dimension which describes repeated and severe incidents of trauma with medical and physical consequences; or major stressors.

9. I. THE FAMILY TRAUMATIC CONTEXT
Items 1-10 cover different trauma types.
sexual abuse physical abuse
emotional abuse neglect
medical trauma family violence
community violence natural/manmade disaster
political violence cultural violence
The nature of the trauma is important for predicting both secondary stressors that the family might be experiencing and also their a response. The FANS TEA covers 10 trauma types.
Political violence - This rating describes the severity of exposure to war, terrorism or torture.
Cultural violence - Cultural violence refers to exposure to conflict or violence related to friction between a family's own cultural identity and the predominant culture in which the family lives.

10. I. THE FAMILY TRAUMATIC CONTEXT
11. IMMEDIATE RISK - This item refers to the family’s current risk of exposure to any of the previously rated traumas.
Because the trauma section rates family exposures based upon historical data, The Immediate Risk item is used to assess current threats or ongoing exposures. This items is critical to taking action relevant to the family’s current context.
Family has no current risk of exposure as could be reasonably expected. 1
Family has some limited risk of exposure to trauma(s) but no current, on-going exposures. 2
Family is at high risk of experiencing trauma(s). 3
Family is experiencing on-going trauma(s).
Family at risk of exposure to: (circle all that apply): sexual abuse, physical abuse, emotional abuse, neglect, medical trauma, family violence, community violence, natural or manmade disaster, political violence
List family members at immediate risk:

11. I. THE FAMILY TRAUMATIC CONTEXT
Items cover potential contextual stressors/strengths:
family life cycle stressors
neighborhood safety
community resources
financial resources
residential stability
military transitions
Traumatic exposures present with greater risk for maladaptation when families are also experiencing other stressors. The FANS TEA includes evaluation of 6 potential family stressors.

12. Assessing Family Needs & Strengths
Section II
14 items assess the Family as a Whole
III
11 items assess Adult family members IV
11 items assess Child family members V
3 items assess Intergenerational family matters VI
4 items assess Adult Intimate Partnerships
VII
9 items assess Caregiving
VIII
2 items assess Caregiver-Child Relations IX
3 items assess Sibling dynamics
In addition to the context section, The FANS TEA has 8 additional sections that include 57 items.
Multiple adults, children, adult partnerships, and caregiving systems can be rated matching the complicated family structures that many families present.
For example, in a family that consists of 3 children being raised by their grandparents, it might be indicated to rate both grandparents and any involved bio-parent on the adult items; the 3 children on the child ratings; the grandparents’ intimate partnership as well as any partnership relationship involving the bio-parent that impacts on the family, etc.
Of course, using a modular approach, programs or clinicians could decide only to use specific subsections of interest to their treatment or service provision.

13. FANS-TEA Scoring Needs Strengths '0' indicates no need for action
These 8 subsections are scored using standard CANS scales.
'0' indicates no need for action
'1' indicates a need for watchful waiting
'2' indicates a need for action/moderate degree
'3' indicates the need for either immediate or intensive action
'0' indicates centerpiece strength
'1' indicates a strength that you can use in planning
'2' indicates an identified strength that must be built
'3' indicates the no strength identified

14. II. THE FAMILY as a Whole
22. EFFICACY- This rating should be based on the family’s belief that it is effective in achieving its goals and able to successfully manage daily family life and handle stressors.
A few example items will give you the flavor of the family systems approach that we are striving for.
I chose example items that are also consistent with important risk and protections regarding a family’s response to trauma.
22. Family Efficacy -- The family’s belief in their ability to negotiate the tasks of daily family life is important to their ability to adapt to stressors and traumas. The experience of multiple or chronic trauma may erode the family’s belief in their abilities to manage.
Family believes in itself and has confidence in its ability to successfully deal with family life. The family takes on problems and stressors with the attitude that they will be able to handle whatever happens. 1
Family members believe that they are able to handle most situations although they can be tentative about their ability to manage stressors at times. 2
Family has limited expectations about its ability to handle situations successfully. Family members are often surprised when they are successful at dealing with problems. 3
Family feels that it fails/is unable to handle most situations. Family members act based on the premise that “we are not able to cope with the things that happen to us”.

15. VI. Adult Intimate Partners
61. Partnership AFFECT management - This item refers to the extent to which adult partners modulate or express emotions and manage their reactions in the context of their relationship.
61. Partnership Affect Management -- Central tenets of systems theory are notable to the family unit’s role in regulation. Systems theory asserts that all systems strive to maintain balance or homeostasis and that when thrown out of balance by threats or traumas, systems try to regain it as quickly as possible. When systems are constantly thrown out of balance, their righting response may not be as quick or as effective.
Uncontrollable, uncertain conditions engender intense feelings that can challenge emotional regulation capabilities (Valiente, Fabes, Eisenberg, & Spinrad, 2004). The inability to tolerate intense emotions, a trauma-related symptom, may further constrict the family’s use of regulation strategies (Johnson et al., 1995). This item rates the ability of adult intimate partners to regulate affect within their relationship.
This rating is given to adult partners with no difficulties co-regulating emotional responses; adult partners manage strong emotions in a healthy, adaptive way. They recognize and respond appropriately to the affect expressed... 1
This rating is given to adult partners with some minor difficulties with affect regulation. They generally recognize and respond appropriately to the affect expressed, but there are some miscues and miscommunications… 2
This rating is given to adult partners with moderate problems with affect regulation. They may exhibit marked shifts in emotional responses… 3
This rating is given to adult partners with highly dysregulated affect…

16. I. Caregiving
65. SATISFACTION/MEANING OF CAREGIVING- This item refers to the importance placed on the role of caregiving and to the sense of accomplishment or pride that the caregiver feels related to carrying out her/his caregiving role and responsibilities.
65. Satisfaction/Meaning of Caregiving -- A protective factor for resilient families is the positive meaning attached to caregiving and the tasks of daily family life and relationships by adults in the family. Such positive meaning is also difficult to maintain in the face of persistent harsh circumstances.
Caregiver gives high priority to her/his caregiving role and responsibilities and gains significant satisfaction from carrying them out. 1
Caregiver places some importance on her/his caregiving role and responsibilities and gains some satisfaction from carrying them out. 2
Caregiver feels that her/his caregiving responsibilities must get done but only occasionally feels a sense of pride in accomplishing them. 3
Caregiver does not value her/his caregiving role and feels little or no sense of satisfaction for accomplishing any of her/his caregiving responsibilities. Caregiving is seen as a burden.

17. FANS-TEA Triggers and Links
Triggers - indicate actions that should be considered based on the section or item rating:
Additional assessments recommended
Plans to be developed/implemented
Reports that need to be made
Referrals that need to be facilitated
Links - indicate additional materials or resources that may be valuable in assisting the clinician in treatment planning or service delivery.
As a field we are just beginning to grapple with the complications created by families who present with complex adaptations to trauma. We all recognize that not dealing with these systemic effects is often a rate-limiting step in achieving positive treatment outcomes, especially for children.
Dealing effectively with complex family trauma requires carefully staging and sequencing a course of treatment to meet the complex needs of the family.
Following assessment, treatment planning must focus and order the therapeutic goals choosing from the many that are relevant for addressing complex adaptations to trauma. The FANS TEA can provide valuable information about what a family needs; specific items and subscales can be used to trigger actions necessary to respond to an individual family’s needs and links to additional resources to support shared decision-making about the best course of treatment.
A couple of examples of triggers and links will help illustrate how they might be used.

18. FANS-TEA Triggers and Links
Links for items 8 & 9 - Disaster/Political Violence
Psychological First Aid was developed by the NCTSN and National Center for PTSD.
It is an evidence-informed approach for assisting children, adolescents, adults, and families in the aftermath of disaster and terrorism:
Items 8 & 9 -- Disaster and Political Violence if rated as an exposure for the family would link the clinician/service provider to resources about Psychological First Aid, an empirically-informed approached to working with victims of disaster or terrorism.

19. FANS-TEA Triggers and Links
Section VII: CAREGIVING
Needs [items = 5; range = 0-15]; Strengths [items = 4; range = 0-12]
High Needs & Low Strengths Triggers - The following table identifies programs that effectively impact on parenting:
Families with high ratings on risk items and low ratings on strength items within the Caregiving subsection would be triggered to consider implementing evidence-based parenting interventions as illustrated in the table.
Program
Developer
Essential Elements
Evidence/ Outcomes
Parent Child Interaction Therapy (PCIT)
Eyberg
(2003)
Therapists coach parents on two major components: relationship enhancement and strategies for compliance.
Shown to be effective in reducing maternal stress and increasing the number of positive parent-child interactions.
STAR (Stop, Think, Ask, Respond) Parenting Program
Nicholson, Anderson, Fox & Brenner (2002)
Utilizes cognitive behavioral & anger management techniques to help parents develop a “thoughtful” parenting style.
Research indicates decreased levels of verbal and corporal punishment, anger, stress, and child behavior problems following this intervention.

20. Looking forward to your input:
For more information on the FANS TEA or to review it, provide feedback, participate in beta testing
Dr. Kiser at
Next steps:
Review
Develop training and reliability
Complete triggers and links
Disseminate
Evaluate
Please visit the FITT Website to learn more about the FITT Center and FITT Model