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Learn more: PMC Disclaimer | PMC Copyright Notice Int J Methods Psychiatr Res . 2026 Apr 9;35(2):e70070. doi: 10.1002/mpr.70070 Search in PMC Search in PubMed View in NLM Catalog Add to search Evolution of a Client‐Level Dataset: 20 Years of National Child Traumatic Stress Network Data Collection C A Purbeck C A Purbeck 1 Duke University Department of Psychiatry and Behavioral Sciences, UCLA/Duke University National Center for Child Traumatic Stress, Durham, North Carolina, USA Find articles by C A Purbeck 1, ✉ , A N Cooke A N Cooke 1 Duke University Department of Psychiatry and Behavioral Sciences, UCLA/Duke University National Center for Child Traumatic Stress, Durham, North Carolina, USA Find articles by A N Cooke 1 , L J Liang L J Liang 2 Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA Find articles by L J Liang 2 , C Smith C Smith 1 Duke University Department of Psychiatry and Behavioral Sciences, UCLA/Duke University National Center for Child Traumatic Stress, Durham, North Carolina, USA Find articles by C Smith 1 , J Staten J Staten 1 Duke University Department of Psychiatry and Behavioral Sciences, UCLA/Duke University National Center for Child Traumatic Stress, Durham, North Carolina, USA Find articles by J Staten 1 , J Epstein J Epstein 3 Children's Advocacy Services of Greater St. Louis, University of Missouri ‐ St. Louis, St. Louis, Missouri, USA Find articles by J Epstein 3 , H B Hodgdon H B Hodgdon 4 Justice Resource Institute, Needham, Massachusetts, USA Find articles by H B Hodgdon 4 , J Eslinger J Eslinger 5 Center on Trauma and Children, University of Kentucky, Lexington, Kentucky, USA Find articles by J Eslinger 5 , A Wells A Wells 6 Children's Research Triangle, Chicago, Illinois, USA Find articles by A Wells 6 , J Goodrich J Goodrich 1 Duke University Department of Psychiatry and Behavioral Sciences, UCLA/Duke University National Center for Child Traumatic Stress, Durham, North Carolina, USA Find articles by J Goodrich 1 , T H Bethel T H Bethel 1 Duke University Department of Psychiatry and Behavioral Sciences, UCLA/Duke University National Center for Child Traumatic Stress, Durham, North Carolina, USA Find articles by T H Bethel 1 , K Willett K Willett 1 Duke University Department of Psychiatry and Behavioral Sciences, UCLA/Duke University National Center for Child Traumatic Stress, Durham, North Carolina, USA Find articles by K Willett 1 , Y C Fu Y C Fu 7 UCLA Department of Psychiatry and Biobehavioral Sciences, UCLA/Duke University National Center for Child Traumatic Stress, Los Angeles, California, USA Find articles by Y C Fu 7 , J A Fairbank J A Fairbank 1 Duke University Department of Psychiatry and Behavioral Sciences, UCLA/Duke University National Center for Child Traumatic Stress, Durham, North Carolina, USA Find articles by J A Fairbank 1 , E C Briggs E C Briggs 1 Duke University Department of Psychiatry and Behavioral Sciences, UCLA/Duke University National Center for Child Traumatic Stress, Durham, North Carolina, USA 8 Department of Psychiatry and Behavioral Sciences, Kennedy Krieger Institute/Johns Hopkins University, Baltimore, Maryland, USA Find articles by E C Briggs 1, 8 Author information Article notes Copyright and License information 1 Duke University Department of Psychiatry and Behavioral Sciences, UCLA/Duke University National Center for Child Traumatic Stress, Durham, North Carolina, USA 2 Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA 3 Children's Advocacy Services of Greater St. Louis, University of Missouri ‐ St. Louis, St. Louis, Missouri, USA 4 Justice Resource Institute, Needham, Massachusetts, USA 5 Center on Trauma and Children, University of Kentucky, Lexington, Kentucky, USA 6 Children's Research Triangle, Chicago, Illinois, USA 7 UCLA Department of Psychiatry and Biobehavioral Sciences, UCLA/Duke University National Center for Child Traumatic Stress, Los Angeles, California, USA 8 Department of Psychiatry and Behavioral Sciences, Kennedy Krieger Institute/Johns Hopkins University, Baltimore, Maryland, USA * Correspondence: C. A. Purbeck, ( [email protected] ) ✉ Corresponding author. Revised 2026 Feb 19; Received 2025 May 23; Accepted 2026 Mar 2; Collection date 2026 Jun. © 2026 The Author(s). International Journal of Methods in Psychiatric Research published by John Wiley & Sons Ltd. This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made. PMC Copyright notice PMCID: PMC13066500 PMID: 41958077 ABSTRACT Objectives For 20 years, the National Child Traumatic Stress Network's (NCTSN) data collection efforts have been a central mechanism for Clinical Quality Improvement (ClQI). The NCTSN is a federally funded initiative in the United States composed of programs dedicated to raising the standard of care and increasing access to services for children and families who have experienced traumatic events. Methods These efforts span three initiatives: the Core Data Set (CDS), the Clinical Improvement through Measurement Initiative (CIMI) Measurement Based Care (MBC), and CIMI Data Sharing (CIMI‐DS) that collected and analyzed client‐level data to improve care for children and families served at participating sites. Across the initiatives, information (e.g., behavioral assessments, trauma exposure, standardized clinical measures) was collected from nearly 26,500 participants at 91 sites. Results Using the Consolidated Framework for Implementation Research (CFIR), we discuss the impact of external forces such as funding, policies, and societal changes and emphasize the importance of collaboration, technology, and flexible data collection methods in advancing ClQI initiatives as well as the field of child traumatic stress across decades. Conclusions We offer lessons learned and recommendations for future work to create large, query‐able datasets across a network and insights to support use in clinical practice. Keywords: data harmonization, large datasets, Measurement‐Based Care, network, trauma 1. Introduction Clinical Quality Improvement (ClQI), a process for evaluating outcomes of and then modifying intervention(s) and intervention delivery methods, is an increasingly central component of mental health care delivery (Rousmaniere et al. 2020 ). Fundamental to these efforts is the systematic collection, analysis, and interpretation of data using standardized measures that allow clients, providers, and funders of mental health care to examine the impact of interventions at the individual or micro level, the organizational or mezzo level, and across systems or macro level. Key practices needed to support ClQI in the mental health arena include: (1) Use of validated measures to assess consumer outcomes, (2) Use of technology to support data collection, (3) Routine assessment of outcomes, and (4) Support for training the workforce in the collection, interpretation, and application of data (Kilbourne et al. 2018 ). As the coordinating center for the National Child Traumatic Stress Network (NCTSN), the UCLA/Duke University National Center for Child Traumatic Stress (NCCTS) is committed to developing processes that benefit the NCTSN, member organizations, and clients served. One such effort, is the systematic collection and use of client‐level data to improve outcomes. This work aligns with the practice of Measurement‐Based Care (MBC), in which routine symptom monitoring, shared feedback, and collaborative treatment planning improve engagement and outcomes (Brooks Holliday et al. 2021 ; de et al. 2021 ). Over time, data‐collection has continually evolved in response to developments in the child‐trauma field, new partnerships, policy shifts, and the expanding composition of NCTSN programs. 1.1. External Factors The field of implementation science has well‐documented the impact of external forces on the success of projects. The Consolidated Framework for Implementation Research (CFIR; Damschroder et al. 2009 ) identifies several key factors influencing the evolution of the NCTSN ClQI initiatives. These factors include financing, partnerships and collaborations, policies, professional guidelines, and laws, and external pressures (e.g., societal and performance measurement). 1.1.1. Financing The NCTSN was established by the United States (US) Congress in 2000 through the Children's Health Act to improve the quality of care and expand access to services for children and families affected by trauma. The Substance Abuse Mental Health Services Administration (SAMHSA) funded the first 17 NCTSN sites in 2001, and by 2025 the NCTSN had grown to more than 200 funded sites and over 200 affiliates, formerly funded sites ( https://www.nctsn.org/about‐us/who‐we‐are ). Over time, the composition of NCTSN has fluctuated and expanded through competitive, multi‐year grants (Pynoos et al. 2008 ). Despite these shifts, the network remains unified and committed to enhancing care and strengthening the evidence base for services for youth who have experienced trauma. 1.1.2. Partnership and Collaboration A unique element of the NCTSN is its shared mission, vision, and values. Sites consistently demonstrate their commitment to increasing access and quality of care, collaborating through technical support and consultation to implement measures that guide care. Additionally, these values embody an esprit de corps, where network members collaborate to contribute to the NCTSN. An important aspect of this collaboration over the last 20 years has been the collection of client‐level data from funded sites to enhance care and build on the body of research and evidence in the child trauma field. These sustained efforts have produced a comprehensive data set gathered from a diverse array of organizations across the country. Collaboration has also been crucial in identifying new areas for investigation in the expanding field of child trauma treatment, such as gender identity, bereavement, separation, trafficking, bullying, and suicidality. These data have supported the exploration of standardized measure performance (Elhai et al. 2013 ), over 60 publications, numerous presentations leading to novel insights about the unique impacts of specific trauma exposures (Kisiel et al. 2014 ; Hall Brown et al. 2016 Brown et al., 2016), correlations between trauma exposure and behaviors (Layne et al. 2014 ; Grasso et al. 2015 ), and links between trauma exposure and service use (Briggs et al. 2013 ; Bravo et al. 2024 ). Analyses have also supported improvements in how the NCTSN approaches client‐level data collection. 1.1.3. Policies, Laws, and Professional Guidelines Over the past 20 years, several policies, laws, and professional guidelines in the United States have influenced NCTSN data‐collection initiatives. The Health Information Technology for Economic and Clinical Health Act, the Meaningful Use: Electronic Health Record Incentive, the Burden and Paperwork Reduction Act, the Health Information Technology for Economic and Clinical Health (HITECH) Act 2009 created financial incentives to migrate from paper to electronic medical records which can more easily be shared between centers. Additionally, there has been an increased emphasis on MBC, particularly in behavioral health (Scott and Lewis 2015 ). MBC involves the collection of data to support treatment planning and case conceptualization. The NCCTS’ approach to data collection has remained agile to stay aligned with best practices. This includes adapting to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‐5; American Psychiatric Association 2013 ); and responding to the growing call to explore co‐morbid conditions (Twenty‐First Century Cures Act, 2016), and expanding language use (American Psychological Association 2023 ). 1.1.4. External Pressures (Societal, Performance Measures) Advancements in technology, changes in societal values, and the increased application of data have shaped behavioral health data collection. New technologies supporting client‐level data collection enhance efficiency by streamlining scoring, enhancing reporting, and tracking improvements in functioning. These tools reduce burdens on clinicians and families while providing insights that support clinical decision‐making. At the same time, society has promoted broader community engagement in care and a patient centered approach which encourage NCTSN sites to engage in practices like MBC and tailor their assessments to better suit their communities and the individuals they serve. As a large, publicly‐funded initiative, the NCTSN has a responsibility to share information to demonstrate value. Opportunities to use these data enable a better understanding of how trauma affects behavior and development while ClQI processes help agencies apply reliable assessment and evidence‐based interventions, to improve outcomes for children who have experienced trauma. 2. Evolution of Approaches to Data Collection 2.1. Initiatives 2.1.1. NCTSN Core Data Set The NCTSN Core Data Set (CDS), collected between 2004 and 2012, marked the first national data collection effort in the child trauma field. This pioneering initiative aimed to standardize clinical assessments and improve the quality of care at NCTSN sites. The CDS enabled clinicians at participating NCTSN sites to gather web‐based data on demographic information, details about children's trauma histories and services utilized, clinical symptoms and clinician diagnostic impressions, and standardized measures of psychosocial functioning. It also provided clinicians with real‐time reporting and relevant information to share with children and families about their care. SAMHSA strongly encouraged data collection and submission from funded sites, while sites were provided with updates on what we were learning from the data via presentations and publications. This reciprocal flow of data further supported this comprehensive ClQI effort. 2.1.2. CIMI Measurement‐Based Care The Clinical Improvement through Measurement Initiative ‐ Measurement‐Based Care (CIMI‐MBC), began data collection in 2014 and continues to this day. This web‐based application effort builds upon lessons learned from the administration and analysis of the CDS. CIMI‐MBC incorporates recommended updates from NCTSN members, including more representative demographic categories, a broader selection of standardized measures, and updated trauma exposure categories. Participation in the CIMI‐MBC is voluntary. Funding to support the technology and implementation is provided by the NCCTS. 2.1.3. CIMI Data Sharing The CIMI Data Sharing (CIMI‐DS) project, initiated in 2018 and continuing to the present, is a collaborative effort between the NCCTS and individual NCTSN sites, each of which have developed their own personalized protocol and data collection methods. The goal of CIMI‐DS is to harmonize data collected from participating sites into a single repository. Participation is voluntary, and a community of users collaboratively decides data processing rules and governance. Funding for the technology and implementation is provided by the NCCTS. Figure 1 provides an overview of the three initiatives, details the samples, and provides examples of the external factors associated with project innovations and expansions. FIGURE 1. Open in a new tab Twenty‐Years of Client‐Level Data Collection in the NCTSN. Outer setting factors refer to the external factors acting upon the projects. HITECH refers to United States legislation that ensures the adoption and meaningful use of electronic health records (EHRs). CIMI = Clinical Improvement through Measurement Initiative; DSM‐5 = Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; NCTSN = National Child Traumatic Stress Network; SAMHSA = Substance Abuse and Mental Health Services Administration. 2.2. Methods 2.2.1. CDS In 2002, members of the NCTSN convened to develop a comprehensive assessment protocol encompassing trauma exposure and history, clinical symptoms and behaviors, severity indicators, functional impairments, demographics, and service utilization. The group also identified standardized, psychometrically sound measures widely used in behavioral health, such as the UCLA PTSD Reaction Index (UCLA PTSD‐RI) for DSM‐IV, the Child Behavior Checklist (CBCL), and the Trauma Symptom Checklist for Children (TSCC), to assess post‐traumatic stress symptoms, internalizing and externalizing problems, and other trauma‐related sequelae. To support implementation, the Duke Clinical Research Institute (DCRI) was engaged to design and test a web‐based data platform that included case‐report forms, real‐time scoring and reporting, auditing capabilities, and analytic tools. DCRI further developed data‐collection strategies, established a centralized data repository, and created regulatory protocols and standard operating procedures to guide participation across the network. 2.2.1.1. Site Recruitment The NCCTS engaged with grantees, providing an in‐person training to standardize the use of the CDS protocol to enhance clinical care. Additionally, NCCTS provided technical assistance and monthly consultation to sites on clinical workflow, engagement of special populations, cultural and linguistic considerations, data security, and regulatory requirements. SAMHSA strongly encouraged participation in these data collection and evaluation initiatives recognizing their potential to demonstrate the impact of the NCTSN on the field of child traumatic stress. 2.2.1.2. Study Population Sites represented in the dataset vary in location across the US (35 states, territories, and Washington DC) and provide a variety of services that align with their funding priorities. In total, data were collected from 19,108 children and youth from a total of 74 sites. Generally, site participation coincided with SAMHSA funding cycles which resulted in some sites participating for a single grant cycle and others across many funding cycles. A small group of sites continued to participate even after funding had ended. 2.2.1.3. Data Collection and Management Procedures From 2003–2009, the NCCTS partnered with the DCRI, to support implementation and use, data collection methods, Institutional Review Board (IRB) support, and data infrastructure. Training, consultation, and technical assistance was provided by the NCCTS to support clinical administration and interpretation of measures, enhance clinical workflow, and assess emerging trends and new treatment needs of children and families exposed to trauma. Data were often provided by clinicians and assessment coordinators. In 2006, ORC MACRO was contracted by SAMHSA to serve as an independent, cross‐site evaluator and aligned its evaluation to be compatible with the CDS. This new initiative occurred in 2010 amid updates to the CDS assessment battery aimed at refining diagnostic, treatment modality, trauma history, and service utilization information; and augmenting our ability to collect additional indicators of health and well‐being, developmental impact of trauma, episodes of care, demographic, and population specific information (e.g., young children, military‐associated children). Updates were also made to address cultural and linguistic considerations. MACRO collaborated with the NCCTS to develop a protocol in which they followed a subset of CDS participants for an additional year post‐end of treatment. To facilitate this evaluation, consent was obtained from participating sites to share a de‐identified dataset. In 2012, the cross‐site evaluation contract was terminated by SAMHSA and data collection ended. The NCCTS was also ordered to end data collection at this time and a final data set was created that included both NCCTS and MACRO datasets as well as corresponding documentation and evaluation reports. 2.2.2. Clinical Improvement Through Measurement Initiative—Measurement Based Care (CIMI‐MBC) Since 2014, CIMI‐MBC has been anchored in the principles of MBC. It was developed in response to requests from NCTSN members to enhance clinical content and create a user‐friendly mobile solution that offers real‐time scoring and reporting to support treatment across a variety of settings (Purbeck et al. 2020 ). Much like the CDS, the platform provides participants with access to a common set of data elements via a web‐based interface. The NCCTS partnered with NCTSN members to review the CDS and identify how the protocol could be enhanced to provide more meaningful insights to clinicians and families. Enhancements included additional trauma exposures, behavioral measures specifically for young children, and additions to the standardized measures such as the Strengths and Difficulties Questionnaire (SDQ). Lessons learned from leading CDS investigations, informed improvements in clinical application and utilization, database functionality, and overall system design. The NCCTS used a training method that included a year‐long implementation strategy with standardized element at each site, as well asIRB and regulatory support, data management, and consultation. Each site formed an implementation team to redesign care by improving case conceptualization, treatment planning, and progress monitoring, while enabling real‐time use of assessment results. Implementation teams often included multiple roles involved in clinical care (e.g., intake coordinators, clinicians, supervisors, and leadership). 2.2.2.1. Site Recruitment CIMI‐MBC is available to any NCTSN member. Recruitment involved meetings, webinars, and promotional materials. An initial cohort of sites participated in implementation and then additional sites were later invited to participate based on the fit of CIMI‐MBC for their agency. Several sites ultimately unenrolled from the project based on implementation factors such as misalignment of available measures, limited fit with clinical practice, staff turnover, or changes in funding. 2.2.2.2. Study Population Over the course of the project, 13 sites across 10 states have participated. Most of these agencies primarily offer outpatient mental health services for children and families, though some also provide services in the context of outpatient substance use treatment, residential treatment, or domestic violence shelters. While not all sites remained active throughout the project's duration, three sites participated for over a decade, contributing a substantial portion of the data. As of 2023, the dataset includes 2666 children and youth. 2.2.2.3. Data Collection and Management Procedures Procedures are managed by NCCTS. Typically, data collection is completed by clinical staff, and occasionally clients enter assessment information directly into a web‐based system within a customized environment, as detailed by Purbeck et al. ( 2020 ). Individual access to the system is granted after training and is secured via multi‐factor identification. One site contributed large amounts of data by uploading their data directly. Clinical staff from this site were trained separately and did not have individual access to the system. Data were regularly exported and securely stored on Duke University's servers. 2.2.3. CIMI‐Data Sharing (CIMI‐DS) CIMI‐DS evolved as an extension of the CIMI‐MBC project, directly responding to feedback from grantees who found that the existing protocol did not include the best content to support clinical care for their communities, align with their grant goals, or meet their organization‐level requirements. Consequently, the CIMI‐DS model allows participating agencies to develop their own assessment protocols by independently identifying client‐level descriptives and measures relevant to their specific site and community needs. These data are then collected through site‐specific methods. Training and data entry procedures varies by site, data are securely submitted to NCCTS, housed and subsequently harmonized into a dataset using a standard. The same clinical measure have a one‐to‐one relationship, making harmonization simple. For content such as demographics and trauma exposure a collaborative approach to harmonization was employed. Participating sites identified the best fit to the data standard. In cases where there was not an existing fit, the standard was expanded. Similar concepts have been outlined by Foran et al. ( 2017 ) and Kassam‐Adams et al. ( 2020 ). At this time cross‐measure harmonization, for example between CBCL and the SDQ, has not been performed. 2.2.3.1. Site Recruitment Participation in CIMI‐DS is open to any NCTSN member. Recruitment efforts included a series of webinars, personalized outreach efforts, and promotional materials. These initiatives successfully attracted an initial cohort of four participating sites, many of whom have participated in other NCTSN data collection activities. 2.2.3.2. Study Population Client‐level data were submitted by each site participating. Depending on the site, data submissions ranged from a few hundred to over three thousand clients. As of 2024, the dataset includes information from 4672 children and youth. 2.2.3.3. Data Collection and Management Procedures Each participating site developed its own protocol, measures, training, and data collection procedures. Data are uploaded to a central, secure cloud‐based platform. NCCTS staff developed and maintained a standard codebook of variables. In collaboration with each site, data elements are mapped and harmonized to a unified data warehouse (Foran et al. 2017 ). Quality control and assurance procedures ensure the accuracy and consistency of the harmonized data, including team reviews of mapping decisions, comparisons of histograms of variable frequency pre‐ and post‐harmonization, and reviews of summary reports (Harris et al. 2007 ; Daws 1996 ). A unique feature of CIMI‐DS is the various ways in which data can be missing. In traditional data collection methods, missing data indicates that the child, caregiver, or clinician did not provide the information (either because the information was withheld or the question was not presented) or the child was not old enough for the measure to be relevant (e.g., UCLA PTSD‐RI recommended age range is 7–18). However, in CIMI‐DS, missing data may occur because one center asks the measure/item while another may not. To aid in future analytical attempts to estimate missing data, codes were created with the site's metadata to distinguish data missing at random (e.g., data withheld) from data not collected at respective sites. 3. The Evolution of Content 3.1. Common Data Elements All three data‐collection initiatives are able to describe a child's progress through treatment over time, additionally there is a common set of data elements: demographics; trauma exposures; trauma‐related symptoms (e.g., Post‐Traumatic Stress); and treatment information. As CIMI‐MBC built upon the CDS, several common elements support a comprehensive assessment of child mental health across both initiatives. These common elements include: information about the child's home environment, indicators of severity of problems, clinician diagnosis, exposure to trauma, treatment information, and standardized measures such as the CBCL (Achenbach and Rescorla 2001 ), UCLA PTSD‐RI (Steinberg et al. 2004 ), and Trauma Symptom TSCC (Briere 1996 ). 3.2. Broadening Demographics Categories Nationally, there has been a growing effort to enhance the understanding of gender identity, race, and ethnicity to better comprehend experiences of these populations and create supportive research questions (gender identity: Cameron and Stinson 2019 ; Fraser 2018 ; McKay and Watson 2020 ; race identity: Atkin et al. 2022 ; Roberts et al. 2020 ; both gender identity and racial identity: Dunham and Olson 2016 ; both racial identity and ethnic identity: Woolverton and Marks 2023 ). Consequently, each of the three data collection projects also evolved in their conceptualizations of demographics. As a result, CIMI‐MBC and CIMI‐DS datasets include a broader selection of identities than did the original CDS (select frequencies are shown in Table 1 ). TABLE 1. Demographic details. CDS a CIMI‐MBC [Link] , d CIMI‐DS [Link] , h (2004–2012) (2013 ‐ present) (2016—present) Total number of clients 19,108 2666 4672 Participating centers 74 13 4 Age group n % n % n % < 6 years 3158 16.5 404 15.2 276 5.9 6–12 years 8950 46.8 1256 47.1 2208 47.3 13–17 years 6666 34.9 896 33.6 2018 43.2 18 years‐25 years 210 1.1 110 4.1 115 2.5 ≥ 26 years 37 0.8 Missing 124 0.7 — — 18 0.4 Ethnicity e , i Hispanic or latino 5344 28.0 306 11.5 476 10.2 Not hispanic or latino 11,535 60.4 2193 82.3 3642 78.0 Unknown 1107 5.8 71 2.7 ** ** Missing 1122 5.9 93 3.5 553 11.8 Race b , f , j White 10,048 52.6 1990 74.6 2112 45.2 Black or African American 5317 27.8 431 16.2 779 16.7 American Indian or Alaska native 611 3.2 508 19.1 199 4.3 Asian 341 1.8 60 2.3 53 1.1 Hawaiian or other Pacific islander 216 1.1 8 0.3 15 0.3 Middle Eastern or north African 13 0.3 Multi‐ or Biracial — — Refused/Prefer not to answer/Unknown 2103 11.0 85 3.2 105 2.3 Missing 1638 8.6 — — 4.8 1.0 Sex/Gender Identity c , k Female 9743 51.0 1470 55.1 2586 55.4 Male 9349 48.9 1158 43.4 1954 41.8 Other 37 1.4 69 1.5 Refused to Answer/Unknown ** ** 6 0.1 Missing 16 0.1 — — 57 1.22 Sexual orientation g , l Heterosexual 671 25.2 164 3.5 Lesbian or gay 18 0.7 8 0.2 Bisexual 74 2.8 10 0.2 Other 26 1.0 24 0.5 Refused to answer 19 0.7 19 0.4 Unknown 345 12.9 247 5.3 Missing 1513 56.8 4200 89.9 Open in a new tab Abbreviations: CIMI‐DS = Clinical Improvement through Measurement Initiative‐Data Sharing, CIMI‐MBC = Clinical Improvement through Measurement Initiative‐Measurement Based Care. a Items listed as “‐” were asked in the dataset but which no participants endorsed. Items with gray indicate datasets where variables do not exist. Items with “**” indicate cells where the number of clients is less than 6. b Clients may select multiple races therefore, percentages do not sum to 100%. c Gender/Sex: In CDS, gender/sex was referred to as “gender”, in CIMI‐MBC was referred to as “sex”, and in CIMI‐DS was referred to as “gender” or “sex” for the participants. d CIMI‐ MBC. e Ethnicity includes additional subcategories of Cuban, Central American, Dominican, Mexican, Puerto Rican, and South American. Refused to answer is asked in CIMI MBC and is collapsed into the Unknown category in the table. f Race categories have been consolidated from the options available in data collection. Although American Indian and Alaskan Native are presented together, this category includes distinct categories for American Indian and Alaskan Native. For Asian, other categories include Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or Other Asian. For Hawaiian/Pacific Islander, although they are shown together, Native Hawaiian and Other Pacific islander are distinct categories; other categories include Guam and Samoan. g Sexual orientation was asked only of clients 12 years of age or older. h CIMI ‐DS. i Ethnicity includes additional subcategories of Cuban, Central American, Dominican, Mexican, Puerto Rican, and South American. j Race categories have been consolidated from the options available in the data collection. For Black, other categories include South/Central African. For Asian, other categories include, Asian Indian, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or Other Asian. For Hawaiian/Pacific Islander, other categories include Guam and Samoan. k Gender/Sex category of Other includes Transmale, Transfemale, Nonbinary, Don't know/questioning, and Other. l Sexual Orientation of Other includes Pansexual/Bisexual, Queer, Questioning, and Other. 3.3. Expansion of Child Trauma Experiences The CDS originally included 20 trauma types (e.g., Physical Abuse, Community Violence, Domestic Violence). At that time, the list of trauma exposures was considered innovative as it went well beyond the 10 commonly assessed metrics of family dysfunction and adversity typically evaluated in Adverse Childhood Experiences (ACEs) studies. As the field's understanding of trauma has evolved, CIMI‐MBC and CIMI‐DS have benefitted from these methodological and conceptual advancements. e.g., CIMI‐MBC has both differentiated trauma types (e.g., Loss and Bereavement are now uncoupled from Separation), and included additional exposure types (e.g., Trafficking, Bullying). Additionally, sites participating in CIMI‐DS contribute trauma information i.e. tailored and relevant to the children, families, and communities they serve, including trauma exposures such as Police Violence, Historical Trauma, and COVID‐19 related adversities and traumas. These specific trauma types are not present in either the CDS or CIMI‐MBC. Table 2 illustrates examples of trauma exposures collected across the 20‐year history of NCTSN data collection. TABLE 2. Trauma types. Trauma type (confirmed only) CDS a ( N = 16,238) CIMI‐MBC b ( N = 2519) CIMI‐DS c , d ( N = 4260) Sexual maltreatment/abuse 2833 (17.5) 432 (17.1) 660 (15.5) Sexual assault/maltreatment 1993 (12.3) 436 (17.2) 957 (22.5) Physical maltreatment/abuse 3961 (24.4) 839 (33.1) 1307 (30.7) Physical assault/maltreatment 1535 (9.5) 308 (12.2) 970 (22.8) Emotional abuse/psych maltreatment 4791 (29.5) 1072 (42.3) 1708 (40.1) Neglect 3797 (23.4) 1088 (43.0) 1368 (32.1) Domestic violence 6762 (41.6) 1454 (57.4) 2207 (51.8) Illness/Medical trauma 1506 (9.3) 727 (28.7) 1308 (30.7) Serious injury/Accident 1716 (10.6) 677 (26.7) 1222 (28.7) Natural disaster 960 (5.9) 330 (13.0) 472 (11.1) Traumatic loss or Bereavement/Separation 7316 (45.1) Bereavement 1106 (43.7) 1939 (45.5) Separation 1980 (78.2) 2314 (54.3) Impaired caregiver 5489 (33.8) 1393 (55.0) 1686 (39.6) Community violence 2275 (14.0) 332 (13.1) 770 (18.1) School violence 1809 (11.1) 238 (9.40) 415 (9.7) Bullying 992 (39.2) 1631 (38.3) Attempted or witness suicide 809 (19.0) Other 2489 (15.3) 408 (16.2) 801 (19.0) Open in a new tab Abbreviations: CDS = Core Data Set, CIMI‐DS = Clinical Improvement Through Measurement Initiative Data Sharing; CIMI‐MBC = Clinical Improvement Through Measurement Initiative Measurement Based Care. a CDS: Other includes the following trauma types in CDS: Extreme Interpersonal Violence, Kidnapping, War/Terrorism/Political Violence, and other. b CIMI‐MBC: Other includes the following trauma types in data sharing: Extreme Interpersonal Violence, Trafficking, Kidnapping, War/Terrorism/Political Violence, and other. c CIMI DS: Other includes the following trauma types in data sharing: Trafficking, Extreme Interpersonal Violence, Kidnapping, War/Terrorism/Political Violence, Robbed, Dog/animal, Police/jail, Poverty, Lived with substance use, Law enforcement, Identity based, and other. d Percentages calculated to include all forms of missing (e.g., site did not have that trauma exposure, client did not provide). 3.4. Enhancing Site‐Specific Approach to Data Elements In the CDS, sites were instructed to complete a core set of measures to standardize an assessment protocol across NCTSN centers. For CIMI‐MBC, centers were asked to complete a common set of questions and measures, with the flexibility to customize additional measures based on site preferences or clinical needs. For example, some centers chose to use the CBCL while others used the SDQ to measure behaviors. Specifically, the SDQ was added to make transitioning to CIMI MBC more adoptable; several centers were utilizing this instead of the CBCL due to lower cost and reduced collection burden. The CIMI‐DS initiative builds on the concept of a data system that has core measurement and accommodates each center's unique assessment protocol, their compilation of trauma exposure types, and applicable ancillary measures. Table 3 expands on some of the methodological strengths and opportunities by project. TABLE 3. Strengths and opportunities for improvement by approach. Features CDS CIMI MBC CIMI DS Strengths Process Consistent use of standardized measures across sites x x Training to sites on administration, interpretation, and application of measures x x Real time assessment results used to guide care in session x External mediary provided to lead implementation and support for clinical care design x Available to all NCTSN members regardless of funding status x x Flexibility for sites to select measures x x Sites shared clinical knowledge and strategies for applying data management techniques x Partnerships supported and clarified harmonization strategies and guided prioritization of data elements x Technology No cost system for tracking of administration of assessment measures x x A system for tracking of administration of assessment measures, which included automated quality assurance features across participants x x Site specific technologies designed for local needs and efficiencies x Outcome Site‐level data shared with the broader network about their contributions x x x Data were reflective of the population served by the NCTSN x Cross site data easily analyzed, little to no work to align variables x x A large‐scale data set utilizing a consistent measurement strategy supported research on unique sub‐populations and use of complex statistical methods x x Opportunities for improvement Process Funding influenced site capacity to participate, complete measures and sustain involvement x x x Perceived time requirements to complete assessment protocol x x Content could not be individualized to meet specific site needs x x Sites incur cost of internal system development and maintenance, including cost of measures. x Intensive, centralized, process requirements needed to understand and map disparate data from across participating sites. x Extensive quality assurance processes are required at each site. x Outcome Data reflects a sample of NCTSN, with potential for site selection bias x x Frequency of missing impacts ability to harmonize all content x Open in a new tab Abbreviations: CIMI = Clinical Improvement through Measurement Initiative; CIMI DS = Clinical Improvement through Measurement Initiative‐ Data Sharing; CIMI MBC = Clinical Improvement through Measurement Initiative—Measurement Based Care; NCTSN = National Child Traumatic Stress Network. 4. Results 4.1. Demographics Characteristics All results presented are based on descriptive analysis of the datasets. Over time, the demographic characteristics used to describe clients have evolved to include nuanced identifiers of race and now reflects the field's current understanding of sex, gender identity, and sexual orientation. On average, children served in the CDS were 10.8 years old (SD = 4.3), 10.7 years old (SD = 4.3) in the CIMI‐MBC, and 10.8 years old (SD = 4.4) in the CIMI‐DS. The demographic category of gender has evolved significantly; the CDS was limited to sex assigned at birth, female (51%) or male (49%). CIMI‐MBC distinguished between sex assigned at birth and gender identity, as well as including options for transgender or non‐conforming (1.4%). CIMI‐DS further harmonized gender identities with 1.1% identifying as transgender and less than 1% as non‐conforming or questioning. Sexual orientation (heterosexual, homosexual, bisexual, unknown, and other) was not collected in the CDS, but was introduced in both CIMI‐MBC and CIMI‐DS. Additionally, race categories in CIMI‐MBC and CIMI‐DS were expanded from the original CDS collection to include more nuanced Asian races (e.g., Chinese, Filipino, Japanese, Korean), Middle Eastern or North African, and South or Central African. See Table 1 for detailed demographics for each initiative. 4.2. Trauma Trauma History Profiles (Table 2 ) include endorsement rates for exposure to each of the 20 trauma types in CDS, the 22 trauma types in CIMI‐MBC, and 43 trauma types in CIMI‐DS. The CIMI‐MBC trauma list expanded to differentiate between Traumatic Loss: Bereavement or Separation (45% in the CDS) which allows researchers to isolate rates of Bereavement (44% in CIMI‐MBC and 46% in CIMI‐DS) and Separation (78% in CIMI‐MBC and 54% in CIMI‐DS). Bullying (39% in CIMI‐MBC and 38% in CIMI‐DS) and Trafficking (less than 1%) were new additions to the CIMI‐MBC trauma list. The CIMI‐DS trauma list further expanded to include Attempted or Witnessing Suicide (19%). Those listed as “Other” trauma types include Extreme Interpersonal Violence, Kidnapping, War/Terrorism/Political Violence, Robbery, Dog/Animal Attack, Family involvement with Law Enforcement/Jail, Poverty, Living with Substance Use, and Identity Based Violence (all less than 1%, individually). 4.3. Strengths and Opportunities for Each Approach Across all initiatives, a major clinical strength was the consistent use of standardized, validated measures combined with trauma‐exposure and treatment data. Findings from the data demonstrate the benefits of treatment completion for children served by the NCTSN (Steinberg et al. 2019 ). Three robust datasets have been established which supported numerous publications. Opportunities also exist to enhance cross‐dataset comparability—for example, recategorizing bereavement and separation exposures using trauma‐specific details, as demonstrated by Kaplow et al. ( 2020 ). From an implementation‐science perspective, each iteration became increasingly flexible and better aligned with site‐specific needs; later systems (CIMI‐MBC and CIMI‐DS) allowed sites to select contextually relevant measures, improving engagement and feasibility. CIMI MBC allowed providers to have real‐time mobile access to scoring and reporting and the ability to track progress over time. Reports could be printed for clients or caregivers to enhance transparency, identify treatment goals, and support treatment modifications. Policy‐related challenges included the burden placed on sites and the impact of changes in SAMHSA funding, which led to uneven participation and potential self‐selection bias. Finally, technological advancements, particularly the cloud‐based CIMI‐MBC system, improved real‐time scoring, reporting, and longitudinal tracking, enabling more transparent and clinically useful feedback for families and providers. Table 3 summarizes the strengths and opportunities for improvement across all three initiatives. Despite these successes, we encountered ongoing challenges. These included the burden placed on sites—financial, time‐related, and administrative—as well as limited flexibility in expanding content within the CDS and, to a lesser extent, CIMI‐MBC to address site‐specific needs aligned with the populations and communities they served. Furthermore, after SAMHSA's support for data collection changed significantly and the mandated closure of the CDS, participation became sporadic, resulting in datasets that often reflected only a subset of NCTSN sites. This introduced potential biases related to site‐self‐selection, readiness, and funding availability. 5. Discussion Since inception, the NCTSN has implemented initiatives to support clinical quality improvement (ClQI) in client‐level data collection. Key components include a shared vision, collaborative processes, robust data collection mechanisms and infrastructures, implementation and regulatory support, and sustained external funding. Collectively, these efforts have fostered a culture of MBC across the NCTSN and enabled consistent examination of childhood traumatic experiences. Our work has also deepened an understanding of how trauma exposure affects functioning in childhood, adolescence and young adulthood. In alignment with the CFIR framework, these initiatives have adapted to fluctuations in funding, policy shifts, and external influences, while maintaining collaboration as a central pillar. Over time, comprehensive data on children served by the NCTSN, including demographics, trauma exposures, Post Traumatic Stress Disorder (PTSD) symptoms, psychosocial outcomes, and treatment details has been gathered. These continuous improvements have positioned us to explore nuanced topics such as developmental considerations for PTSD diagnosis and developmental trauma disorder; service utilization across systems‐involved and demographically diverse youth; benefits of treatment engagement and completion; developmental impact of different trauma types and potential synergies; distinctions between bereavement, grief, and traumatic separation; bullying and racial/identity‐based discrimination; and exploration of constructs related to suicidality across developmental and demographic groupings. At the outset of client‐level data collection, NCTSN members collaborated to establish a centralized set of core elements to support care across treatment centers. This centralized approach offered several advantages: it was standardized, provided a no‐cost system for sites to collect and evaluate data on outcomes, and promoted a network‐wide culture of data‐informed decision making. Data collection and use became more routine among NCTSN centers This broad participation resulted in a robust and consistent dataset capable of addressing critical questions in the field of child trauma. Sites new to data collection were supported through training, consultation, regulatory support, and technical assistance. However, challenges emerged. Clinicians reported that the protocol was lengthy and sometimes burdensome, customization for use with some populations (e.g., children ages birth‐3, young adults ages 18–25) was limited, and participation was heavily influenced by and contingent on continuation of SAMHSA funding. The transition in funding for the CDS, combined with a continued commitment to data‐informed care, led to the development of a new initiative by the NCCTS: CIMI‐MBC. This initiative built on prior experiences, incorporated technological advancements, and responded to emerging priorities in the field. In addition to the benefits provided under the CDS, CIMI‐MBC emphasized clinical utility by providing free access to real time scoring and reporting of psychometrically validated measures, along with coaching and implementation support. It was made available to both current and former NCTSN grantees, and several members extended its use to other settings where NCTSN knowledge was being shared for this project, this included a domestic violence shelter and child advocacy center. CIMI‐MBC proved especially valuable for CDS participants and for sites lacking their own data management systems. Its user‐friendly interface accommodated staff across diverse roles and its expanded content allowed for greater flexibility in measurement and alignment with evolving trauma concepts. However, CIMI‐MBC does not yet include all measures used by NCTSN sites, limiting full network participation. This gap may reflect factors such as evolving grant requirements, the maturation of the field, proliferation of site‐specific systems (e.g., following the HITECH Act of 2009), and the demands made by funders beyond SAMHSA. In our latest initiative, CIMI‐DS, we are adopting a more flexible, community‐responsive approach to data collection. Rather than requiring a uniform protocol, participating sites are empowered to define their own data elements based on local needs and capacities. This site‐centered model is supported by a centralized data repository, enabling sites to contribute what they can while maintaining autonomy. The initiative was co‐designed by members of the NCTSN who collaborated to establish core content requirements and recommend infrastructure requirements for data sharing. While this approach introduces analytical challenges, such as limited harmonization due to varying site protocols and resource constraints, it also reflects a realistic and an inclusive strategy. By embracing a “come as you are” philosophy CIMI‐DS, allows sites to identify relevant measures, build their own systems, and share available data in a way that minimizes extra content burden and maximizes clinical and cultural relevance. This model supports the broader vision of a trauma‐informed NCTSN, while honoring the unique contexts of the communities, families, and children we serve. Ultimately, it represents a scalable and respectful method for building a national data repository on child trauma. Over time and across three major initiatives, the NCCTS has remained steadfast in its commitment to clinical quality improvement. This commitment is reflected in the use of validated measures of functioning; the integration of advanced, technology‐enabled data collection systems; routine outcome assessments; and the cultivation of communities of practice that provide mentorship and support for sites. As funding models, field knowledge, technological capabilities, and societal expectations have evolved, so too have the NCTSN's data strategies ‐ driving iterative enhancements in how data is securely collected, managed, and applied. In this context, the emerging CIMI‐DS system is uniquely positioned to become the nation's leading resource for data that illuminates the scope and impact of childhood trauma. Its flexible, community‐centered design ensures both relevance and rigor and will enable cross‐measure harmonization to increase analytic power, setting a new standard for trauma‐informed data infrastructure. Given the many lessons learned from our efforts, future projects looking to develop multi‐site data collection efforts would do well to consider establishing a shared vision across stakeholders, adopting flexible yet scalable data systems, and investing in technologies that ethically and securely provide real‐time, clinically meaningful feedback. Ongoing training, technical assistance, and communities of practice are essential for supporting implementation across sites. Universally, there are ethical and equity standards that must be upheld to protect client confidentiality as part of collecting sensitive information. Prioritizing equity and community input can enhance relevance and applicability, while common data elements and harmonization strategies improve analytic power. Finally, securing stable funding and maintaining transparent communication about the value of collected data are critical for long‐term sustainability and impact. Author Contributions C. A. Purbeck: conceptualization, investigation, writing – original draft, methodology, visualization, writing – review & editing, software, project administration, supervision, data curation, validation, resources. A. N. Cooke: conceptualization, data curation, formal analysis, methodology, writing – original draft, writing – review and editing. L. J. Liang: conceptualization, formal analysis, methodology, writing – review and editing. C. Smith: data curation, project administration, validation, writing – review and editing. J. Staten: formal analysis, writing – review and editing. J. Epstein: conceptualization, writing – original draft, writing – review and editing. H. B. Hodgdon: conceptualization, writing – original draft. J. Eslinger: conceptualization, writing – original draft. A. Wells: conceptualization, writing – original draft, writing – review and editing. J. Goodrich: conceptualization, data curation, software, writing – original draft. T. H. Bethel: data curation, project administration, writing – review and editing. K. Willett: data curation, software. Y. C. Fu: data curation, software. J. A. Fairbank: conceptualization, funding acquisition, supervision, writing – review and editing. E. C. Briggs: conceptualization, data curation, methodology, project administration, supervision, writing – original draft, writing – review and editing. Funding Funding was supported under Grant Nos. H79SM062976 and H79SM084928 from the Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration (SAMHSA), and the U.S. Department of Health and Human Services (HHS). The views, policies, and opinions expressed therein are those of the authors and do not necessarily reflect those of the CMHS, SAMHSA, or the HHS. Ethics Statements These data were collected following Institutional Review Board at Duke University approved protocols. Consent The purpose of this study, procedures to be followed, and risks and benefits have been explained to me. I have been allowed to ask the questions I have, and my questions have been answered to my satisfaction. I have been told whom to contact if I have additional questions. I have read this consent form and agree to allow my child to be in this study with the understanding that I may withdraw him/her at any time. If my child is 7 years or older, this study has been explained to him/her and he/she agrees to participate. I have been told that I will be given a signed copy of this consent form. Conflicts of Interest The authors declare no conflicts of interest. Permission to Reproduce Material From Other Sources The authors have nothing to report. 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[ DOI ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Data Availability Statement The data generated and analyzed during this study are not publicly available. Data collected in this study was done so in partnership with participating National Child Traumatic Stress Network sites under the stipulation that datasets would not be shared beyond UCLA/Duke University National Center for Child Traumatic Stress and the Substance Abuse and Mental Health Services Administration. 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