Building Capacity for Trauma-Informed Care in the Child Welfare System: Initial Results of a Statewide Implementation

Trauma-informed care beliefs scale-comprehensive for child welfare carers using Rasch analysis

BACKGROUND

The literature on trauma-informed care practices (TIC) indicates that this framework is beneficial for young people, carers, and staff. However, a significant gap in the literature and practice is the absence of psychometrically sound scales to measure carer adherence to TIC principles. Emerging evidence suggests that TIC practices shift carer attitudes and beliefs, which mediate positive outcomes for both carers and young people.

OBJECTIVE

To develop a theoretically comprehensive and psychometrically sound measure of carer TIC beliefs using Rasch methodology.

PARTICIPANTS AND SETTING

Active carers (N = 719, M = 43 years, SD = 10.7 years) from online support groups in Australia, Canada, the United States of America, the United Kingdom, and the Republic of Ireland completed the questionnaire online.

METHODS

Based on previous research (e.g., limitations of the Trauma-Informed Belief Scale-Brief [TIBS-B]; Beehag, Dryer, et al., 2023a) and a scoping review of the TIC literature (Beehag, 2023), 61 candidate items were created that covered the three main characteristics of carer-related TIC theory (i.e., beliefs on TIC strategies to manage trauma symptoms, beliefs on the impact of adverse childhood experiences (ACE), and beliefs on the importance of self-care/reflection). The resulting data was subjected to Rasch analyses.

RESULTS

Following analyses and minor modifications, a 35-item version of the questionnaire was confirmed, which fitted the Rasch model and demonstrated unidimensionality, reasonable targeting, and sound internal consistency reliability (Person Separation Index = 0.81).

CONCLUSIONS

The TIBS-C is a psychometrically sound measure of child welfare carer TIC beliefs. Future studies are needed to provide further evidence of its validity (e.g., predictive validity), reliability (e.g., test-retest reliability) and clinical utility.

Evaluating a Trauma-Informed Care Training Program for Mental Health Clinicians

The aim of this study was to evaluate the interRAI Trauma-Informed Care (TIC) training program based on evidence-informed Collaborative Action Plans. Focus groups and the Attitude Related Trauma-Informed Care (ARTIC) questionnaire addressed clinicians' and mental health professionals' attitudes toward the application of TIC with their child and youth clients. An explanatory sequential design was conducted. In total, 105 clinicians and mental health professionals who participated in a 4-hour, in-person or virtual TIC training, two comprehensive seminars, and 28 trauma-informed training web-based modules completed the ARTIC questionnaire. Researchers conducted seven focus groups with clinicians/participants (N = 23) to discuss the views and effectiveness of the interRAI TIC educational training modules. To quantitatively measure the change of attitudes towards TIC, descriptive statistical analysis was completed using the means and standard deviation of the ARTIC scores at the initial time point, the follow-up time point, and the difference between scores at both time points. Paired sample t-tests were conducted on both the overall score and each of the subscales in each of the three samples (total sample, online subsample, and hybrid subsample). A thematic analysis was conducted to generate qualitative findings from the focus groups. Findings from the quantitative and qualitative analyses suggest that the interRAI TIC training provided clinicians with an improved sense of knowledge and ability to apply trauma-informed care planning with their clients.

An evaluation of a trauma-informed educational intervention to enhance therapeutic engagement and reduce coercive practices in a child and adolescent inpatient mental health unit

High-risk behaviours are sometimes encountered in Child and Adolescent inpatient mental health units and can prompt the use of coercive practices to maintain safety. Coercive practices may lead to re-traumatisation of young people and deteriorating therapeutic relationships. Trauma-informed practice (TIP) has successfully reduced coercive practices. While education is identified as foundational to implementation, evaluations of programmes remain minimal. The aim of this study was to explore mental health professionals' views and experiences of a trauma-informed education programme and its likely impact on their approach to practice. Five mental health professionals agreed to participate, four contributed in a focus group and one in an individual interview. Data were analysed thematically using the Braun and Clarke Framework. Three main themes were identified. Firstly, shifting attitudes and perceptions of trauma-informed practice. Participants believed they had developed more compassion towards clients and these attitudes were reflected in their clinical practice. Secondly, challenges associated with trauma-informed practice educational intervention. Staffing issues and shift work made it difficult for participants to attend education sessions regularly. Participants identified barriers to practicing in a trauma-informed manner in the current clinical environment. Finally, the need for interdisciplinary communication and support was identified. Participants saw the need for all professionals, not only nurses, to take responsibility for changing practice, and for stronger support at the organisational level. Trauma-informed practice is crucial to recovery-focused mental health nursing practice. These findings highlight the importance of TIP education and suggest areas for further improvement to enhance positive mental health outcomes for young people.

Trauma-Informed Care Interventions Used in Pediatric Inpatient or Residential Treatment Mental Health Settings and Strategies to Implement Them: A Scoping Review

Trauma-informed care (TIC) is an approach to care emerging in research and in practice that involves addressing the needs of individuals with histories of trauma. The aim of this scoping review was to examine the current literature relating to TIC interventions used in pediatric mental health inpatient and residential settings. We sought to answer the following two research questions: (a) What are the TIC interventions used in pediatric inpatient and residential treatment mental healthcare settings and what are their components? and (b) What are the implementation goals and strategies used with these TIC interventions? We conducted this scoping review according to JBI (formerly Joanna Briggs Institute) methodology for scoping reviews. We included any primary study describing a TIC intervention that was implemented at a specific site which identified and described implementation strategies used. Of 1,571 identified citations and 54 full-text articles located by handsearching, 49 met the eligibility criteria and were included, representing 21 distinct TIC interventions. We present the reported aim, ingredients, mechanism, and delivery (AIMD) of TIC interventions as well as the implementation goals and strategies used, which varied in detail, ranging from very little information to more detailed descriptions. In the context of these findings, we emphasize the complexity of TIC and of TIC interventions, and the importance of identifying and clearly reporting TIC intervention goals, intervention details, and implementation strategies. We suggest applying intervention frameworks or reporting guidelines to support clear and comprehensive reporting, which would better facilitate replication and synthesis of published TIC interventions.

Implementing Trauma-Informed Care-Settings, Definitions, Interventions, Measures, and Implementation across Settings: A Scoping Review

Traumatic experiences can have long-lasting negative effects on individuals, organizations, and societies. If trauma is not addressed, it can create unsafe cultures with constant arousal, untrusting relationships, and the use of coercive measures. Trauma-informed care (TIC) can play a central role in mitigating these negative consequences, but it is unknown how and in which way(s) TIC should be implemented. Our objective was to conduct a scoping review that systematically explored and mapped research conducted in this area and to identify existing knowledge about the implementation of TIC. The search was conducted on the CINAHL, Cochrane, Embase, ERIC, Medline, PsycINFO, and Web of Science databases, and more than 3000 empirical papers, published between 2000 and 2022, were identified. Following further screening, we included 157 papers in our review, which were mainly from the USA, Australia, New Zealand, and Canada, focusing on study settings, methodologies, and definitions of TIC, as well as the types of interventions and measures used. This review shows that TIC is a complex and multifaceted framework, with no overarching structure or clear theoretical underpinnings that can guide practical implementations. TIC has been defined and adapted in varied ways across different settings and populations, making it difficult to synthesize knowledge. A higher level of agreement on how to operationalize and implement TIC in international research could be important in order to better examine its impact and broaden the approach.

Allied health professional support for children and young adults living in and leaving care: A systematic scoping review

BACKGROUND

Children and young people living in and leaving care are known to have experienced significant childhood adversity and trauma resulting in potentially deleterious impact on their health and well-being across the life course. Studies point to the complex needs of this population who may benefit from allied health professional (AHP)-related support with limited studies located. This review sought to address this gap by systematically scoping empirical literature focused on the provision of AHP support to this cohort of children and young adults to assist an understanding of the service needs for this vulnerable population.

METHODS

This scoping review followed Arskey and O'Malley's five steps framework (2005) to identify and review relevant literature. A focus on identifying the evidence, challenges and gaps in research relating to AHP support for children and young people living in and leaving care was initially agreed, followed by a systematic search using a combination of three key concepts to identify relevant studies in five AHP disciplinary areas to identify best evidence in the past decade (2011-2021). Study inclusion criteria were based on empirical studies of children and young people living in care (0-17 years) and leaving care (18-25 years). A data extraction table was formulated as a means of charting the data, aligned with the scope and objectives of this review. Finally, data were subsequently collated, synthesised and reported based on key thematic areas emerging from included studies regarding AHP support to children and young people living in and leaving care.

RESULTS

A total of 13 studies met the review inclusion criteria. Included studies reported specifically on speech and language therapist (SLT; n = 5), occupational therapist (OT; n = 3) and arts-based therapies (n = 5). No studies were identified with regard to the use of physiotherapy and dietetics with this population. Results indicated that children and young people living in and leaving care have high rates of speech, language, communication and sensory needs. More rigorous screening, assessment and early intervention were identified as essential for this vulnerable group. Increased multidisciplinary collaboration and OT support for young adults in preparation for transition to independent living was identified as an urgent requirement. Included studies indicate promising results in relation to access to arts-based therapies with particular reference to identity formation for children and young people living in and leaving care.

CONCLUSIONS

Although evidence of effectiveness remains limited, AHP service provision (specifically speech and language therapy, occupational therapy and arts-based therapies) has the potential to contribute positively to addressing the complex and interacting needs of this vulnerable population. As a result, it is recommended that AHP service provision is integrated into the collaborative, multidisciplinary care available to children living in and leaving care. More extensive, higher quality research related to the benefits of AHP provision for this population of children and young people is essential to provide a more robust evidence base across the various professional disciplines that constitute allied health provision.

Expanding the Trauma-Informed Care Measurement Toolkit: An Evaluation of the Attitudes Related to Trauma-Informed Care (ARTIC-45) Scale with SUD Workers in PIMH

Human service organizations (HSO) have increasingly recognized the value of employing trauma-informed care (TIC) in a variety of practice settings. Evidence suggests that effectively adopting TIC has shown client improvements. Organizational barriers to TIC implementation, however, exist. To improve TIC practice, the attitudes related to trauma-informed care (ARTIC) scale was developed to measure staff attitudes and beliefs towards TIC. The ARTIC has been widely adopted by researchers without evaluating its psychometric performance in diverse practice settings. The purpose of this study was to independently validate the ARTIC scale drawn from a sample of staff (n = 373) who provide services to substance-using parents. Psychometric tests were conducted to evaluate how the ARTIC performs with our HSO population. Results from a confirmatory factor analysis showed poor fit (X² = 2761.62, df = 2.96; RMSEA = 0.07 [0.07, 0.08]; CFI = 0.72). An exploratory factor analysis was conducted to analyze how the data fit with our specific population, yielding 10 factors. Finally, a qualitative inter-item analysis of these factors was conducted, resulting in nine factors. Our findings suggest that measuring TIC attitudes and beliefs may vary according to field of practice and ethno-racially diverse workers. Further refinement of the ARTIC may be necessary for various services domains.

Traumatised Children's Perspectives on Their Lived Experience: A Review

Introduction: Most children have exposure of traumatic events during their life, such as natural disasters, accidents, and abuses. A review of traumatised children's perspective on traumatic events plays an important role in enhancing our understanding and promoting appropriate tailor-made intervention and support to these children. Methods: Four main health-related electronic databases were searched for all English full-text qualitative research articles over the past 11 years to uncover the recent best available perspective/evidence from traumatised children. The PRISMA checklist was adopted to guide the review process. Results: Five themes about children's experiences and perspectives towards the traumatic events encountered were summarised and integrated from 19 qualitative studies identified. They included daily life problems related to trauma, negative responses to trauma, perceived health needs, coping strategies related to trauma and stress, and growth from traumatic experience. Conclusions: This systematic review provides evidence about responses/impacts and perceived health needs of traumatised children and informs the direction caregivers' training can take, helping these children by early identification and timely intervention. More research is needed to examine/compare traumatised children's responses and coping between diverse traumatic experiences, time from exposure, and the sociodemographic characteristics of these children.

Measuring Trauma- (and Violence-) Informed Care: A Scoping Review

Trauma- (and violence-) informed care (T(V)IC) has emerged as an important practice approach across a spectrum of care settings; however how to measure its implementation and impact has not been well-examined. The purpose of this scoping review is to describe the nature and extent of available measures of T(V)IC, including the cross-cutting concepts of vicarious trauma and implicit bias. Using multiple search strategies, including searches conducted by a professional librarian from database inception to Summer 2020, 1074 articles were retrieved and independently screened for eligibility by two team members. A total of 228 were reviewed in full text, yielding 13 measures that met pre-defined inclusion criteria: 1) full-text available in English; 2) describes the initial development and validation of a measure, that 3) is intended to be used to evaluate T(V)IC. A related review of vicarious trauma measures yielded two that are predominant in this literature. Among the 13 measures identified, there was significant diversity in what aspects of T(V)IC are assessed, with a clear emphasis on "knowledge" and "safety", and less on "collaboration/choice" and "strengths-based" concepts. The items and measures are roughly split in terms of assessing individual-level knowledge, attitudes and practices, and organizational policies and protocols. Few measures examine structural factors, including racism, misogyny, poverty and other inequities, and their impact on people's lives. We conclude that existing measures do not generally cover the full potential range of the T(V)IC, and that those seeking such a measure would need to adapt and/or combine two or more existing tools.

The role of secondary traumatic stress breakthrough champions in reducing worker trauma and improving organizational health using a configurational analysis approach

Background

Emerging research has demonstrated that organizational efforts at becoming secondary traumatic stress (STS)-informed can improve the overall well-being of the workforce, especially when implementation activity by a champion team is high. Questions remain, however, regarding the mechanisms that enable these improvements.

Method

This study uses configurational analysis to determine necessary and sufficient conditions to produce reductions in STS symptoms in workers as well as organizational improvements toward being more STS-informed in a cohort survey of 6,033 professionals working with individuals exposed to trauma representing 52 organizations. The Secondary Traumatic Stress Informed Organizational Assessment (STSI-OA) was used to measure professional's perceptions of how well the unit addressed secondary trauma in the workplace, and the Secondary Traumatic Stress Scale (STSS) assessed traumatic stress symptoms in respondents. Champions' activity was scored using the categories suggested by Shea.

Results

For the STSS outcome, either a STSI-OA positive increase of 10 or more points or high levels of champion problem-solving were independently sufficient for an improvement in the outcome. The STSI-OA model had two pathways: high levels of peer engagement via the scaling up of innovations using PDSAs or the combination of facilitation of peer knowledge and skills together with working in a child welfare organization. Either pathway was sufficient by itself to yield the STSI-OA outcome.

Conclusions

Identifying and cultivating the champions' use of problem-solving and peer engagement strategies can transform the threat posed by indirect trauma exposure into an opportunity for shared experience and healing.

Plain Language Summary

Organizational champions are individuals or teams that strive to promote change within their workplace. These champions are integral to spreading innovative ideas and strategies and creating organization-wide changes ( Powell et al., 2015). However, little is known about the processes or specific strategies that make champions successful. One area in which champions are needed is in improving organizations' response to and understanding of secondary traumatic stress (STS), among those in helping professions that are indirectly exposed to trauma through the traumatic stories of those they work with. In fact, research has shown that organizational efforts to address STS improve the well-being of individual professionals within that organization ( Sprang et al., 2021). The present study sought to better understand what champion-related processes or conditions led to organizational change in addressing the effects of indirect exposure and improving symptoms related to STS. Results showed that organizational change in addressing STS and champions' problem-solving strategies resulted in reductions in individual professionals' STS symptoms. Furthermore, champions' use of peer engagement or sharing of knowledge among peers in child welfare settings led to improvements at an organizational level. These results show that organization-level change can have a direct impact on individual well-being and there are specific champion activities that can promote this change. Specifically, results demonstrate a need to identify and support champions' use of problem-solving and peer engagement strategies to turn the individual and organizational threat posed by indirect trauma into an opportunity for shared healing.

Does screening or routine enquiry for adverse childhood experiences (ACEs) meet criteria for a screening programme? A rapid evidence summary

BACKGROUND

Adverse childhood experiences (ACEs) are traumatic events in childhood that can have impacts throughout life. It has been suggested that ACEs should be 'screened' for, or routinely enquired about, in childhood or adulthood. The aim of this work is to review evidence for this against the United Kingdom National Screening Committee (UKNSC) programme criteria.

METHODS

A rapid review of evidence on ACEs screening was conducted using the approach of the UKNSC.

RESULTS

Good quality evidence was identified from meta-analyses for associations between ACEs and a wide range of adverse outcomes. There was no consistent evidence on the most suitable screening tool, setting of administration, and time or frequency of use. Routine enquiry among adults was feasible and acceptable to service users and professionals in various settings. A wide range of potentially effective interventions was identified. Limited evidence was available on the potential for screening or routine enquiry to reduce morbidity and mortality or possible harms of screening.

CONCLUSIONS

Based on the application of available evidence to UKNSC screening criteria, there is currently insufficient evidence to recommend the implementation of a screening programme for ACEs. Further research is needed to determine whether routine enquiry can improve morbidity, mortality, health and wellbeing.

Establishing and validating a survey for trauma-informed, culturally responsive change across multiple systems

Aim

The purpose of the present study was to establish and validate the Survey for Trauma-Informed Systems Change (STISC), a measure of culturally responsive trauma-informed care (TIC) and services that can be administered to professionals in any field or industry.

Subject/methods

The current study with 262 respondents from judicial, healthcare, political, non-profit, and for-profit settings examined the internal consistency reliability and factor structure of the STISC.

Results

A total of 262 respondents from various industries accessed the pre-training survey. Seven of the 59 items were reassigned to alternate subscales and three subscales were merged following correlation analysis. Internal consistency reliability for subscales based on the final item assignments was good or excellent (lower 95% confidence limits for hierarchical omega ≥ 0.85). The root mean square error of approximation estimate for the confirmatory factor analysis based on final item assignments was acceptable (0.073; 90% CI 0.71, 0.76). Neither the comparative fit index value of 0.76 nor the Tucker–Lewis fit index value of 0.75 approached conventional thresholds for acceptable fit.

Conclusion

Given the absence of a validated alternative, this study supports use of the STISC tool to measure the degree of an individual’s trauma-informed knowledge and positive attitudes toward trauma-informed systems change, as well as trauma-informed practices in the workplace. Further study and refinement will aim to determine whether the STISC survey is sensitive to change, which will provide stronger support for the survey’s potential usefulness as a cost-effective method of standardizing trauma-informed systems change programs across multiple fields and industries.

Benchmarking Trauma in Child Welfare: A Brief Report

Trauma exposure is common; however, considerably higher rates are reported in some vulnerable groups including adults and children involved in child welfare systems. In this context, early screening and service linkage may ameliorate its negative impact on the physical and mental well-being of adults and children alike. Using data from two Ohio-based child welfare interventions targeting co-occurring maltreatment and substance use (Ohio START¹ and EPIC2), the purpose of this brief report was to first describe the rate of trauma exposure among participating adults (Adverse Childhood Experiences or ACEs, N = 402), children 0-5 years (CTAC, N = 271) and youth 6-18 years (CTAC, N = 177), and second to benchmark observed rates against reported rates in other child welfare or similar populations across the United States. Results show that adults were exposed to 4.2 ACEs on average, a 24% increase over previous child welfare estimates. While mean CTAC scores were not significantly different among young children ages 0-5, older children reported on average 5.6 exposures which is 27% higher than previously reported estimates. Our findings highlight the difference in risk profiles between families involved child welfare due primarily to substance misuse and those without substance misuse concerns, or where substance misuse was not the primary cause of entry. We discuss implications for service provision and time-sensitive child welfare requirements.

Understanding the Conceptualization and Operationalization of Trauma-Informed Care Within and Across Systems: A Critical Interpretive Synthesis

Policy Points In order to achieve successful operationalization of trauma-informed care (TIC), TIC policies must include conceptual clarity regarding the definition of both trauma and TIC. Furthermore, TIC requires clear and cohesive policies that address operational factors such as clearly delineated roles of service providers, protocol for positive trauma screens, necessary financial infrastructure, and mechanisms of intersectoral collaboration. Additionally, policy procedures need to be considered for how TIC is provided at the program and service level as well as what TIC means at the organizational, system, and intersectoral level.

CONTEXT

Increased recognition of the epidemiology of trauma and its impact on individuals within and across human service delivery systems has contributed to the development of trauma-informed care (TIC). How TIC can be conceptualized and implemented, however, remains unclear. This study seeks to review and analyze the TIC literature from within and across systems of care and to generate a conceptual framework regarding TIC.

METHODS

Our study followed a critical interpretive synthesis methodology. We searched multiple databases (Campbell Collaboration, Econlit, Health Systems Evidence, Embase, ERIC, HealthSTAR, IPSA, JSTOR, Medline, PsychINFO, Social Sciences Abstracts, Sociological Abstracts and Web of Science),as well as relevant gray literature and information-rich websites. We used a coding tool, adapted to the TIC literature, for data extraction.

FINDINGS

Electronic database searches yielded 2,439 results and after inclusion/exclusion criteria were applied, a purposive sample of 98 information-rich articles was generated. Conceptual clarity and definitional understanding of TIC is lacking in the literature, which has led to poor operationalization of TIC. Additionally, infrastructural and ideological barriers, such as insufficient funding and service provider "buy-in," have hindered TIC implementation. The resulting conceptual framework defines trauma and depicts critical elements of vertical TIC, including the bidirectional relationship between the trauma-affected individual and the system, and horizontal TIC, which requires intersectoral collaboration, an established referral network, and standardized TIC language.

CONCLUSIONS

Successful operationalization of TIC requires policies that address current gaps in systems arrangements, such as the lack of funding structures for TIC, and political factors, such as the role of policy legacies. The emergent conceptual framework acknowledges critical factors affecting operationalization.

Leveraging Leadership in Child Welfare Systems: Large-scale Trauma- and Resilience-informed Training Initiative

Strengthening the infrastructure of public health systems around trauma-informed principles is crucial to addressing the needs of traumatized children in the child welfare system. In fact, many local and state initiatives have focused on large-scale evaluation studies to determine the value of training direct service staff on trauma foundations. Less yet is known about the benefits of training leaders on trauma foundations, which is crucial given their unique influence on implementation decisions. The current study evaluates a trauma training delivered to leadership-level stakeholders through a large-scale training initiative for the Los Angeles County Department of Children and Family Services. Findings indicated that leaders improved in trauma knowledge from baseline to post-training and reported changes in their professional wellbeing and leadership approach after the reflective training component. The leadership trauma program may have positive downstream implications for direct service staff, organizational culture, and child and family outcomes.

Understanding key implementation determinants for a school-based universal prevention intervention: a qualitative study

This study examined how teachers discuss various factors as impacting their ability to execute with fidelity the Michigan Model for Health (MMH), an evidence-based health universal prevention curriculum widely adopted throughout Michigan. Researchers have found a robust relationship between fidelity and participant outcomes, including in schools. While previous studies have identified barriers that inhibit fidelity, few have focused on identifying key barriers and deepening our understanding of how these factors influence intervention fidelity. We conducted a thematic analysis using the reflexive thematic approach to identify key barriers and facilitators and deepen our understanding of how these factors influence MMH implementation. Guided by the Consolidated Framework for Implementation Research (CFIR) and the Implementation Outcomes Framework, we conducted semistructured interviews with 23 high school health teachers across Michigan. Teachers identified intervention characteristics (e.g., design quality, packaging, and program adaptability), student needs (e.g., trauma exposure, substances), and the fit between the intervention and the context as factors that contributed to acceptability. They also discussed the curriculum and its alignment with their teaching style and/or experiences as contributing to fidelity. Teachers shared how they would often go "off protocol" to improve intervention-context fit and meet students' needs. Our results identified acceptability, a perceptual implementation outcome, as demonstrating an important role in shaping the relationship between CFIR factors and fidelity. Results provide guidance for systematically designing implementation strategies that address key barriers to improve acceptability, enhance fidelity, and ultimately achieve desired public health objectives.

Trauma-informed care for children involved with the child welfare system: A meta-analysis

BACKGROUND

There has been a burgeoning development of trauma-informed care (TIC) interventions for children involved with the child welfare system. A quantitative synthesis of these interventions' effects on child wellbeing is warranted for the advancement of evidence-based practices.

OBJECTIVES

We conducted a systematic review and meta-analysis to estimate TIC interventions' pooled effect on the wellbeing of children involved with the child welfare system, while examining factors that may moderate the effect.

METHODS

The search and review yielded 15 eligible studies. We first estimated the interventions' pooled effect based on a compound child wellbeing indicator, and then on three specific child wellbeing indicators: posttraumatic stress disorder (PTSD) symptom reduction, behavioral problem reduction, and other psychological wellbeing improvement. We further conducted subgroup meta-analyses to evaluate factors that may moderate the effect.

RESULTS

TIC interventions had a moderate effect as shown through the compound child wellbeing indicator (SMD = 0.47, 95% CI = [0.27, 0.67]) as well as the three specific indicators (SMD = 0.37 to 0.52, 95% CI = [0.02, 0.88]). Subgroup meta-analyses indicated that the intervention effects varied but generally remained at a moderate level across study and intervention characteristics.

CONCLUSIONS

The findings suggest that TIC interventions for children involved with the child welfare system are promising, but the effect may vary by intervention strategies and other factors. Implications for practices and research are discussed.

Understanding trauma experiences and needs through a comprehensive assessment of transition age youth in child welfare

BACKGROUND

In the context of child welfare, Transition Age Youth (TAY) have high rates of trauma experiences (TEs) and are more likely to exhibit negative outcomes as they transition into adulthood.

OBJECTIVE

This study describes the frequency and distribution of TEs among TAY in child welfare, as a whole and across sex and race/ethnicity. This study also examines the relationship between TEs and Child and Adolescent Needs and Strengths (CANS) needs.

PARTICIPANTS AND SETTING

Participants included 3324 TAY (14.5 to 21-year-olds) who were under the care of the Illinois Department of Child and Family Services (IDCFS) and in out-of-home care for at least one year.

METHODS

The CANS was the primary measure for this study. Administrative and clinical data were examined for youth who met the identified criteria. Pearson's chi-square tests of association were conducted to determine differences in TEs across race/ethnicity and sex. Negative binomial regressions were used to determine the association between TEs and needs.

RESULTS

Most TAY had at least one TE (91%) and the majority had four or more TEs (52%). Significant differences occurred in relation to sex and race/ethnicity. Furthermore, TEs were significantly associated with needs across all CANS domains examined (e.g., behavioral/emotional needs, life domain functioning).

CONCLUSIONS

This is one of the few empirical studies to examine TEs and related functional, behavioral, and emotional needs of TAY in child welfare. Overall, findings suggest a need for improving trauma-informed approaches and interventions that serve TAY.

Maternal-Child Health Outcomes from Pre- to Post-Implementation of a Trauma-Informed Care Initiative in the Prenatal Care Setting: A Retrospective Study

Background: There has been an increase in use of trauma-informed care (TIC) approaches, which can include screening for maternal Adverse Childhood Experiences (ACEs) during prenatal care. However, there is a paucity of research showing that TIC approaches are associated with improvements in maternal or offspring health outcomes. Using retrospective file review, the current study evaluated whether differences in pregnancy health and infant birth outcomes were observed from before to after the implementation of a TIC approach in a low-risk maternity clinic, serving women of low medical risk. Methods: Demographic and health data were extracted from the medical records of 601 women (n = 338 TIC care, n = 263 pre-TIC initiative) who received prenatal care at a low-risk maternity clinic. Cumulative risk scores for maternal pregnancy health and infant birth outcomes were completed by health professionals. Results: Using independent chi-squared tests, the proportion of women without pregnancy health risks did not differ for women from before to after the implementation of TIC, χ2 (2, 601) = 3.75, p = 0.15. Infants of mothers who received TIC were less likely to have a health risk at birth, χ2 (2, 519) = 6.17, p = 0.046. Conclusion: A TIC approach conveyed modest benefits for infant outcomes, but not maternal health in pregnancy. Future research examining other potential benefits of TIC approaches are needed including among women of high socio-demographic and medical risk.

Trauma Symptoms and Relationship With Child and Family Team Meeting Characteristics and Outcomes in a Statewide System of Care

Systems of care (SOCs) are comprehensive, community-based services for youth with emotional and behavioral disorders. For these youth, little is known about how trauma symptoms influence participation in SOC care coordination through the Child and Family Team (CFT) meeting. The current study assessed the extent to which exposure to potentially traumatic events (PTEs) and trauma symptoms were associated with participation in CFTs and youth and family outcomes. Participants were 464 youth (M _age = 11.02, SD = 3.72) and their caregivers. Families completed measures of youth and caregiver functioning, PTEs, and trauma symptoms at enrollment and 6-month follow-up. Care coordinators completed surveys assessing CFT characteristics following each meeting and assessments of youth functioning. Moderated multiple regression analyses tested the conditional effects of youth trauma symptoms on the relationships between CFT characteristics and youth and caregiver outcomes. Trauma symptoms moderated the relationship between the number of days to the first CFT meeting and youth impairment and the relationship between CFT meeting duration and youth impairment. Results suggest the presence of trauma and other contextual factors contributed to difficulty in initiating services and to changes in youth impairment. Implications for the provision of trauma-informed SOC services are discussed.

Trauma-informed care as a rights-based "standard of care": A critical review

BACKGROUND

A growing body of literature on the concept of trauma-informed care (TIC) has emerged in response to greater recognition of the prevalence of childhood trauma. Currently, no review has examined the conceptualization of TIC in various child-serving systems, specifically TIC as a standard of care, the outcomes examined relevant to care, and whether child rights are part of the TIC discourse.

METHOD

A systematic search of 12 health and non-health databases, reviewed for relevance to children and youth specifically, was conducted to form a critical review of the literature.

RESULTS

Forty-nine documents were selected, which included articles from child welfare (n = 16), education (n = 15), juvenile justice (n = 8), health (n = 7), and multiple sectors (n = 3). A common theme across all sectors was a lack of clear understanding regarding what is TIC and how to implement it. While trauma symptoms are seemingly a good-fit outcome and reflective of a right to rehabilitative health, validated assessment tools were not commonly used. Few studies explicitly included a child rights perspective within TIC.

CONCLUSION

Emerging evidence encourages systematic inquiry into the operationalization of TIC to better assess whether it is an established model with consistent measurement. Empirical studies need to embrace established intervention methodology (e.g., improvement from baseline, control groups). From this expanded rigor, the issue as to whether TIC can evolve to a rights-based standard of care can be addressed.

Educational Practices for Providers of Trauma-Informed Care: A Scoping Review

BACKGROUND

As more is learned about trauma and the ways in which trauma informed care (TIC) is provided, it is important to explore the education and training offered to those individuals who provide TIC.

PURPOSE

This scoping review examined training provided to individuals who interact with persons aged birth to 21 years old who have experienced or are experiencing trauma.

METHOD

The researchers searched six databases and identified 16 peer-reviewed articles in the areas of medicine/nursing, social work, and education published from 2012 to 2019 that met inclusion criteria.

DISCUSSION

Although most training protocols had a similar foundation, the findings from this review suggested that trauma informed care training practices vary across disciplines.

CONCLUSIONS

As training approaches varied greatly across disciplines, a conclusion on best practice guidelines cannot be stated for the professional environments.

Sustainment of Trauma-Focused and Evidence-Based Practices Following Learning Collaborative Implementation

Given the need to develop and validate effective implementation models that lead to sustainable improvements, we prospectively examined changes in attitudes, behaviors, and perceived organizational support during and after statewide Community-Based Learning Collaboratives (CBLCs) promoting trauma-focused evidence-based practices (EBPs). Participants (N = 857; i.e., 492 clinicians, 218 brokers, and 139 senior leaders) from 10 CBLCs completed surveys pre- and post-CBLC; a subsample (n = 146) completed a follow-up survey approximately two years post-CBLC. Results indicated (a) medium, sustained increases in clinician-reported use of trauma-focused EBPs, (b) medium to large, sustained increases in perceived organizational support for trauma-focused EBPs, and (c) trivial to small, sustained increases in perceived organizational support for EBPs broadly. In contrast, clinician-reported overall attitudes towards EBPs decreased to a trivial degree pre- to post-CBLC, but then increased to a small, statistically significant degree from post-CBLC to follow-up. Notably, the degree of perceived improvements in organizational support for general and trauma-focused EBPs varied by professional role. Findings suggest the CBLC implementation strategies may both increase and sustain provider practices and organizational support towards EBPs, particularly those EBPs a CBLC explicitly targets.

Care-experienced cHildren and young people's Interventions to improve Mental health and wEll-being outcomes: Systematic review (CHIMES) protocol

INTRODUCTION

The mental health and well-being of children and young people who have been in care (ie, care-experienced) are a priority. There are a range of interventions aimed at addressing these outcomes, but the international evidence-base remains ambiguous. There is a paucity of methodologically robust systematic reviews of intervention effectiveness, with few considering the contextual conditions under which evaluations were conducted. This is important in understanding the potential transferability of the evidence-base across contexts. The present systematic review will adopt a complex systems perspective to synthesise evidence reporting evaluations of mental health and well-being interventions for care-experienced children and young people. It will address impact, equity, cost-effectiveness, context, implementation and acceptability. Stakeholder consultation will prioritise a programme theory, and associated intervention, that may progress to further development and evaluation in the UK.

METHODS AND ANALYSIS

We will search 16 bibliographic databases from 1990 to June 2020. Supplementary searching will include citation tracking, author recommendation, and identification of evidence clusters relevant to included evaluations. The eligible population is children and young people (aged ≤25 years) with experience of being in care. Outcomes are (1) mental, behavioural or neurodevelopmental disorders; (2) subjective well-being; (3) self-harm; suicidal ideation; suicide. Study quality will be appraised with methodologically appropriate tools. We will construct a taxonomy of programme theories and intervention types. Thematic synthesis will be used for qualitative data reporting context, implementation and acceptability. If appropriate, meta-analysis will be conducted with outcome and economic data. Convergent synthesis will be used to integrate syntheses of qualitative and quantitative data.

ETHICS AND DISSEMINATION

We have a comprehensive strategy for engagement with care-experienced children and young people, carers and social care professionals. Dissemination will include academic and non-academic publications and conference presentations. Ethical approval from Cardiff University's School of Social Sciences REC will be obtained if necessary.

PROSPERO REGISTRATION NUMBER

CRD42020177478.

Systematic Review of Evaluations of Trauma-Informed Organizational Interventions That Include Staff Trainings

Enthusiasm for trauma-informed practice has increased dramatically. Organizational interventions that train staff about trauma-informed practice are frequently used to promote trauma-informed systems change, but evidence about these interventions' effects has not been integrated. A systematic review was conducted of studies that evaluated the effects of organizational interventions that included a "trauma-informed" staff training component. A search was conducted in July 2017 and studies were identified in PubMed, PsycINFO, and the Published International Literature on Traumatic Stress database, limited to articles published in English after 2000. Six hundred and thirty-two articles were screened and 23 met inclusion criteria. Seventeen studies used a single group pretest/posttest design, five used a randomized controlled design, and one used a quasi-experimental design with a nonrandomized control group. The duration of trauma-informed trainings ranged from 1 hr to multiple days. Staff knowledge, attitudes, and behaviors related to trauma-informed practice improved significantly pre-/posttraining in 12 studies and 7 studies found that these improvements were retained at ≥1month follow-up. Eight studies assessed the effects of a trauma-informed organizational intervention on client outcomes, five of which found statistically significantly improvements. The strength of evidence about trauma-informed organization intervention effects is limited by an abundance of single group, pretest/posttest designs with short follow-up periods, unsophisticated analytic approaches, and inconsistent use of assessment instruments. In addition to addressing these methodological limitations, priorities for future research include understanding intervention effects on clients' perceptions of care and the mechanisms through which changes in staff knowledge and attitudes about trauma-informed practice influence client outcomes.

Transformational Leadership and Turnover Intention in Child Welfare: A Serial Mediation Model

PURPOSE

This study examined a serial mediation model testing the effects of STS on turnover intention through executive leaders' use of transformational leadership as perceived by child welfare workers and then organizational commitment while controlling for age, gender, and social work degrees.

METHOD

Survey data were collected from 264 child welfare workers at one Midwestern state.

RESULTS

The results supported the serial mediation model, corroborated by the finding that the impact of STS on turnover intention has disappeared as a result of transformational leadership and organizational commitment between the two variables.

DISCUSSION

The findings of the study provide practical implications for training transformational leadership styles to leaders training at the middle manager and executive leadership levels in child welfare agencies.

Effect of trauma-informed care on hair cortisol concentration in youth welfare staff and client physical aggression towards staff: results of a longitudinal study

BACKGROUND

Professional caregivers working in child and youth welfare institutions are frequently faced with the complex mental health issues, emotional needs and challenging coping strategies of clients with cumulated traumatic experiences, leaving them prone to developing high levels of stress, burn-out and compassion fatigue. Trauma-informed care (TIC) is a milieu-therapeutic approach that aims to promote the self-efficacy and self-care of youth welfare staff by guiding them to a better understanding of their own and their clients' stress symptoms and countertransference. Despite increasing efforts to implement TIC practices, and more widespread recognition of their value in youth welfare systems, there is a lack of studies evaluating the effectiveness of this approach. The aim of this study was to assess the effects of TIC practices in youth welfare institutions on both the physiological stress of staff members and clients' physical aggression towards their caregivers. .

METHODS

Data was obtained from a longitudinal study investigating the effectiveness of TIC in 14 residential youth welfare institutions. Our sample consisted of 47 youth welfare employees (66.0% female) aged from 23 to 60 years (M = 37.4, SD = 10.4 years). Hair cortisol concentration (HCC) and occurrences of client physical aggression were assessed at four annual measurement time points (T1 to T4).

RESULTS

Participants in five institutions employing TIC practices (intervention group) showed significantly lower HCC at T4 than staff members from institutions who did not receive training in TIC (control group), indicating reduced physiological stress levels. At T4, the intervention group reported significantly less physical aggression than the control group.

CONCLUSIONS

TIC might be a promising approach for reducing the emotional burden of employees and institutions should invest in training their staff in TIC practices. More research is necessary, to investigate the benefits and efficacy of TIC, both to youths and staff members, and to foster a better understanding of which specific factors may contribute to stress reduction.

Identifying adverse childhood experiences in pediatrics to prevent chronic health conditions

Despite evidence that over 40% of youth in the United States have one or more adverse childhood experiences (ACEs), and that ACEs have cumulative, pernicious effects on lifelong health, few primary care clinicians routinely ask about ACEs. Lack of standardized and accurate clinical assessments for ACEs, combined with no point-of-care biomarkers of the "toxic stress" caused by ACEs, hampers prevention of the health consequences of ACEs. Thus, there is no consensus regarding how to identify, screen, and track ACEs, and whether early identification of toxic stress can prevent disease. In this review, we aim to clarify why, for whom, when, and how to identify ACEs in pediatric clinical care. To do so, we examine the evidence for such identification; describe the efficacy and accuracy of potential screening instruments; discuss current trends in, and potential barriers to, the identification of ACEs and the prevention of downstream effects; and recommend next steps for research, practice, and policy.

Implementing Trauma Screening, Brief Intervention, and Referral to Treatment (T-SBIRT) within Employment Services: A Feasibility Trial

Research suggests that low-income adults accessing employment services have experienced high levels of trauma exposure and associated consequences. Moreover, the health-related effects of trauma undermine employment and employability. A trauma-informed protocol-trauma screening, brief intervention, and referral to treatment or T-SBIRT-was therefore implemented within employment service programs serving low-income urban residents. To assess the feasibility of integrating T-SBIRT within employment services, five domains were explored as follows: suitability, acceptability, client adherence, provider adherence or fidelity, and intended outcomes. With a sample of low-income adults (N = 83), the study revealed that T-SBIRT is suitable for employment service participants given high rates of trauma exposure (90.4% experienced two or more lifetime traumas), along with high rates of positive screening results for post-traumatic stress disorder (48.8%), major depression (35.4%), and generalized anxiety (47.6%). Study participants appeared to find T-SBIRT acceptable as evidenced by an 83% acceptance rate. All participants accepting T-SBIRT services completed them, revealing strong client adherence. Provider adherence or model fidelity was high, that is, 98.5%. Finally, the majority of participants accepted a referral to a mental health care (i.e., 56.6%), and over three-quarters accepted a referral to any outside service including primary or mental health care. Implications of findings are discussed.

Trauma-Informed Programs Based in Schools: Linking Concepts to Practices and Assessing the Evidence

When children experience stress and adversity in their homes and communities, schools become a critically important setting in which to intervene and foster their resilience. Changing practices within schools so that vulnerable and traumatized children are better understood and more compassionately served is a goal shared by many school professionals, yet schools remain poorly equipped to address the needs of these children. Any number of school-based programs have the potential to benefit children with an elevated risk for academic difficulties and mental health disorders, although questions remain as to which programs are most promising, effective, and sustainable. Questions also remain about which programs best serve diverse populations and which have potential to reach the largest number of children, including those who do not outwardly manifest behaviors consistent with an underlying disorder but nonetheless require support. In this review, we take stock of existing programs used in schools to address the social, emotional, and academic needs of children with trauma histories. We summarize components of a various trauma-focused programs, categorized as: (a) individual and group-based approaches, (b) classroom-based approaches, and (c) school-wide approaches. For each category, we review and comment on the state and quality of research findings and provide illustrative examples from the literature to show how programs address trauma in the school context. Findings of the review suggest that empirical evidence currently favors individual and group-based approaches, although classroom-based and school-wide programs may be better positioned for integration, access to services, and sustainability. Implications and recommendations center on future research, practice, and policy.

Enhancing Capacity for Trauma-informed Care in Child Welfare: Impact of a Statewide Systems Change Initiative

Youth involved in the child welfare system (CWS) are disproportionally impacted by the negative effects of exposure to trauma. While efforts to develop trauma-informed CWSs are accelerating, little research is available about the effects of these efforts on system capacity to respond to the needs of youth exposed to trauma. No studies evaluate longer-term effects of these efforts. In 2011, Connecticut implemented CONCEPT, a multi-year initiative to enhance capacity of the state's CWS to provide trauma-informed care. CONCEPT used a multi-component approach including workforce development, deployment of trauma screening procedures, policy change, improved access to evidence-based trauma-focused treatments, and focused evaluation of program effects. Changes in system capacity to deliver trauma-informed care were assessed using statewide stratified random samples of child welfare staff at three time points (Year 1: N = 223, Year 3: N = 231, Year 5: N = 188). Significant improvements across nearly all child welfare domains were observed during the first 3 years of implementation, demonstrating system-wide improvements in capacity to provide trauma-informed care. These gains were maintained through the final year of implementation, with continued improvements in ratings of collaboration between child welfare and behavioral health settings on trauma-related issues observed. Responses documented familiarity with and involvement in many of the CONCEPT activities and initiatives. Staff reported greater familiarity with efforts to increase access to specific evidence-based services (e.g., TF-CBT) or to enhance trauma-related policy and practice guidelines, but less familiarity with efforts to implement new practices (e.g., trauma screening) in various sectors. Staff also reflected on the contribution of these components to enhance system capacity for trauma-informed care.

Population Health and Trauma-Informed Practice: Implications for Programs, Systems, and Policies

Population studies indicate that trauma exposure is ubiquitous and has a significant impact on health. Trauma-informed practice seeks to address the health consequences of trauma through integrative responses that incorporate an understanding of the effects of trauma, the multiple pathways to recovery, and the potential for re-traumatization. Current trauma-informed practice considers trauma exposure an individual clinical problem rather than a societal problem with population health consequences. Population health refers to the aggregated health status of individuals who share some characteristic, such as trauma exposure, and includes the study of determinants that shape the distribution of health outcomes in specific populations. In this paper, we describe a population health perspective for trauma-informed practice that complements the current clinical perspective, and then discuss implications of that perspective for programs, systems, and policies. We summarize essential concepts about trauma over the life course and describe principles of population health science relevant to trauma-informed practice. We then discuss implications of these principles by identifying four priorities for trauma-informed practice from a population health perspective: (a) adopting trauma-informed policies to prevent trauma exposure and to foster resilience in the aftermath of trauma; (b) infusing trauma-informed practice into everyday activities so it is a routine part of interpersonal transactions; (c) incorporating trauma-informed practices into existing service systems; and (d) adapting existing treatments to incorporate trauma-informed principles for population health impact.

Elucidating the influence of supervisors' roles on implementation climate

Background

Supervisors play an essential role in implementation by diffusing and synthesizing information, selling implementation, and translating top management’s project plans to frontline workers. Theory and emerging evidence suggest that through these roles, supervisors shape implementation climate—i.e., the degree to which innovations are expected, supported, and rewarded. However, it is unclear exactly how supervisors carry out each of these roles in ways that contribute to implementation climate—this represents a gap in the understanding of the causal mechanisms that link supervisors’ behavior with implementation climate. This study examined how supervisors’ performance of each of these roles influences three core implementation climate domains (expectations, supports, and rewards).

Materials and methods

A sequenced behavioral health screening, assessment, and referral intervention was implemented within a county-based child welfare agency. We conducted 6 focus groups with supervisors and frontline workers from implementing work units 6 months post-implementation (n = 51) and 1 year later (n = 40) (12 groups total). Participants were asked about implementation determinants, including supervision and implementation context. We audio-recorded, transcribed, and analyzed focus groups using an open coding process during which the importance of the supervisors’ roles emerged as a major theme. We further analyzed this code using concepts and definitions related to middle managers’ roles and implementation climate.

Results

In this work setting, supervisors (1) diffused information about the intervention proactively, and in response to workers’ questions, (2) synthesized information by tailoring it to workers’ individual needs, (3) translated top managements’ project plans into day-to-day tasks through close monitoring and reminders, and (4) justified implementation. All four of these roles appeared to shape the implementation climate by conveying strong expectations for implementation. Three roles (diffusing, synthesizing, and mediating) influenced climate by supporting workers during implementation. Only one role (diffusing) influenced climate by conveying rewards.

Conclusions

Supervisors shaped implementation climate by carrying out four roles (diffusing, synthesizing, mediating, and selling). Findings suggest that the interaction of these roles convey expectations and support for implementation (two implementation climate domains). Our study advances the causal theory explaining how supervisors’ behavior shapes the implementation climate, which can inform implementation practice.

Trauma Informed Child Welfare Systems-A Rapid Evidence Review

Trauma informed care (TIC) is a whole system organisational change process which emerged from the seminal Adverse Childhood Experiences (ACE) study, establishing a strong graded relationship between the number of childhood adversities experienced and a range of negative outcomes across multiple domains over the life course. To date, there has been no systematic review of organisation-wide implementation initiatives in the child welfare system. As part of a wider cross-system rapid evidence review of the trauma-informed implementation literature using systematic search, screening and review procedures, twenty-one papers reporting on trauma-informed implementation in the child welfare system at state/regional and organisational/agency levels were identified. This paper presents a narrative synthesis of the various implementation strategies and components used across child welfare initiatives, with associated evidence of effectiveness. Training was the TIC implementation component most frequently evaluated with all studies reporting positive impact on staff knowledge, skills and/or confidence. The development of trauma-informed screening processes, and evidence-based treatments/trauma focused services, where evaluated, all produced positive results. Whilst weaknesses in study design often limited generalisability, there was preliminary evidence for the efficacy of trauma-informed approaches in improving the mental and emotional well-being of children served by community-based child welfare services, as well as their potential for reducing caregiver stress and improving placement stability.

Effectiveness of a Trauma-Informed Care Initiative in a State Child Welfare System: A Randomized Study

Trauma-informed care (TIC) initiatives in state child welfare agencies are receiving more attention, but little empirical evidence exists as to their efficacy. The purpose of this study was to assess changes in self-reported practices and perceptions of child welfare staff involved in a multifaceted, statewide TIC intervention. Ten child welfare offices were matched and randomized to an early or delayed cohort. Staff were surveyed at Time 1 prior to any intervention, Time 2 postintervention for Cohort 1, and Time 3 postintervention for Cohort 2. The survey covered six domains: trauma screening, case planning, mental health and family involvement, progress monitoring, collaboration, and perceptions of the state's overall system performance. Linear mixed modeling assessed the effect of the intervention. Cohort by time interaction was significant for three intervention targets. We demonstrate, using a rigorous study design, the mixed results of a multimodal intervention to improve trauma-informed attitudes, practices, and system performance. TIC initiatives must account for complex, dynamic contextual factors.

Effectiveness of capacity building interventions relevant to public health practice: a systematic review

Background

This systematic review assessed the effectiveness of capacity building interventions relevant to public health practice. The aim is to inform and improve capacity building interventions.

Methods

Four strategies were used: 1) electronic database searching; 2) reference lists of included papers; 3) key informant consultation; and 4) grey literature searching. Inclusion (e.g., published in English) and exclusion criteria (e.g., non-English language papers published earlier than 2005) are outlined with included papers focusing on capacity building, learning plans, or professional development plans within public health and related settings, such as non-governmental organizations, government, or community-based organizations relating to public health or healthcare. Outcomes of interest included changes in knowledge, skill or confidence (self-efficacy), changes in practice (application or intent), and perceived support or supportive environments, with outcomes reported at the individual, organizational or systems level(s). Quality assessment of all included papers was completed.

Results

Fourteen papers were included in this review. These papers reported on six intervention types: 1) internet-based instruction, 2) training and workshops, 3) technical assistance, 4) education using self-directed learning, 5) communities of practice, and 6) multi-strategy interventions. The available literature showed improvements in one or more capacity-building outcomes of interest, mainly in terms of individual-level outcomes. The available literature was moderate in quality and showed a range of methodological issues.

Conclusions

There is evidence to inform capacity building programming and how interventions can be selected to optimize impact. Organizations should carefully consider methods for analysis of capacity building interventions offered; specifically, through which mechanisms, to whom, and for which purpose. Capacity-building interventions can enhance knowledge, skill, self-efficacy (including confidence), changes in practice or policies, behaviour change, application, and system-level capacity. However in applying available evidence, organizations should consider the outcomes of highest priority, selecting intervention(s) effective for the outcome(s) of interest. Examples are given for selecting intervention(s) to match priorities and context, knowing effectiveness evidence is only one consideration in decision making. Future evaluations should: extend beyond the individual level, assess outcomes at organizational and systems levels, include objective measures of effect, assess baseline conditions, and evaluate features most critical to the success of interventions.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5591-6) contains supplementary material, which is available to authorized users.

Measuring Costs to Community-Based Agencies for Implementation of an Evidence-Based Practice

Healthcare reform has led to an increase in dissemination of evidence-based practices. Cost is frequently cited as a significant yet rarely studied barrier to dissemination of evidence-based practices and the associated improvements in quality of care. This study describes an approach to measuring the incremental, unreimbursed costs in staff time and direct costs to community-based clinics implementing an evidence-based practice through participating in a learning collaborative. Initial implementation costs exceeding those for providing "treatment as usual" were collected for ten clinics implementing trauma-focused cognitive behavioral therapy through participation in 10-month learning collaboratives. Incremental implementation costs of these ten community-based clinic teams averaged the equivalent of US$89,575 (US$ 2012). The most costly activities were training, supervision, preparation time, and implementation team meetings. Recommendations are made for further research on implementation costs, dissemination of evidence-based practices, and implications for researchers and policy makers.

Barriers and facilitators for access to mental health services by traumatized youth

Polytrauma is a highly prevalent public health problem in the U.S. with even higher rates in urban areas. Children with polytrauma often end up in multiple child-serving systems (e.g., mental health, child welfare, education, juvenile justice) with needs that are both complex and severe. Providers within these child-serving systems have potential to serve as gatekeepers to trauma services by linking youth with trauma-informed treatments and supports that promote recovery. The purpose of our study was to assess the perspective of providers who participated in a nine-month, trauma-informed care (TIC) training intervention on 1) their capacity to make referrals to trauma-specific services following the training, and 2) factors external to the training intervention that supported or hindered their ability to link traumatized youth with services. A subset of sixteen participants from the TIC training completed individual interviews. These participants were predominantly female, African American, and based in the social services sector. The constant comparative method was used to derive three thematic domains related to participant perceptions regarding youth referrals: 1) Organizational and provider capacity to provide trauma treatment or to make referrals to trauma-specific services, 2) Barriers to youth accessing trauma services, and 3) Suggestions for improving coordination of care and referrals. Our study highlights the influence of contextual factors on whether a TIC training can improve the capacity of agencies and individual providers to support traumatized youth in accessing appropriate services. The development of a structure that formally connects youth-serving agencies and providers with specialists trained in addressing traumatized youth is recommended.

Organizational and provider level factors in implementation of trauma-informed care after a city-wide training: an explanatory mixed methods assessment

Background

While there is increasing support for training youth-serving providers in trauma-informed care (TIC) as a means of addressing high prevalence of U.S. childhood trauma, we know little about the effects of TIC training on organizational culture and providers’ professional quality of life. This mixed-methods study evaluated changes in organizational- and provider-level factors following participation in a citywide TIC training.

Methods

Government workers and nonprofit professionals (N = 90) who participated in a nine-month citywide TIC training completed a survey before and after the training to assess organizational culture and professional quality of life. Survey data were analyzed using multiple regression analyses. A subset of participants (n = 16) was interviewed using a semi-structured format, and themes related to organizational and provider factors were identified using qualitative methods.

Results

Analysis of survey data indicated significant improvements in participants’ organizational culture and professional satisfaction at training completion. Participants’ perceptions of their own burnout and secondary traumatic stress also increased. Four themes emerged from analysis of the interview data, including “Implementation of more flexible, less-punitive policies towards clients,” “Adoption of trauma-informed workplace design,” “Heightened awareness of own traumatic stress and need for self-care,” and “Greater sense of camaraderie and empathy for colleagues.”

Conclusion

Use of a mixed-methods approach provided a nuanced understanding of the impact of TIC training and suggested potential benefits of the training on organizational and provider-level factors associated with implementation of trauma-informed policies and practices. Future trainings should explicitly address organizational factors such as safety climate and morale, managerial support, teamwork climate and collaboration, and individual factors including providers’ compassion satisfaction, burnout, and secondary traumatic stress, to better support TIC implementation.

Violence against children in Latin America and Caribbean countries: a comprehensive review of national health sector efforts in prevention and response

Background

Violence against children (VAC) remains a global problem. The health sector has an opportunity and responsibility to be part of the multi-sector collaboration to prevent and respond to VAC. This review aimed to assess the health sector’s response to VAC among Latin American & Caribbean (LAC) countries, particularly as it relates to physical violence, sexual violence, and neglect.

Method

National protocols for the identification and provision of health care to child survivors of violence, abuse and neglect were solicited in partnership with UNICEF and PAHO/WHO country offices within the LAC region. A parallel systematic review was undertaken in January 2015 to review studies published in the last 10 years that describe the regional health sector response to VAC.

Results

We obtained health sectors guidelines/protocols related to VAC from 22 of 43 (51 %) countries and reviewed 97 published articles/reports that met the review inclusion criteria. Country protocols were presented in Spanish (n = 12), Portuguese (n = 1), and English (n = 9). Thematic areas of country protocols included: 1) identifying signs and symptoms of VAC, 2) providing patient-centered care to the victim, and 3) immediate treatment of injuries related to VAC. The systematic review revealed that health professionals are often unaware of national protocols and lack training, resources, and support to respond to cases of VAC. Further, there is limited coordination between health and social protection services.

Conclusions

VAC remains an international, public health priority. Health professionals are well-positioned to identify, treat and refer cases of VAC to appropriate institutions and community-based partners. However, poor protocol dissemination and training, limited infrastructure, and inadequate human resources challenge adherence to VAC guidelines.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3562-3) contains supplementary material, which is available to authorized users.