innovative approach to the application of trauma systems therapy in child welfare. Children and. Youth Services Review, 76, 170–180. 36 Ward-Lasher et al., 2017

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SUMMARY | June 201 9 Review of Trauma – Informed Initiatives at the Systems Level Trauma – Informed Approaches: Connecting Research, Policy, and Practice to Build Resilience in Children and Families Authors Heidi Melz, Colleen Morrison, and Erin Ingoldsby James Bell Associates Karen Cairone and Mary Mackrain Education Development Center Submitted to Kelly Jedd McKenzie, Lindsey Hutchison, and Pamala Trivedi Project Officers Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Servic es Contract Number: HHSP233201500133I Prepared by James Bell Associates 3033 Wilson Boulevard , Suite 650 Arlington, VA 22201 (703) 528 – 3230 www.jbassoc.com Erin Ingoldsby Project Directo r

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Review of Trauma – Informed Initiatives at the Systems Level i Contents Executive Summary .. .. .. .. 1 Introduction .. .. .. 3 Why Take a Systems – Level A pproach? .. .. .. 3 What Type of Information Is Presented? .. .. . 4 Research Question 1. How Are Child – and Family – Serving Systems at the State or Local Level Defining Trauma – Informed Approaches? .. . 6 Research Question 2. What Are the Central Activities and Program Components of a Systems – Level Trauma – Informed Approach? .. .. .. 8 Training .. .. .. .. 8 Trauma Screening .. .. .. 9 Service Improvements .. .. .. . 10 Research Question 3. What Outcomes Are Targeted by These Approaches and What Evidence of Progress Toward These Outcomes Has Been Demonstrated? .. 12 What Outcomes Are Targeted? .. .. .. .. 12 What Evidence of Progress Toward These Outcomes Has Been Demonstrated? . 14 Implications .. .. .. . 18 Gaps in Studies Reviewed .. .. .. 18 Methodological Concerns .. .. .. .. 19 Common Barrier s to Implementing Trauma – Informed Approaches .. .. 20 Conclusion and Future Directions .. .. .. 22 References .. .. .. .. 24 Exhibits Exhibit 1. Service Sec tors Studied .. .. 5

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Review of Trauma – Informed Initiatives at the Systems Level ii Exhibit 2. Assumptions a nd Principles of a Trauma – Informed Approach (SAMHSA Framework) .. .. .. 6 Exhibit 3. Key Activities of a Trauma – Informed Approach (NCTSN Def inition) . 7 Exhibit 4. Sample Topics for Trauma – Focused Trainings .. . 8 Exhibit 5. C apacities That May Support Trauma – Informed Service Systems . 14

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Review of Trauma – Informed Initiatives at the Systems Level 1 Executive Summary The effects of childhood trauma can last well into adulthood. Trauma – informed (TI) approaches provide a framework that applies to all levels of a community or organization for preventing and addressing childhood trauma and building resili ence in children and families. Despite growing efforts to integrate TI approaches into the delivery of services for children and families, there is limited research examining implementation and effectiveness. This research review summarizes current knowled ge of TI initiatives at the systems level a in response to three questions: How are child – and family – serving systems at the state or local level defining TI approaches? What are the central activities and program components of a systems – level TI approach? What outcomes are targeted by these approaches and what evidence of progress toward these outcomes has been demonstrated? Results draw from 33 peer – reviewed studies identified through a robust search and review process. b Key findings of the studies, which evaluate TI efforts spanning nine service sectors, include: There is no broad consensus on what defines a TI approach. However, of the 20 studies that defined TI or described related principles or components, 13 referenced a framework developed by the Sub stance Abuse and Mental Health Services Administration (SAMHSA ) . TI approaches in the reviewed studies typically included program activities in three categories: training, trauma screening, and service improvements. Studies reviewed typically evaluated cha nges in program staff or caregiver knowledge and attitudes, implementation outcomes, and/or changes in staff skills and behaviors. Among studies measuring staff knowledge and attitudes after TI trainings, respondents generally reported high levels of knowl edge of and satisfaction with training content and materials. However, some studies suggest that staff who receive training are still uncomfortable asking children and families about sensitive topics, such as trauma and substance abuse. Attitudes toward an d understanding of trauma – informed care (TIC) generally improved after training. ______ a In this review, systems – level efforts refers to efforts to address the climate and conditions in which direct services are provided through development of organizational capacities such as organizational climate and culture, staff knowledge and skills, engagement and partnership, organizational infrastructure, and resources. b This research review examines current knowledge about TI initiativ es at the systems level (see footnote a ). Though the initiatives included in this review are ultimately intended to improve outcomes for children and/or families impacted by trau ma, the review does not summarize or discuss any child – and family – level outco mes reported in the studies.

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Review of Trauma – Informed Initiatives at the Systems Level 2 Studies examining the use of TI practices and availability and uptake of evidence – based treatments (EBTs) reported mixed results. Some projects could only partially implement their plans, noting challenges in staff and organizational resources, competing issues faced by implementing agencies, and insufficient funding. Many studies acknowledged the importance of organizational capacities to ensure an effective TI service syste m (e.g., readiness, organizational culture, collaboration and/or partnerships, sustainable financing, organizational linkages, leadership, policy supports, interconnected data systems, and/or data sharing), yet few studies actually measured these system co mponents. The studies reviewed suggest how to develop the evidence base for TI approaches at the systems level, support and strengthen current efforts, and conceptualize and plan future efforts. Specifically, there is a need to address: Current gaps in th e research Methodological concerns that can impact efforts to build the evidence base Common barriers to developing TI service systems and implementing TIC

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Review of Trauma – Informed Initiatives at the Systems Level 4 What Type of Information Is Presented? This research review examines current knowledge about TI initiatives at the systems level drawn from published, peer – reviewed studies. In this review, systems – level efforts address the climate and condi tions in which direct services are provided through the development of capacities such as organizational climate and culture, staff knowledge and skills, engagement and partnership, organizational infrastructure, and resources (e.g., staffing, information) . c Though the initiatives included in this review are ultimately intended to improve outcomes for children and/or families impacted by trauma, the review does not summarize or discuss any child – and family – level outcomes reported in the studies. Three rese arch questions guided the review and the presentation of findings: How are child – and family – serving systems at the state or local level defining TI approaches? What are the central activities and program components of a systems – level TI approach? What outcomes are targeted by these approaches and what evidence of progress toward these outcomes has been demonstrated? A search of the research literature produced 1,973 studies (see appendix A for search terms used). To be included i n this review, studies had to meet the following criteria: Be peer reviewed Describe an effort o Specified as a TI initiative or program o Implemented at a systems level (as defined above) o Intended to impact child and family outcomes, even if children and families were not the direct recipient of the strategies Include measurement and evaluation of implementation and/or systems – level outcomes ______ c For a discussion of organizational capacity, see What is organizational capacity and what does it look like in child welfare? Washington, DC: Author. Trau ma – informed care (TIC) refers to services that incorporate an understanding of trauma into all aspects of care and service provision but do not treat trauma symptoms. Trauma – specific interventions are clinical treatments shown to treat trauma symptoms and promote recovery.

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Review of Trauma – Informed Initiatives at the Systems Level 5 Of the 1,973 studies identified through the search, 33 studies met these incl usion criteria and were included in the review. (See appendix A for further details on the search methodology and appendix B for a list of studies reviewed.) the systems level, articles were excluded if they only focused on child and family outcomes and did not include the study of contextual, systems – level changes. For example, a study would not meet the inclusion criteria if it assessed the impacts of a clinical trauma treatmen t on child outcomes but did not include evaluation of changes in agency/organizational factors. The final set of studies reflect TI efforts conducted in and across nine service sectors (see exhibit 1). Findings from the review are organized by each of the three research questions in the following sections, followed by implications. Sectors Number of studies Child welfare 11 Mental health 7 K 12 education 4 Juvenile justice 3 Early care and education 2 Intimate partner violence 2 Medicine 2 Home visiting 1 Substance abuse 1 Exhibit 2. Assumptions and Principles of a Trauma – Informed Approach (SAMHSA Framework) Sectors Number of studies Child welfare 11 Mental health 7 K 12 education 4 Juvenile justice 3 Early care and education 2 Intimate partner violence 2 Medicine 2 Home visiting 1 Substance abuse 1 Exhibit 2. Assumptions and Principles of a Trauma – Informed Approach (SAMHSA Framework) Exhibit 2. Assumptions and Principles of a Trauma – Informed Approach (SAMHSA Framework) Sectors Number of studies Exhibit 1 . Service Sectors Studied Exhibit 1 . Service Sectors Studied Exhibit 1 . Service Sectors Studied Exhibit 1 . Service Sectors Studied Exhibit 1 . Service Sectors Studied Exhibit 1 . Service Sectors Studied Exhibit 1 . Service Sectors Studied Exhibit 1 . Service Sectors Studied

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Review of Trauma – Informed Initiatives at the Systems Level 6 Research Question 1. How Are Child – and Family – Serving Systems at the State or Local Level Defining Trauma – Informed Approaches? There is no broad consensus on what defines a TI approach. While most studies used well – known framewor ks developed by organizations such as SAMHSA or the National Child Traumatic Stress Network (NCTSN), others provided their own definitions or descriptions. Of the 20 studies that defined TI or described related principles or components, 13 referenced elements of a well – known framework developed by SAMHSA (see its own, while others combined it with other definitions, s uch as the one created by NCTSN. 7 NCTSN defines a TI service system according to specific activities rooted in a client – partnerships that create mutuality among children, families, caregivers, and professionals at a n individual race, gender, location, and language, acknowledge the compounding impact of structural inequity, and [be] responsive to the uniqu Exhibit 3 presents more information. Many studies similarly emphasized respect for child and family histories, needs, and goals. For example, a study of a TI approach for home visitors and parent educators 8 stated that TI framework that emphasizes family self – determination, working from a strengths – based perspective, and the importance of engagement and rapport. . . Trauma Assumptions A TI program, organization, or system: Realize s the widespread impact of trauma and understands potential paths for recovery Recognize s the signs and symptoms of trauma in clients, families, staff, and others involved with the system Respond s by fully integrating knowledge about trauma into policies, procedures, and practices Seeks to actively resist re traumatization Key Principles Safety Trustworthiness and transparency Peer support Collaboration and mutuality Empowerment, voice, and choice Cultural, historical, and gender issues Exhibit 3. Key Ac tivities of a Trauma – Informed Approach (NCTSN Definition) Assumptions Exhibit 2. Assumptions and Principles of a T rauma – Informed Approach (SAMHSA Framework) Exhibit 2. Assumptions and Principles of a Trauma – Informed Approach (SAMHSA Framework) Exhibit 2. Assumptions and Principles of a Trauma – Informed Approach (SAMHSA Framework) Exhibit 2. Assumptions and Princip les of a Trauma – Informed Approach (SAMHSA Framework) Exhibit 2. Assumptions and Principles of a Trauma – Informed Approach (SAMHSA Framework) Exhibit 2. Assumptions and Principles of a Trauma – Informed Approach (SAMHSA Framework) Exhibit 2. Assumptions and Principles of a Trauma – Informed Approach

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Review of Trauma – Informed Initiatives at the Systems Level 7 informed care is about shifting the conversation from ‘what’s Studies also emphasized the need for staff at all levels to understand trauma. Study authors – 9 10 grat(es) knowledge about trauma into policies, procedures, and practices. 11 histories or secondary traumatic stress, d despite acknowledgment by both SAMHSA and NCTSN o f their importance. However, some efforts did seek to provide staff with information on secondary trauma and self – care. 12 , 13 , 14 , 15 Healthy Environments and Response to Trauma in Schools Program promoted staff wellness through onsite mental health consultation that focused on understanding and addressing burnout and secondary trauma in school staff via self – care and organizational strategies. 16 ______ d Secondary traumatic stress refers to physiological symptoms that resemble posttraumatic stress reactions, typically experienced by social workers, police officers, emergency workers, therapists, and others who work directly with trauma – affected individuals . For more information, see Bell, H., Kulkarni, S., & Dalton, L. (2003). Organizational prevention of vicarious trauma. Families in Society: The Journal of Contemporary Social Services , 84 (4), 463 470. Exhi bit 3. Key Activities of a Trauma – Informed Approach (NCTSN Definition) Exhibit 3. Key Activities of a Trauma – Informed Approach (NCTSN Definition) Exhibit 3. Key Activities of a Trauma – Informed Approach (NCTSN Definition) Exhibit 3. Key Activities of a T rauma – Informed Approach (NCTSN Definition) Exhibit 3. Key Activities of a Trauma – Informed Approach (NCTSN Definition) Exhibit 3. Key Activities of a Trauma – Informed Approach (NCTSN Definition) Exhibit 3. Key Activities of a Trauma – Informed Approach (NCTSN Definition) Exhibit 3. Key Activities of a Trauma – Informed Approach (NCTSN Definition) Routinely screens for trauma exposure and related symptoms Uses evidence – based, culturally responsive assessment and treatment for traumatic stress and associated mental health symptoms Makes resources available to children, families, and providers on trauma exposure, its impact, and treatment Engages in efforts to strengthen the resilience and protective factors of children and families affected by and vulnerable to trauma Addresses parent and caregiver trauma and its impact on the family system Emphasizes continuity of care and collaboration across child service systems Maintains an environment of care f or staff that addresses, minimizes, and treats secondary traumatic stress and increases staff wellness Exhibit 4. Sample Topics for Trauma – Focused Trainings Routinely screens for trauma exposure and related symptoms Uses evidence – based, culturally respon sive assessment and treatment for traumatic stress and associated mental health symptoms Makes resources available to children, families, and providers on trauma exposure, its impact, and treatment Engages in efforts to strengthen the resilience and protec tive factors of children and families affected by and vulnerable to trauma Addresses parent and caregiver trauma and its impact on the family system Emphasizes continuity of care and collaboration across child service systems Maintains an environment of care for staff that addresses, minimizes, and treats secondary traumatic stress and increases staff wellness Routinely screens for trauma exposure and related symptoms Uses evidence – based, culturally responsive assessment and treatment for traumatic str ess and associated mental health symptoms Makes resources available to children, families, and providers on trauma exposure, its impact, and treatment Engages in efforts to strengthen the resilience and protective factors of children and families affected by and vulnerable to trauma Addresses parent and caregiver trauma and its impact on the family system

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