Evidence Review: Developing Trauma Informed Practice in Northern Ireland
Deanne Mitchell, information specialist, the Social Care Institute for Excellence (SCIE)
Monday, September 23, 2019
This large evidence review carried out for the Northern Ireland government looked at the evidence in relation to trauma-informed practice in public services.
Author Lisa Bunting et al.
Publisher Queens University Belfast, (2018)
For the purposes of this summary, only the findings related to child welfare services are reported.
The review included peer-reviewed literature, focused on trauma-informed care in child welfare systems, ranging from state-wide initiatives targeting multiple system levels, to small programmes aimed primarily at workforce development and staff training.
This review identified eight state-wide initiatives to implement trauma-informed care in child welfare systems in the United States. One of the most comprehensive and extensively evaluated of these was the Massachusetts Child Trauma Project (MCTP), a five-year state-wide systems improvement initiative funded in 2011 by the Children's Bureau and US Department of Health and Human Services.
The MCTP used a Breakthrough Series Collaborative method and Intensive Learning Community workforce development training design. This was used to enhance the capacity of child welfare workers and child mental health providers to identify, respond, and intervene early and effectively with children traumatised by chronic loss, abuse, neglect and violence. The MCTP evaluation studies, taken together, provide promising results with regards to system-wide implementation of trauma-informed approaches.
When it comes to screening, most of the initiatives reviewed involved state-wide implementation of trauma screening for children within the child welfare system in the US. Although there were wide variations in the number of children screened, screening generally resulted in identification of high rates of trauma exposure and was generally perceived favourably by child welfare workers and mental health professionals. However, the extent to which this may have led to improved assessment and treatment, or improved child outcomes, still remains to be evaluated.
One study, the Connecticut Collaborative on Effective Practices for Trauma (CONCEPT) state-wide implementation strategy, identified the core components of successful implementation, this entailed:
- Creation of a core team and subcommittee to guide trauma-informed systems change
- Development of a cohort of 40 "trauma champions" who organised in-service training about trauma every month
- State-wide mandatory preservice and in-service trauma training for child welfare staff
- Creation of worker wellness (self-care) teams and quarterly training in self-care
- Revision of agency policies for alignment with trauma-informed practice
- Training in trauma-focused cognitive behavioural therapy.
Some models place an emphasis on a grassroot partnership approach - for example, the Michigan Children's Trauma Assessment Center provided training to community members that fostered interest and encouraged some to become champions.
Core elements for a trauma-informed child welfare system were identified in Henry et al. (2011) as:
- The development of champions
- Screening and identification of trauma in children
- The comprehensive assessment of the impact of trauma
- The development of a cadre of community therapists (public and private) for provision of evidence-based trauma treatment
- The establishment of common trauma-informed language and trauma-informed decision making.
When it comes to UK initiatives, the best evidence came from a review by McGee et al in 2015 of the implementation of Routine Enquiry About Childhood Adversity (REACh) at Blackburn with Darwen Borough Council. The initiative was broader than child welfare and included children and family health services as well as a range of community organisations. However, the training programme aimed to increase health professionals' and practitioners' knowledge about the potential consequences of childhood adversity as well as increase their confidence in routinely asking and responding to disclosures.
Evaluation of the implementation pack pilot by Quigg et al last year indicated that there were significant issues in embedding routine inquiry; and the child and adolescent mental health service decided that it would not be implemented.
When it comes to the implementation of trauma-informed frameworks and models in residential care and / or residential treatment, a moderate amount of evidence was identified. This includes two recent systematic reviews which looked at effective strategies for implementing trauma-informed care in youth inpatient psychiatric and residential treatment settings (Bryson et al., 2017); and organisation-wide, trauma-informed care models in out-of-home care settings (Bailey et al., 2018), as discussed in study one.
Six core models were identified in the literature these include:
- Risking Connection
- Attachment, Self-Regulation, and Competency Framework (ARC) Model
- The Sanctuary Model
- The Six Core Strategies (6CS)
- The Fairy Tale Model
- CARE Model.
Bryson et al. (2018) identified five factors as instrumental in implementing trauma-informed care across the spectrum of initiatives:
- Senior leadership commitment. Actions such as senior leaders making trauma-informed care a standing item in high-level meetings, allocating resources, setting clear targets, communicating the rationale for the initiative with staff, and articulating a clear belief that goals are achievable.
- Sufficient staff support. Comprehensive rather than one-off training to help staff understand the purpose of trauma-informed care and to develop staff buy-in, giving staff a common language. Post-training support through re-certification, ongoing training, coaching and supervision.
- Amplifying the voices of patients and families. Involving patients and family members as well as staff in training, and involving patients in incident debriefing.
- Aligning policy and programming with trauma-informed principles. Making changes to the physical environment of the unit to make the treatment space feel safe and welcoming for both patients and staff, including trauma-informed principles in mission and vision statements; and posting these visibly in the unit.
- Using data to help motivate change. Establishing clear targets and goals, collecting data to monitor progress and regularly sharing with staff.
In the UK, the Social Care Institute for Excellence (MacDonald et al. 2012) reviewed the implementation of six different therapeutic approaches being piloted in residential child care settings in Northern Ireland. These included the CARE Model, ARC Model and Sanctuary Model (see study one).
Initially, most staff involved in implementing these models across Northern Ireland were sceptical that the models offered anything new, over-and-above good social work practice skills, and were concerned about increases in workload. All respondents emphasised the importance of ongoing training and support. Other factors identified as important to successful implementation included:
- Addressing system issues such as staff turnover, the numbers of young people in home and admission processes
- Giving staff opportunities and support to reflect on their practice
- The fit of the model with existing culture, language and practice within the home
- The fit of the model with other organisational changes occurring at the same time.
Overall, interviewees felt that all of the models had enhanced practice in some significant ways, bringing about positive culture change within homes, improving staff morale and confidence and changing the ways in which staff viewed or responded to the children in their care. Staff reported increased job satisfaction and being reminded of their original reasons for working in residential care; to help young people.
When it comes to foster care most of the evidence is from the United States. The most extensively evaluated trauma-informed framework in use is the KVC initiative, a private organisation providing out-of-home care to children served by the Kansas Department for Children and Families. Implementation entailed system wide implementation of a Trauma Systems Therapy (TST) model. Other models identified and in use were:
- The ADOPTS programme. This involved a 16-week structured application of the ARC treatment framework designed to be used as a brief outpatient intervention with adoptive children and their families
- The Training for Adoption Competency (TAC). This was developed by the Centre for Adoption Support and Education (CASE) in Virginia
- The Promoting Safe and Stable Families Programme. This was implemented in just one US state
- Intensive Permanence Services (IPS). This was developed by a treatment foster care agency in Wisconsin and Minnesota.
Implications for practice
- Greater attention needs to be paid, not just to presenting problems, but the complex trauma history of parents and children when developing trauma-informed approaches.
- The development of trauma-informed child welfare requires a wider multi-level systems approach which recognises the role different stakeholders play in facilitating post-trauma recovery.
- Common elements considered essential to the implementation of trauma-informed care in children's services include: workforce development, trauma-focused services and organisational change.
- Practice in this area is primarily led by the National Child Traumatic Stress Network (NCTSN) in the United States. The NCTSN have developed the Child Welfare Trauma Training Toolkit and the Chadwick Trauma-Informed System Project, the Trauma-Informed Child Welfare Practice Toolkit.
- A range of specific trauma-informed therapeutic models such as Sanctuary, the Attachment, Self-Regulation, and Competency Framework and Risking Connections, have been developed and implemented within residential, group care and treatment settings.
- With the exception of the Massachusetts Child Trauma Project, most interventions have not been substantially evaluated to demonstrate effectiveness.
- The lack of appropriate evidence based treatment availability, together with limited buy-in, could act as barriers to the implementation of trauma-informed approaches.