3.2. Contextual Questions

Results - Trauma Informed Care: A Systematic Review - NCBI Bookshelf An official website of the United States government Here's how you know The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site. The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Log in Show account info Close Account Logged in as: username Dashboard Publications Account settings Log out Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation Bookshelf Search database Books All Databases Assembly Biocollections BioProject BioSample Books ClinVar Conserved Domains dbVar Gene Genome GEO DataSets GEO Profiles GTR Identical Protein Groups MedGen MeSH NLM Catalog Nucleotide OMIM PMC Protein Protein Clusters Protein Family Models PubChem BioAssay PubChem Compound PubChem Substance PubMed SNP SRA Structure Taxonomy ToolKit ToolKitAll ToolKitBookgh Search term Search Browse Titles Advanced Help Disclaimer NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health. Nguyen-Feng VN, Ramirez M, Behrens KL, et al. Trauma Informed Care: A Systematic Review [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2025 Jan. Trauma Informed Care: A Systematic Review [Internet]. Show details Nguyen-Feng VN, Ramirez M, Behrens KL, et al. Rockville (MD): Agency for Healthcare Research and Quality (US) ; 2025 Jan. Contents Search term < Prev Next > 3 Results 3.1. Overview Figure 1 presents the literature flow of the search results. Database searches of published literature resulted in 4,379 unique publications for screening. After dual review of abstracts and titles, we assessed 245 articles for eligibility at full text, of which 229 were excluded ( Appendix B ). We identified 12 unique eligible studies discussed in 16 publications. See Figure 1 for details of the screening process. Figure 1 Literature flow diagram. The most common reasons for exclusion were issues related to outcomes or study designs. For the outcome exclusion, the vast majority were excluded for only reporting intermediate outcomes, the most common example being studies of training interventions that reported intermediate outcomes such as competency, attitudes, or intentions of a clinician or service provider. The other studies excluded for outcomes were commonly implementation studies that reported implementation outcomes such as feasibility or acceptability of an intervention but lacked patient/client related outcomes. Publications excluded for study design were largely studies of an intervention at a single site that reported only descriptive statistics, or simple comparisons of outcomes before and after the Trauma Informed Care ( TIC ) intervention was implemented. These single arm pre/post study designs are unable to address concerns about selection bias and other possible counterfactual explanations that could account for any observed difference and are, by definition, high risk of bias. Publications excluded for intervention examined only established treatments such as Trauma-Focused Cognitive Behavioral Therapy without additional TIC components. We identified three studies of adult only populations for Key Question (KQ) 1 , all conducted within the United States. Settings consisted of primary care or psychiatric hospitals. Nine studies assessing youth/adolescents were identified for KQ 2 ; studies of children and their families or caregivers were also included in KQ 2 . Seven of the KQ 2 studies were U.S.-based, one study was in Canada, and one in Switzerland. We chose to place one study of pregnant adolescents in KQ 2 , even though the average age was 18, based on study author identification of the setting as an adolescent obstetric clinic. While adult settings tended to focus on racially/ethnically minoritized groups, the children and youth setting tended to be predominately white and male. Only four of the 12 included studies were cluster randomized controlled trials (RCTs), the remaining were variations of comparative nonrandomized studies of interventions (NRSIs). Seven studies were funded by government agencies and the remaining were generally funded by philanthropic foundations. Below we provide the results for the Contextual Questions, providing detailed information in tables available in Appendix D . We then follow with the results and Key Points for each Key Question and describe the included evidence as well as the summary of the findings and strength of evidence. Appendix C provides details for both KQs on evidence tables, summary risk of bias assessments, and strength of evidence for each comparison and outcome. 3.2. Contextual Questions This section addresses Contextual Question (CQ) 1 and 2 . The CQs were developed to provide information on the content and context of TIC interventions. To restate the CQs: CQ 1. How is TIC defined in theory and research and according to professional guidelines or other clinical, system, or policy-level guidance or recommendations? CQ 2. What are the organizational and clinical components of TIC , including components of different TIC models? Are common components of TIC found across settings, populations, conditions, and models? We drew on publications identified from the search algorithms (i.e., articles that did not meet inclusion criteria for the Key Questions) as well as the grey literature. The potentially relevant research, perspective pieces, descriptions of theory-based TIC approaches, or advocacy pieces are extensive, and an exhaustive examination of the literature is beyond the scope of this review. That is, the listed models are not exhaustive of all TIC models, and surely many additional models exist in the extant literature. Our goal with the Contextual Questions is to present a comprehensive discussion and one that approximates saturation of the ideas. 3.2.1. Trauma Informed Care Definitions in Theory and Research 3.2.1.1. Key Point TIC definitions vary considerably, and no globally accepted definition has been adopted for TIC from youth to adult services. For instance, TIC may be referenced as principles, approaches, specific interventions, and/or frameworks. TIC was generally conceptualized on a systems level, such as by referencing programs, organizations, and cultures of care without specific operationalization. Current definitions encompass various settings and disciplines for both youth and adults. 3.2.1.2. Definitions of Trauma Informed Care No globally accepted definition exists for TIC from pediatric to adult services, much less a globally accepted definition of “trauma.” Herein lies a core challenge with TIC, considering that many definitions of TIC rely on a certain understanding of what constitutes “trauma.” Although not all-encompassing, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision 31 defines trauma as exposure to actual or threatened death, serious injury, or sexual violence through ways such as directly experiencing the traumatic event(s) and/or witnessing, in person, the event(s) as it occurred to others. The International Classification of Diseases 11 th Revision 32 defines potentially traumatic events as those with a stressor of an extremely threatening or horrific nature. These various definitions of trauma may be perceived as subjective and are difficult to operationalize, with differences even in delineating trauma as an exposure, event, or experience (internal or external). The difficulties and confusion related to defining “trauma” carry forward to defining TIC . Authors of TIC guidelines most often credited their definitions of TIC as drawn from six key TIC principles (although noted as trauma-informed approaches) developed by the Substance Abuse and Mental Health Services Administration ( SAMHSA ). 33 – 44 Further, conceptualizations of what constitutes “trauma” vary, with trauma framed as both systemic and interpersonal. Example definitions of TIC originally developed by national centers and/or are commonly used include: “A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization.” — SAMHSA , U.S. Department of Health and Human Services 15 “the development of a culture… all of which serve goals that simultaneously create a sound treatment environment while counteracting the impact of chronic and unrelenting stress.” —The Sanctuary Institute, Andrus 45 “… all parties involved recognize and respond to the impact of traumatic stress on those who have contact with the system including children, caregivers, and service providers. Programs and agencies within such a system infuse and sustain trauma awareness, knowledge, and skills into their organizational cultures, practices, and policies.” —National Child Traumatic Stress Network (NCTSN) 46 “framework that extends the philosophy of person-centered care which recognizes and values the individual perspectives of care recipients and those providing care, while promoting a positive social environment. TIC further emphasizes the fundamental role of psychological trauma in shaping a person’s experience of care. As distinct from trauma specific clinical treatment, trauma-informed services are organized in ways that engender safety for all and do not re-traumatize survivors.” —Creating Cultures of Trauma-Informed Care (CCTIC); Community Connections, Washington, DC 47 Appendix D , Table D.1 provides an overview of TIC definitions from seven universal/cross-cutting models as well as 24 setting-specific models. The table lists the core principles and/or domains of each TIC model, as numerated by the model developers. As the study included in the effectiveness review on TIC for a patient-centered adolescent obstetric clinic illustrates, the “devil is in the details” wherein 37 separate “solutions” were identified and implemented to address ten problem areas across the six key principles. Many of these solutions were of themselves behavior change interventions involving some health system-level complexity. The universal/cross-cutting models (Collaborative Care Model, 48 Creating Cultures of Trauma-Informed Care, 37 , 47 , 49 , 50 Creating Presence (Partnership and power, Reverence and restoration, Emotional wisdom and empathy, Safety and social responsibility, Embodiment and enactment, Nature and nurture, Culture and complexity, Emergence and evolution) 51 National Child Traumatic Stress Network, 52 – 57 Solution-Focused Trauma-Informed Care, 58 , 59 SAMHSA , 33 – 44 Trauma and Resiliency Informed Practice 60 ) are intended to apply to a variety of settings and contexts, whereas the setting-specific models were developed with a particular context and/or population in mind—not that these models are constrained to only their early contexts and/or populations. For setting-specific models for adults, we identified three TIC models on adult medical care (Fifth Vital Sign: HOUSE [Housing precarity, Outcomes of mental illness, Understanding income, Start case management for mental health, Evaluate substance use]; 61 Trauma-Informed Primary Care; 62 Trauma-Informed Treatment Model; 63 ), one of which focuses on emergency room physicians (Fifth Vital Sign: HOUSE [Housing precarity, Outcomes of mental illness, Understanding income, Start case management for mental health, Evaluate substance use] 61 ); otherwise, the models were broadly intended for adult primary care and hospital settings. All models consider external factors and social determinants of health, such as housing, income, community safety, and cultural contexts that include experiences of violence. Five TIC models on adult mental healthcare were identified (Portal Project Model; 64 Trauma-Informed Care and Practice; 58 Trauma-Informed Care Pyramid; 65 , 66 Trauma-Informed Social Work Practice; 67 Women, Co-Occurring Disorders, and Violence Study 68 , 69 ), one of which focuses on social work practice (Trauma-Informed Social Work Practice 67 ); otherwise, the models were broadly intended for adult mental healthcare settings. Although models might have been informed by findings outside of traditional psychotherapeutic contexts, such as dental work (Trauma-Informed Care Pyramid 65 – 67 ), all such models were intended to be translatable to mental health settings. Further, although one model was developed for a specific community (women who use substances and identify as survivors of violence, Women, Co-Occurring Disorders, and Violence Study 68 , 69 ), the model is noted to be applicable to individuals across various populations. Regarding youth, two TIC models were developed for youth juvenile detention settings (A Developmental Trauma Informed Response for the Criminal Justice System 70 ; Trauma-Informed Juvenile Justice 71 ), both of which discuss individual- and group-level factors. A broad range of groups and systems are mentioned, including families, agencies, cross-systems, courts, and others who have contact within the juvenile justice system. Six TIC models were identified for youth residential and inpatient treatment (Attachment, Regulation, and Competency Framework; 72 – 75 Fairy Tale Model of Trauma-Informed Treatment; 76 , 77 Massachusetts Child Trauma Project; 78 , 79 National Association of State Mental Health Program Directors; 80 Sanctuary Model; 45 , 81 – 83 Trauma-Informed Care in Residential Treatment 84 ), which include considerations of the child as well as their caregivers, family, and staff service providers. Sense of self, identity, self-care, and self-regulation are emphasized along with relational aspects such as increasing connections, understanding attachment styles, and building social responsibility. Further, there are considerations around long-term wellbeing as well as future challenges. Two TIC models were identified for youth under child protection services (Chadwick Trauma-Informed Systems Project and the Community Assessment Process; 85 , 86 Trauma-Informed Child Welfare Systems 87 ), both of which emphasize the importance of systems and assessments. Further, both models highlight the importance of determining the impacts of trauma and traumatic stress on the child. Lastly, there were nine TIC models in additional settings that were not encompassed in the review’s inclusion criteria. These settings included approaches such as interviewing (A Trauma Informed Approach to Interviewing 88 ) and sites such as schools (Healthy Environments and Response to Trauma in Schools; 89 Therapeutic Crisis Intervention in Schools; 90 Trauma-Informed Positive Education 91 , 92 ), adult correctional care (The Four E’s; 93 Trauma-Informed Correctional Care 94 ), neighborhood resource and recreation centers (Trauma-Informed Neighborhood Resource and Recreation Centers 75 ), and additional body-related or physical wellbeing arenas (Trauma-Center Trauma Sensitive Yoga; 95 Trauma-Informed Weight Lifting 96 ; Yoga 4 Change) 97 . 3.2.2. Organizational and Clinical Components of Trauma Informed Care 3.2.2.1. Key Points TIC models vary considerably in their socioecological components (cultural relevance, training, screening, system embedding) from youth to adult services across settings and disciplines. Current organizational and clinical components encompass a broad range of considerations with some overlap stated within both the organizational and clinical domains (e.g., incorporating psychoeducation for organizational staff as well as within patient/client treatment). Fewer than half of the TIC models had specific elements of cultural competence and/or humility (e.g., emphasizing a need to understand patient/client symptoms within the context of life experiences, culture, and historical issues). 3.2.2.2. Organizational and Clinical Components Given the variability of TIC , organizational and clinical components were defined based on broad characteristics and descriptive approaches rather than firmly structured, delineated characteristics. Specifically, per the American Psychological Association, components of clinical nature were loosely defined as factors related to observation of clients/patients, diagnosing disorders, and treatment of disorders and clients/patients. 20 Components of organizational nature were loosely defined from the American Psychological Association as various factors within an entity that “interact to perform one or more functions.” 20 Nearly two dozen clinical components were identified across TIC models, with close to the same number for organizational components. The majority of identified organizational components were present primarily within their unique TIC model, with only a handful of factors found across multiple TIC models. Approximately half of the identified clinical components were present primarily within their unique TIC model, with the remaining half of the clinical components commonly found across multiple TIC models. No components were universally found across all examined models. Table 3 provides a summary of the socioecological and treatment-related components. Detailed information is provided in Appendix D , Tables D.2 - D.5 . Table 3 Summary of models: TIC socioecological and treatment-related components. 3.2.2.2.1. Organizational Components Organizational components commonly comprised staff training on trauma, which usually included modules on understanding patient/client behaviors as being influenced by trauma exposures. Expanding on increasing understanding and awareness of trauma among patients/clients, TIC organizations noted a need to focus first on patient/client-centered care rather than on other factors, such as monetary profits. Relatedly, organizational components relied on collaboration across levels, emphasizing the importance of leadership support to create a workplace culture of TIC. Given the reliance of leadership support to effect change, TIC models also commonly highlighted the importance of recognizing power and privilege (e.g., protecting autonomy and sharing power dynamics by providing choices); recognition of power and privilege extended beyond titular hierarchies by including cultural “competency” and/or cultural humility, with the latter focused on having an open stance in understanding fellow peer’s cultural experiences. Lastly, although TIC was commonly considered as an approach that needed ongoing assessment, quality assurance and framework evaluation were more simply acknowledged rather than stringently tested. 3.2.2.2.2. Clinical Components as Organizational Components A few organization components were common clinical components in TIC models. Similar to staff training noted in the “Organizational Components” section, importance was placed on synthesizing patient/client’s history and presenting concerns, including the ability to show an understanding of trauma and take a trauma lens (e.g., view situations and behavioral responses from the perspective of a client/patient who had experienced trauma). Some models note that this understanding of patient/client perspectives could be further bolstered by recognizing power and privilege in the patient/client–provider relationship and imbuing cultural “competency” and/or humility in patient/client conceptualization. Alongside provider humility (e.g., openness to others and to self-evaluation), TIC models also commonly discussed cultivating a sense of choice through patient/client empowerment, emphasizing patient/client strengths rather than deficits. Through rapport building and a focus on relationships, TIC models additionally highlighted the importance of creating an interpersonal dynamic built on trust and safety, as defined and determined by the patient/client. Across TIC models, clinical components emphasized the importance of minimizing re-traumatization in the patient/client–provider relationship and setting (e.g., sanctuary trauma) 51 , 111 while acknowledging it is impossible to eliminate the risk entirely. Although views differed on whether and/or how screening for patient/client trauma history may cause re-traumatization, such assessments were common across the TIC models and used variably in the context of service delivery. Less common yet still present organizational components discussed in TIC models aligned with some TIC clinical components. These organizational components included safety; trustworthiness and transparency; collaboration and mutuality; empowerment, voice, and choice; trauma awareness in training; and developing positive working relationships among staff. Additional less-commonly discussed organizational components were offshoots of more-commonly discussed organizational components in TIC models, such as increasing understanding of cultural, historical, and gender issues (e.g., cultural relevance); incorporating data-driven incident monitoring and feedback as part of quality assurance; providing leadership and administrative support; and providing system-wide universal supports. TIC organizational components mentioned in singular models included the idea of providing social work and clinical services to staff; developing supervision around post-crisis responses; emphasizing a “do no harm” approach; and building community partnerships. 3.2.2.2.3. Additional Clinical Components Regarding clinical components, some TIC models discussed increasing psychological resources (e.g., cognitive processing, emotion regulation, identity formation, social support, empathy training). A couple of TIC models stated the clinical goal of increasing patient/client psychological resources, while a few discussed how client goals might be achieved through trauma-focused interventions to resolve trauma and consolidate loss and related memories. Similarly, some TIC models discussed approaches that were psychological in nature, such as assisting patients/clients with emotional regulation and with exploring and understanding their self-identities. A couple of models focused on building relationships outside of the patient/client–provider dynamic, with nods toward peer support and child–caregiver dynamics. Finally, the importance of empathy was briefly discussed as a clinical component in TIC models. 3.2.2.2.3.1. Treatments Appendix D , Table D.4 details TIC treatment/intervention-related descriptions for each TIC model. All seven universal/cross-cutting models discuss TIC in relation to psychotherapeutic treatment/intervention skills and/or goals. All but two of these models (Creating Presence 51 , 60 , Trauma and Resiliency Informed Practice 60 ) include some form of psychotherapeutic treatment, whether trauma-centered or on a broader well-being scale. Of the eight setting-specific adult models, only one was silent on linkage to treatment or treatment within their TIC model (HOUSE [Housing precarity, Outcomes of mental illness, Understanding income, Start case management for mental health, Evaluate substance use] 61 ). The remaining seven models all discussed TIC in relation to treatment/intervention, and all but one model (Trauma-Informed Care Pyramid 65 , 66 ) included some form of psychotherapeutic treatment/intervention. Regarding the 10 setting-specific youth models, all but one (A Developmental Trauma Informed Response for the Criminal Justice System 70 ) discussed TIC in relation to psychotherapeutic treatment skills and/or goals. Furthermore, all but one youth model (Fairly Tale Model 76 ) included some form of psychotherapeutic treatment/intervention. Of the nine models in additional settings, all but one (which focused on interviewing as a trauma-informed approach and was silent on linkage to treatment) discussed TIC in relation to psychotherapeutic treatment skills and/or goals (A Trauma Informed Approach to Interviewing 110 ). Of the remaining eight models, all but the three physical wellbeing related models (Trauma Center Trauma-Sensitive Yoga 112 , Yoga for Change 97 , Trauma-Informed Neighborhood Resource and Recreation Centers 75 , Trauma-Informed Weight Lifting 96 ) included some form of psychotherapeutic treatment/intervention. 3.2.2.2.3.2. Targets and Populations Appendix D , Table D.2 details TIC intervention targets for the seven universal/cross-cutting models, the models within the five specific settings (three for adult medical care, five for adult mental healthcare, two for youth juvenile detention, six for youth residential and inpatient treatment, and two for youth in child protection), and the nine additional settings. Nearly all models considered the health system as well as the individual as intervention targets. The universal/cross-cutting models and the adult-specific models tended not to consider family/interpersonal intervention targets whereas all the youth models considered family/interpersonal intervention targets. There did not appear to be consistency in whether community was considered an intervention target with the exception that none of the adult mental health are models included community while both youth in child protection models included community. The universal/cross-cutting and the youth juvenile detention setting models generally included policy as an intervention target although the remaining settings generally did not consider policy. 3.2.2.2.4. Socioecological Components Appendix D , Table D.3 details TIC socioecological component descriptions for each TIC model. All seven universal/cross-cutting models discussed ways to embed TIC on a systems level, and nearly all discussed some form of training and/or screening. Two of the seven universal/cross-cutting models (CCTIC, 49 SAMHSA 33 , 35 , 39 , 103 , 113 ) examined the cultural relevance of their TIC approach with different populations. All eight adult models (3 medical and 5 mental health) discussed training as a component of TIC, and near all discussed some form of screening and/or system embedding. Three of the eight adult models (HOUSE [Housing precarity, Outcomes of mental illness, Understanding income, Start case management for mental health, Evaluate substance use], 61 Portal Project Model, 64 WCDVS [Women, Co-Occurring Disorders, and Violence Study] 68 ) discussed cultural relevance of their TIC approach within different contexts (e.g., housing shortages, sociopolitical environment) and/or named cultural competence as important. Near all of the 10 youth models (2 in juvenile detention, 6 in residential and inpatient treatment, and 2 in child protection settings) discussed some form of training, screening, and/or system embedding; and two of the 10 youth models discussed cultural considerations in their TIC approach, in which one named cultural competence as important (Trauma-Informed Juvenile Justice 71 ) and the other noted the importance of family and community (Fairy Tale Model 76 ). Of the nine additional settings that were not encompassed in the review’s included literature, nearly all discussed some form of training, screening, and/or system embedding. Regarding consideration of cultural contexts, one of the nine additional models discussed implementing the model in under-resourced areas (HEARTS [Healthy Environments and Response to Trauma in Schools] 89 ), and all three physical wellbeing-related models discussed tailoring the model and/or considering inequalities, power, and privilege (Trauma Center Trauma-Sensitive Yoga, 108 Trauma-Informed Neighborhood Resource and Recreation Centers, 75 Trauma-Informed Weight Lifting 96 ). 3.3. Findings for Key Question 1 : TIC for Adults 3.3.1. Key Point Evidence was insufficient to draw conclusions about the effect of TIC in primary care or psychiatric hospitals for adult patients for any outcome. 3.3.2. Adult Medical Care Settings We identified two unique studies 104 , 114 from three publications 104 , 114 , 115 that examined TIC approaches in medical settings to improve patient or organizational/process related outcomes. One study used trauma-informed collaborative care ( TICC ) delivered to 42 African American primary care clinic patients. The enhanced usual care ( EUC ) arm of the study consisted of a 2-hour onsite training about posttraumatic stress disorder ( PTSD ) and TIC for all primary care staff, and an evidence-based medicine training and medication decision aid for Federally Qualified Health Center physicians. Patients who had a provisional PTSD diagnosis were provided with an information sheet adapted from patient education resources from the National Institute of Mental Health and the International Society for Traumatic Stress Studies. The TICC arm included all EUC components plus active patient education and engagement, facilitated linkages to community resources by trained care managers (CMs). CMs also had cross-disciplinary communications with the patient/client’s providers, participated in monthly meetings, facilitated measurement-based care through an initial in-person visit and 7 follow up phone calls over 9 months to monitor care. 104 The other study targeted primary care physicians (17 family medicine residents and 13 community providers), with primarily low-income ethnic minority patients, to participate in Trauma Informed Medical Care (TI-Med), a 6-hour continuing medical education course adapted from Risking Connection, 116 a trauma-focused communication training program. 111 Table 4 summarizes the characteristics of the literature set. Both were assessed as high risk of bias. Both studies did not describe the randomization process. 28 – 30 One RCT (n=42 patients) had differential attrition over follow up (24 percent attrition in the intervention arm versus 5 percent attrition in the control arm), did report masking of participants to treatment allocation, and had baseline imbalance in covariates (compared to the intervention arm, the control arm had more participants with history of psychoses and less than high school education). 104 One cluster RCT (n=30 primary care providers) recruited 400 patients by convenience sampling, measured patient/client-reported outcomes (patient/client ratings) using a survey instrument that was not externally validated, did not report whether patients/clients were masked to provider intervention assignment, and measured posttraining and pretraining scores (patient/clients ratings) in different sample of patients/clients. 30 Table 4 Basic characteristics of literature set: adult medical settings. Evidence was insufficient to draw conclusions about the effects of TIC on outcomes. Table 5 summarizes the findings. One study reported that patients/clients with PTSD showed PTSD symptom improvement in both the trauma-informed collaborative care group and the control group that received a minimal TIC approach, 104 no differences between groups were found. Another study looked at whether patients/clients’ noticed differences in provider communication between trained and untrained clinicians. 114 , 115 This study used brief screening for trauma and PTSD to establish baseline demographic characteristics and for use in the regression analysis; there was no further information regarding different care for patients/clients with high screener scores. No organizational outcomes, adverse events, or unintended consequences were collected for either study. Table 5 Summary of findings: adult medical settings. 3.3.3. Adult Mental Health Service Settings We identified one unique study that examined TIC approaches in mental health settings to reduce the use of seclusion and restraint in a large state-funded hospital. 105 The Engagement Model in this study including TIC staff training, rules and language intervention, therapeutic environment changes (including the addition of comfortable furniture, pleasant lighting and plants, and the removal of signs and use of terms like “security check” or “seclusion room”), and patient involvement in treatment planning using a “teamwork approach” for reducing seclusion and restraint procedures and enhancing patient safety in psychiatric settings. 105 Table 6 summarizes the characteristics of the single study in the literature set. This RCT randomized five inpatient units within the same hospital to implement the intervention and implemented a multiple baseline design with stepped rollout of intervention across units, which could lead to contamination in effect estimation. The study did not report information about nonparticipation within unit or attrition over follow up, did not report information about missing data, and did not report information about masking; thus, this study had a high risk of bias. 31 Table 6 Basic characteristics of literature set: adult mental health settings. Evidence was insufficient to draw conclusions about the effects of TIC on outcomes. Table 7 summarizes the findings. This study reported a reduction in the rate of seclusion and restraint between the baseline phase and the followup, postintervention phase. Environmental changes (e.g., painting walls with warm colors, decorative throw rugs and plants, new furniture, regular staff-patient group meetings) reported strongest associations with reductions. No organizational outcomes, adverse events, or unintended consequences were collected for the study. Table 7 Summary of findings: adult mental health settings. 3.4. Findings for Key Question 2 : TIC for Children/Youth 3.4.1. Key Point Evidence was insufficient to draw conclusions about the effect of TIC in any setting for children or youth patients/clients for any outcome. 3.4.2. Primary Prevention for Children We identified one study that examined TIC approaches in primary prevention settings to improve patient related outcomes. 119 Families OverComing Under Stress-Early Childhood ( FOCUS-EC ) was delivered to military families through an in-home, virtual telehealth platform. FOCUS-EC is a trauma-informed, family-centered preventive intervention designed to promote family resilience and well-being, consisting of core elements delivered in 6 modules that are typically delivered over 4-10 meetings that last 60–90 min each. The core elements include (1) Web-based Family Resilience Check-In; (2) personalized trauma-informed psychoeducation, parenting education and developmental guidance; (3) development of a parental narrative timeline to support reflection, empathy, meaning making and communication; and (4) development of family resilience and parenting/co-parenting skills. 119 Table 8 summarizes the characteristics of the literature set. In this study, there was greater attrition in the intervention arm (14 percent) compared to the control arm (6 percent), missing data were imputed using mean scores of available data, power calculations were not reported, the quantity of missingness in data were not described, and analyses tested multiple outcomes at multiple timepoints without statistical adjusting for multiple comparisons; thus, this study was assessed as having high risk of bias. 119 Table 8 Basic characteristics of literature set: primary prevention settings for children. Table 9 summarizes the findings. This study reported that military parents showed psychological health symptom improvement in both the FOCUS-EC group and the control group that received an alternate online education program; no differences between groups was found. 119 However, parent-child interactions and child behavior improved for the FOCUS-EC group. No organizational outcomes, adverse events, or unintended consequences were collected. Table 9 Summary of findings: primary prevention settings for children. 3.4.3. Adolescent Medical Care Settings We identified one study 101 from two publications 101 , 122 that examined TIC approaches in medical settings to improve adolescent patient or organizational/process related outcomes. The Colorado Adolescent Maternity Program (CAMP) is an obstetric and pediatric medical home for pregnant and parenting adolescent girls located within a children’s hospital. CAMP used the six SAMSHA key principles to identify 10 problem areas to develop 32 solutions, as shown in Table 10 . Table 10 Ashby Trauma-Informed Care Model. The clinic held weekly team meetings and regular in-services led by behavioral health staff who provided education on TIC . Two mandatory retreats were held for all providers and staff, including behavioral health staff. Psychology and psychiatry faculty also requested feedback about how the changes impacted clinical care and clinic flow and made modifications as needed. Medical providers, patient/client educators, and care coordinators attended training on motivational interviewing to improve skills and efficacy. Behavioral health providers were available in the clinic at all times to provide immediate and ongoing support to the rest of the team as TIC implemented. 101 , 122 Table 11 summarizes the study. In this study, the historical control group was not selected using any matching or statistical weighting techniques, history of trauma in the historical control group was unknown, baseline differences between the intervention arm and the historical control arm were not examined except for age and race, and the univariate pre-post analyses did not address potential confounding; thus, this study was assessed as having high risk of bias. This study also conducted a comparison of changes in outcomes between Black and white and Hispanic mothers. Table 11 Basic characteristics of literature set: adolescent medical settings. Evidence was insufficient to draw conclusions about the effects of TIC on outcomes. Table 12 summarizes the findings. This study reported increased prenatal appointment attendance and less low birthweight deliveries for TIC versus historical controls, but no differences in preterm deliveries. Further, Black adolescent mothers receiving TIC no longer showed differences in outcomes compared with white and Hispanic adolescent mothers. No organizational outcomes, adverse events, or unintended consequences were collected for either study. Table 12 Summary of findings: adolescent medical settings. 3.4.4. Residential Child Welfare Settings Four TIC studies in residential child welfare settings included patient focused outcomes. 107 , 123 – 125 One intervention targeted all youth living in two juvenile detention facilities; it included Think Trauma “train the trainer” training (2 sessions in 8 weeks) for all staff, and Skills Training for Affective and Interpersonal Regulation 126 skill-building group program for youth (3 sessions). 125 The second was set in a psychiatric residential treatment ( PRT ) facility for children and used Trauma-Informed PRT ( TI-PRT ). TI-PRT included as clinical components 24-hr provision of care, basic needs and medical care, educational services (on- or off-campus school), improving self-concept, teaching problem-solving skills, and trauma-focused individual therapy—eye movement desensitization and reprocessing or trauma-focused and general cognitive behavioral therapy cognitive processing therapy, family therapy (when feasible), psychiatric services, and family-center services. Organizational components included, trauma orientation/ongoing training, safety planning/documentation, determining program mission and shadow mission or underlying thoughts and behaviors that undermine achieving the mission, daily member (client/staff) check-ins, and family/caregiver education. 107 The third was a TIC staff training initiative in 44 residential units for children and youth in Canada. The training explored differences between units and type of measures used (restraints, seclusions, time-outs), for 6 months prior to and 12 months following the training. 123 The fourth, set in a residential treatment program in Switzerland, was mandatory for all employees and delivered over three years. Experienced professionals conducted advanced training to implement and support TIC (six 3-day trainings for management and counselors, eight 2.5-day trainings for youth welfare staff). Between trainings, institutions received supervision in implementing a trauma-informed philosophy and services, debriefing on critical incidents and support in promoting an organizational culture of well-being, permanency, safety, care, and respect toward clients and co-workers. 124 All were NRSIs with the exception of one longitudinal study. 124 Table 13 summarizes the characteristics of the literature set. All included studies were assessed as high risk of bias. One large study (n=14,856 juvenile participants) did not account for confounding and compared rates postintervention versus preintervention without accounting for period effect with methods such as difference in difference modeling. 125 One study (n=205 youth) employed a nonrandomized quasi-experimental design, did not measure preintervention and postintervention outcomes in the same sample of patients nor did the study use matching or statistical weighting for appropriate pre/post comparisons, did not describe missing data, and did not adequately address confounding. 107 One longitudinal study (n=914 children and youth) conducted preintervention versus postintervention comparisons without a control group, did not sufficiently address selection bias, confounding, or missing data, did not measure fidelity or compliance with intervention, and analyzed administrative data prone to reporting bias and misclassification of exposure and outcomes. 123 One nonrandomized longitudinal study (n=142 staff) had very high level of missingness in data (> 66 percent) which was not adequately accounted for in the analyses, had a very small sample size, relied solely on staff-reported subjective measures for incidents of aggressive behaviors by patients, and did not adequately address potential confounding in analyses. 124 Table 13 Basic characteristics of literature set: residential child welfare settings. Evidence was insufficient to draw conclusions about the effects of TIC on outcomes. Table 14 summarizes the findings from these studies. One study 125 looked at violent incidents in a juvenile detention center and found favorable results following a TIC intervention. Another study examined several outcomes in pediatric psychiatric residential treatment following a TIC intervention and found positive changes in functional impairment, mixed results on physical restraints and locked seclusion room incidents, improvement in length of time in care, and no statistical difference in discharge placement type. 107 A third study examined the impact of a TIC program on use of restrictive measures in a residential treatment program for children and found no statistical differences following the intervention. 123 Lastly, a study evaluated patient aggression toward staff following a TIC intervention and found favorable reductions in aggression. 124 No organizational outcomes, adverse events, or unintended consequences were collected for any study. Table 14 Summary of findings: residential child welfare settings. 3.4.5. Non-Residential Child Welfare Settings Three TIC studies (in five publications) set in non-residential child welfare settings that examined patient/client-focused outcomes. 102 , 106 , 131 – 133 One examined Trauma Systems Therapy ( TST ) integration across the organization’s entire continuum of care; core facets of TST were (1) repeatedly assessing children’s emotional and behavioral regulation capacity and the functioning of children’s social environment to determine treatment; (2) training all staff on how trauma impacts child development and how to effectively respond to children’s trauma; and (3) embedding the TST model throughout an organization or system. 106 The second examined the Massachusetts Child Trauma Project, which focuses on three central activities: (1) training in child welfare; (2) statewide dissemination of three trauma treatments with empirical support via community-based mental health organizations; (3) trauma-informed leadership teams to share best practices across systems and raise awareness of trauma’s impact on children, create consistency across systems, and address service gaps related to TIC. 131 The third study piloted a trauma-informed parenting curriculum in a private, nonprofit, specialized community mental health agency. Forty parents involved in the state child welfare system were recruited to participate. Facilitators met with parents one time per week online for a total of 3 hours over 10 weeks. Facilitators followed the Breakthrough Parenting Curriculum manual with predetermined topics and activities. Sessions included a welcome followed by a brief icebreaker and reminder of group-established rules. Facilitators then reviewed the previous week’s content before the new lesson and closed with quiet reflection. 102 Table 15 summarizes these studies. All were NRSI in design and were assessed as high risk of bias for the following reasons. One study (n=1,499 children) employed a quasi-experimental design without a control group, analyzed administrative data prone to reporting bias, and tested multiple outcomes at multiple timepoints. 106 One mixed methods study (n=91,253 children) did not use validated tools for subjective self-reported outcome measurement, did not measure adherence to intervention, analyzed administrative data prone to reporting bias, differences between intervention and control groups were not sufficiently accounted for (leading to selection bias), did not adequately address potential confounding in analyses, and tested multiple outcomes without statistical adjustment. 131 , 132 One exploratory study (n=40 parents) employed a non-equivalent group quasi-experimental design, was likely underpowered due to small sample size, and did not adequately address selection bias, confounding, or potential bias from missing data. 102 Table 15 Basic characteristics of literature set: non-residential child welfare settings. Table 16 summarizes the findings from these studies. All took place in a variety of public and private child welfare organizations. The first study found favorable outcomes related to child functioning, behavior regulation, and placement stability, with mixed results in emotional regulation. 106 The next study was published in two articles that found favorable results related to substantiated maltreatment, permanency (adoption), child PTSD , and child behavior, mixed results with unsubstantiated maltreatment, and no statistical difference in out of home placements. 131 , 132 The final study found favorable results for both parental/caregiver and child-wellbeing following a TIC intervention. 102 Evidence was insufficient to draw conclusions for all studies about the effects of TIC on outcomes. No organizational outcomes, adverse events, or unintended consequences were collected for either study. Table 16 Summary of findings: non-residential child welfare settings. Copyright Notice Bookshelf ID: NBK614497 Contents < Prev Next > Share Views PubReader Print View Cite this Page Nguyen-Feng VN, Ramirez M, Behrens KL, et al. Trauma Informed Care: A Systematic Review [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2025 Jan. 3, Results. PDF version of this title (1.9M) Disable Glossary Links In this Page Overview Contextual Questions Findings for Key Question 1: TIC for Adults Findings for Key Question 2: TIC for Children/Youth Recent Activity Clear Turn Off Turn On Results - Trauma Informed Care: A Systematic Review Results - Trauma Informed Care: A Systematic Review Your browsing activity is empty. Activity recording is turned off. Turn recording back on See more... Follow NCBI Twitter Facebook LinkedIn GitHub NCBI Insights Blog Connect with NLM Twitter Facebook Youtube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov