Journal of Child and Youth Care Work Copyright 2015 by the National Organization

of Child Care Worker Associations, Inc./0741-9481

TRAUMA-INFORMED CARE: AN ECOLOGICAL RESPONSE

Carmela J. DeCandia, Psy. D.

Center for Social Innovation

Kathleen Guarino
American Institutes for Research

Exposure to traumatic stress is increasingly understood as a common denomi-

nator of children and youth across service systems. Unlike the usual stresses of
our daily lives, traumatic experiences occur outside the realm of usual experience,
threaten one’s life or bodily integrity, and invoke intense feelings of helplessness,
powerlessness, and terror (American Psychological Association, 2008). These
events “overwhelm the ordinary systems of care that give people a sense of con-
trol, connection, and meaning” (Herman, 1992).
Exposure to traumatic experience is common for children and adolescents
across service systems. For example, in community samples, more than two-thirds
of children report experiencing a traumatic event by age 16 (Copeland, Keeler, An-
gold, & Costello, 2007). One in four children attending school have been exposed
to a traumatic event (National Child Traumatic Stress Network Schools Commit-
tee, 2008), and over 80% of children and youth who live in dangerous neighbor-
hoods have experienced trauma (National Center for Children in Poverty, 2007).
Interpersonal violence is one of the most common forms of traumatic stress for
children and youth. Based on the National Survey of Children’s Exposure to Vio-
lence (NatSCEV), 38% of children and youth ages 2–17 reported more than one
type of direct victimization in the previous year, and nearly half (49%) suffered
two or more types of direct or indirect victimization (Finkelhor, Turner, Ormrod,
Hamby, & Kracke, 2009).
Advances in the neurological and developmental sciences have brought an
explosion of evidence demonstrating the devastating, long-term impact of trau-
matic stress on the developing brain and body (Center on the Developing Child at
Harvard University, 2010; Felitti et al., 1998; Felitti & Anda, 2010; Shonkoff et al.,
2012a, 2012b; Shonkoff & Phillips, 2000; van der Kolk, Roth, Pelcovitz, Sunday, &
Spinazzola, 2005). As severe stresses and traumatic events accumulate, the physi-
ological and psychological impact becomes more profound, resulting in a range of
adverse responses including neurobiological changes, difficulties regulating affect,
and problems forming supportive relationships (Cook et al, 2005; National Scien-
tific Council on the Developing Child, 2005; van der Kolk et al., 2005). As a result,
many survivors of trauma suffer the debilitating consequences for the remainder
of their lives.
Historically, health and human service systems have served people who have
experienced trauma without understanding its impact and the need for tailored
8 Journal of Child and Youth Care Work

responses (Harris & Fallot, 2001). However, as the science of traumatic stress has
evolved, it can no longer be ignored in public systems of care. This recognition has
galvanized a cross-sector call to action, from the local to federal levels, to adopt
trauma-informed care as a practice across service settings (Report of the Federal
Partners Committee on Women and Trauma, 2011).
Trauma-informed care represents an emerging shift in paradigm and prac-
tice. An ecological approach, trauma-informed care can be viewed as a universal
design for serving trauma survivors; the entire system is used as a vehicle for in-
tervention (Bloom, 1997; Clervil & DeCandia, 2013; Guarino et al., 2009; Guarino,
2014; Harris & Fallot, 2001; Hopper, Bassuk, & Olivet, 2010; Substance Abuse and
Mental Health Services Administration (SAMHSA), 2014). Trauma-informed care
is a “strengths-based framework that is grounded in an understanding of and re-
sponsiveness to the impact of trauma that emphasizes physical, psychological, and
emotional safety for both providers and survivors; and creates opportunities for
survivors to rebuild a sense of control and empowerment” (Hopper, Bassuk, &
Olivet, 2010, p. 82). Accomplishing this requires a commitment and a coordinated
effort at all levels—federal, state, and local—to changing the practices, policies,
and cultures of entire organizations within and across systems, using knowledge
of trauma and recovery to design and deliver services (Guarino et al., 2009; Gua-
rino, 2012).
This article provides a comprehensive review of trauma-informed care—its
evolution, current models and practice, and evidence base. First, we discuss the
contextual factors underlying this paradigm shift. Next, we review the current
state of the field, and lastly, we conclude with a discussion of research, policy, and
practice implications. We pose the following questions: Is the field ready to em-
brace this paradigm and respond with a new perspective and practice? How can
the pitfalls of the past be avoided? What will it take to build and sustain a truly
trauma-informed system of care?

The Evolution of Trauma-Informed Care

As a society, we have a long history of alternately denying and prioritizing
traumatic stress as a cause of suffering (Bloom, 2000; Herman, 1992; McFarlane,
2000; Ringel, 2012). When denied, the paradigm of individual responsibility and
individual pathology leading to a “blame the victim” mentality prevails; when pri-
oritized, social context and the impact of environment, experience, and relation-
ships on human development are seen as central to the cause of, and solution to,
human suffering. In her book, Trauma and Recovery, Herman (1992) writes, “The
study of psychological trauma has a curious history . . . Periods of active investi-
gation have alternated with periods of oblivion. Repeatedly, in the past century,
similar lines of inquiry have been taken up and abruptly abandoned, only to be
rediscovered much later . . . It [the field] has been periodically forgotten and must
be periodically reclaimed” (p. 7).
DeCandia, Guarino 9

Why does this occur? To study or treat those affected by traumatic stress de-
mands engaging with the reality and magnitude of violence and abuse in our so-
ciety. Often the feelings associated with this reality are too much to bear (Ringel,
2012). “The larger society will continue to deny the magnitude of the problem, not
only because of the emotional arousal exposure causes, but also because it is be-
coming increasingly clear that fixing the problems and actually preventing trauma
will cost a great deal” (Bloom, 2000, p. 45). Denial allows us to distance ourselves
from the feelings and moral obligations to act; the consequence is that pathology
and intervention are situated within the individual rather than the social realm
(Bloom, 2000; Herman, 1992; McFarlane, 2000).
Shifts in society’s consciousness about trauma often occur following periods
of war (Herman, 1992; McFarlane, 2000; Ringel, 2012; Terr, 1990) and when sup-
ported by social, humanitarian, and political movements (Bloom, 2000). For exam-
ple, the acceptance of posttraumatic stress disorder (PTSD) in the Diagnostic and
Statistical Manual-III in 1980 was preceded by almost two decades of cultural and
political movements focused on civil rights, as well as the ending of the Vietnam
era that for the first time graphically televised the trauma of war to the American
public. This period supported the reemergence of the study of traumatic stress
among veterans and linked it to the trauma of rape survivors and child abuse
(Benedek & Ursano, 2009; Bloom, 2000; Figley, 2002; Kramer & Greene, 1997; Mc-
Farlane, 2001; SAMHSA, 2014).
The current sociopolitical climate, including post-9/11 and military actions
Operation Iraqi Freedom and Operation Enduring Freedom, combined with the
mounting neurodevelopmental research on the prevalence and impact of trauma,
and the recognition of the social determinants of health (e.g., family and commu-
nity factors), have created a context ripe for further evolution of the trauma field.
Traumatic stress is once again being viewed as central to the problems of those
served by our health and human service systems, and ecological responses that
can be brought to scale are gaining favor. This context has begun to unite policy-
makers, researchers, and service providers, setting the stage for the current para-
digm shift to trauma-informed care (Report of the Federal Partners Committee on
Women and Trauma, 2011; SAMHSA, 2014).

Awareness of Violence and Trauma in the Lives of Children, Youth, and

Families
Over the past two decades, researchers have documented the prevalence of
trauma in the lives of children and youth across service sectors; the staggering
numbers are impossible to ignore. For the nearly 500,000 children in the foster
care system (U.S. Department of Health and Human Services, 2012), traumatic
experiences include abuse, neglect, and significant family stressors (Stukes Chi-
pungu & Bent-Goodley, 2004). In the juvenile justice system, up to 90% of youth
reported having experienced at least one traumatic event (Ford, Hartman, Hawke,
10 Journal of Child and Youth Care Work

& Chapman, 2008). Of psychiatrically hospitalized adolescents, 93% have histories

of physical or sexual and emotional trauma (Lipschitz et al., 1999). In addition,
children in the homeless service system demonstrate high rates of lifetime trauma
(Anooshian, 2005; Gewirtz, 2010). By age 12, 83% have been exposed to at least
one serious violent event (Bassuk et al., 1996; Bassuk et al., 1997; Buckner, Beard-
slee, & Bassuk, 2004).
The rates of trauma for children’s parents across service sectors are also ex-
traordinarily high. For example, in the public mental health sector, 51–98% of adult
clients with severe mental illness have experienced childhood physical or sexual
abuse (Cusack, Frueh, Heirs, Suffoletta-Maierie, & Bennett, 2003; Goodman et
al., 1999; Mueser et al., 1998). In substance abuse settings, 75% of clients report
histories of significant trauma (Jennings, 2004).
Exposure to interpersonal violence is considered a major cause of post-trau-
ma responses for women (Report of the Federal Partners Committee on Women
and Trauma, 2011). It is so widespread that many consider it a normative ex-
perience. In a nationally representative survey, nearly 1 in 5 women reported
experiencing rape at some time in their lives, and more than 1 in 3 women have
experienced rape, physical violence, or stalking by an intimate partner (CDC,
2012a; CDC, 2010). In mental health settings, over 50% of women report ex-
periences of domestic violence (Friedman & Loue, 2007; Mowbray, Oyserman,
Saunders, & Rueda-Riedle, 1998). In the criminal justice sector, 96% of female
offenders have experienced trauma (Sarchiapone, Carli, Cuomo, Marchetti, &
Roy, 2009), most often related to sexual abuse and domestic violence (Battle,
Zlotnick, Najavits, Gutierrez, & Winsor, 2002; Zlotnick, Najavits, Rohsenow, &
Johnson, 2003).
Low-income populations are disproportionately affected by trauma and
served by social service systems of care. Unemployment and severe poverty, con-
ditions that unduly affect African American and Latino populations, leave many
low-income adults feeling frustrated, ashamed, and hopeless, and at increased risk
for relationship violence (Catlett, Toews, & Wahilko, 2010; Daly, Power, & Gon-
dolf, 2001; Heise & Garcia-Moreno, 2002; Kantor & Jasinski, 1998). For example,
research indicates that over 90% of severely poor, homeless mothers have a life-
time history of trauma (Bassuk et al., 1996, 1997; Hayes, Zonneville, & Bassuk,
2013), 81% experienced multiple traumas, and more than half were victimized as
children (Hayes, Zonneville, & Bassuk, 2013). Similarly, low-income minority men
experience high rates of violence in their lives, few social supports, and high rates
of PTSD (National Center for Injury Prevention and Control, 2003; Rich & Grey,
2005). The consequences of untreated trauma for mothers and fathers can be pro-
found for the next generation.
DeCandia, Guarino 11

Neurodevelopmental and Economic Impact of Trauma

A growing body of research has emerged on the impact of traumatic stress.
Advancing knowledge of the neurobiology of trauma offers compelling evidence
of its long-term impact on the brain and body, and the significant costs to society
when trauma goes unaddressed.
An event becomes traumatic when it overwhelms the neurophysiological
system for coping with stress and leaves people feeling unsafe, vulnerable, and
out of control (Herman, 1992; Macy, Behar, Paulson, Delman, & Schmid, 2004).
In the face of a confirmed threat, the amygdala and hypothalamus, structures in
the limbic system—the brain’s emotional control center—activate the body’s sur-
vival responses: fight (actively confronting the source of the stress), flight (avoid-
ing the stress), or freeze (shutting down) (Cohen et al., 2002; Perry, 2001; Saxe et
al., 2006). Neurohormones, including adrenaline and cortisol, prepare the body
for action to combat the threat and protect itself, and later, support a return to a
physiological state of balance once the threat has passed (Perry & Pollard, 1998;
Perry et al., 1996). Real and perceived threats continually retrigger the stress re-
sponse, causing a person’s neurological system to go into a state of disequilib-
rium. In this constantly dysregulated state, an array of maladaptive behavioral
responses can develop.
For children, exposure to early and ongoing traumatic stress (e.g., child abuse,
neglect, family violence) without adequate parental and other supports can lead to
a “toxic stress” response that has profound effects on brain development (Center
for the Developing Child at Harvard University, 2010; Cook et al., 2005). The neu-
robiological impact of prolonged heightened stress responses and elevated stress
hormones includes changes to brain architecture and to the functioning of neural
pathways including those associated with learning, memory, and the ability to
self-regulate and cope. Also, it results in a heightened baseline state of physiologi-
cal arousal and increased sensitivity to internal and external triggers (Cohen et al.,
2002; National Scientific Council on the Developing Child, 2005; Perry, 2001; Perry
et al., 1996; Putnam, 2006; Saxe et al., 2006). These alterations place children at
greater risk for adverse developmental, emotional, functional, and academic out-
comes (Berliner, 2006; Cook et al., 2005; Fairbank & Fairbank, 2009; Hopson &
Lee, 2011; van der Kolk et al., 2005).
Trauma that goes unrecognized and unaddressed in childhood has long-
term individual and societal implications. The groundbreaking Adverse Child-
hood Experiences (ACE) Study highlights the significant connection between
childhood exposure to trauma and adverse adult outcomes. Specifically, mul-
tiple ACE (e.g., physical or sexual abuse, witnessing violence) are associated
with social, emotional, and cognitive impairment; high-risk behaviors as cop-
ing mechanisms (e.g., eating disorders, smoking, substance use, self-harm);
severe health problems; and greater risk of early death (Felitti & Anda, 2010;
Felitti et al., 1998).
12 Journal of Child and Youth Care Work

The cost of not addressing trauma in both human and economic terms is sig-
nificant. PTSD, often a chronic condition lasting for many years, is comparable
to that of other serious mental disorders (Kessler, 2000). For example, for female
victims of domestic violence, 50% suffer from clinical depression and 24% meet
criteria for PTSD (Goodwin, Chandler, & Meisel, 2003). Children who witness
domestic violence also suffer from high rates of PTSD, depression, and anxiety
and are at greater risk for becoming perpetrators of violence as adults (Ehrensaft
et al., 2003; Kitzmann, Gaylord, Holt, & Kenny, 2003; Renner & Slack, 2006; Wolfe
et al., 2003).
It is estimated that for domestic violence alone, the total cost across health,
justice, and child serving systems is $37 billion annually (National Center for Inju-
ry Prevention and Control, 2007). In addition, the lifetime cost for child maltreat-
ment per victim is approximately $210,000 in 2010 dollars (Fang, Brown, Florence,
& Mercy, 2012). Just one year of confirmed cases of child maltreatment is estimated
to cost approximately $124 billion (Fang et al., 2012; CDC, 2012b). Costs impact
healthcare, employment, child welfare, criminal justice, and education. Taken to-
gether, the extraordinary toll that traumatic stress and interpersonal violence can
take on individuals and society necessitates that we address trauma, and its im-
pact, across all systems of care.

An Ecological View of Trauma and Intervention

Awareness of trauma and advances in the science of traumatic stress have
helped practitioners in the field to understand, diagnose, and address posttrauma
responses. PTSD is now a well-established diagnostic category (American Psychi-
atric Association, 2013); as a diagnosis, it is unique in its focus on context in the
cause and relief of symptom expression (United States Department of Veterans
Affairs, 2014).
Within the field, there is growing interest in understanding more about the
complex manifestations of PTSD and its relationship to individual and external
factors, (e.g., age of onset, number and type of traumatic experiences, social sup-
ports, and family and cultural context) (Cook et al., 2005). In particular, much
attention has recently been paid to understanding the dynamic relationship be-
tween risk and protective factors. Research on trauma and resiliency highlights the
importance of factors beyond individual traits in the human response to traumatic
experiences (Bonanno et al., 1995, 2002, 2004; Bonanno, 2014; Cutuli & Herbers,
2014; Harvey, 2007; Masten et al., 1999, 2011; Masten & Coatsworth, 1995, 1998;
Masten, Herbers, Cutuli, & Lafavor, 2008; Pat-Horenczyk, Rabinowitz, Rice, &
Tucker-Levin, 2009). This represents a move away from a strictly medical model of
individual illness towards a broader understanding of how environmental factors
impact functioning and recovery (Bloom, 1997; Harvey, 2007; SAMHSA, 2014).
Trauma-informed care represents an ecological approach to trauma interven-
tion based on the understanding that (a) environmental factors influence well-
DeCandia, Guarino 13

being; (b) health is, at least in part, socially-determined; and (c) interventions must
target individual, interpersonal, and community systems (Bronfenbrenner & Mor-
ris, 1998; SAMHSA, 2014; Saxe et al., 2006). This approach reflects a heightened
awareness of context and the role that providers play in hindering or fostering
recovery for trauma survivors (Harris & Fallot, 2001; Jennings, 2008). From an
ecological perspective, organizations and systems are seen as critical targets of
trauma intervention. As such, the focus of interventions expands beyond the in-
dividual therapy hour into the larger environment. As the paradigm shifts from
asking survivors “what’s wrong with you,” to “what happened to you” (Harris
& Fallot, 2001; SAMHSA, 2014), trauma-informed care broadens the approach to
intervention from “how can I fix you” to “what do you need to support your devel-
opment and recovery?”

Trauma-Informed Care: Current Models and Practice

As an outgrowth of the study of traumatic stress, trauma-informed care is
relatively new. The U.S. Department of Health and Human Services Substance
Abuse and Mental Health Services Administration (SAMHSA) spearheaded this
movement and led the call for trauma-informed care. The seminal Women Co-
Occurring Disorders and Violence Study, a five-year multisite study that began
in 1998, was the first federal effort to address the service needs of women with
co-occurring substance use and mental health disorders who experienced trauma
and helped set the federal direction around trauma-informed care (Moses, Reed,
Mazelis, & D’Ambrosio, 2003). SAMHSA continues to be a leader in the field in de-
fining and integrating trauma-informed care with efforts including supporting the
National Child Traumatic Stress Network (NCTSN) to develop and pilot interven-
tions to address the mental health impact of traumatic stress on children; launch-
ing its National Center for Trauma-Informed Care (NCTIC) to provide training
and consultation to support service systems, particularly behavioral health, to ad-
dress trauma; and most recently, developing a comprehensive treatment improve-
ment protocol (TIP) to set the standard for trauma-informed care in behavioral
health (SAMHSA, 2014).
In addition to federal leadership, many others played an early role in shap-
ing the field of trauma-informed care. The National Association of State Mental
Health Program Directors (NASHMPD), who passed a resolution in 1999 to rec-
ognize the pervasive impact of violence and trauma, called for trauma-specific
services in mental health agencies, and developed criteria for building a trauma-
informed mental health system (Power, 2011). In 2001, Maxine Harris and Roger
Fallot published Using Trauma Theory to Design Service Systems, and articulated an
early vision of trauma-informed care in social service systems. In addition, Sandra
Bloom’s Sanctuary model brought trauma-informed care to the therapeutic milieu
within residential treatment and beyond (Bloom, 1997).
14 Journal of Child and Youth Care Work

Current Models and Tools for Implementing Trauma-Informed Care

A range of established models and tools have been developed to help orga-
nizations become trauma-informed. In Using Trauma Theory to Design Service Sys-
tems, Harris and Fallot (2001) articulate a comprehensive array of strategies that
organizations can take to adopt trauma-informed care. To accompany this book,
Community Connections developed Creating Cultures of Trauma-Informed Care
(CCIT), a model that includes (a) a trauma-informed services self-assessment
and planning protocol; (b) a trauma-informed self-assessment checklist; and (c)
a trauma-informed services implementation form (Fallot & Harris, 2011). Sandra
Bloom’s Sanctuary model offers organizations concrete tools for operationalizing
the model’s core principles within milieu settings (Bloom, 1997). The Sanctuary
Institute offers intensive training and consultation over several years to fully adopt
the model.
In addition to these models, there are a number of organizational self-assess-
ments to guide agencies through the change process including Maine’s System
of Care Trauma-Informed Agency Assessment for child serving agencies (Yoe,
Hornby, Goan, & Tiernan, 2012); The National Council for Behavioral Health’s
Organizational Self-Assessment (National Council for Behavioral Health, unpub-
lished); the Chadwick Center’s Trauma System Readiness Tool for child welfare
agencies (Chadwick Center for Children & Families, 2013); and The National Cen-
ter on Family Homelessness’s Trauma-Informed Organizational Self-Assessment,
adapted for homeless service settings, such as agencies that serve women veterans
and community-based organizations that serve displaced children and families
(Clervil, Guarino, DeCandia, & Beach, 2013; Guarino et al., 2009; Guarino, 2011).
Assessment tools include concrete benchmarks of trauma-informed care for daily
practice. Though not formal measures of the extent to which an organization is
trauma-informed, these tools provide a valuable roadmap and process for organi-
zation-wide, trauma-informed change.

Key Components of Trauma-Informed Care

Providing trauma-informed care requires an organizational commitment to
building employees’ awareness, knowledge, and skills to support recovery. At min-
imum, trauma-informed organizations endeavor to do no further harm and avoid
retraumatizing clients (Moses, Reed, Mazelis, & D’Ambrosio, 2003). Core prin-
ciples of trauma-informed care across models include trauma knowledge, safety,
choice, empowerment, and cultural competence (Hopper et al., 2010). Regardless
of the services an agency provides, organizations can adopt these trauma-informed
principles to assist those they serve in reaching goals and achieving success.
Providing trauma-informed care requires an organization-wide commitment
to translating principles into concrete practices across all areas of programming.
Although variability exists across current models, organizational domains identi-
fied as areas to target for developing trauma-informed practices include (a) sup-
DeCandia, Guarino 15

porting staff development; (b) creating a safe and supportive environment; (c) as-
sessing and planning services; (d) involving consumers; and (e) adapting policies
(Guarino et al., 2009).

Implementation: Challenges of Shifting Models

In traditional service systems, the impact of trauma is not well understood by
providers, and traumatic experiences are generally not seen as related to problems
or symptoms. Service providers are viewed as experts, and compliance by the cli-
ent is expected. Force and coercion may sometimes occur to ensure compliance
(Prescott, Soares, Konnath, & Bassuk, 2008; Jennings, 2008; Bloom, 2000). Tra-
ditional systems may also cause additional harm by engaging in retraumatizing
practices that mimic past trauma (e.g., rigid rules, lack of confidentiality, and harsh
and punitive discipline practices) (Jennings, 2004, 2008). These experiences often
leave trauma survivors feeling abused by the system and reluctant to trust service
providers (Bloom, 2000; Elliott et al., 2005; Harris & Fallot, 2001; Jennings, 2008).
Without an awareness of trauma and its impact, service providers run the risk
of misunderstanding, misdiagnosing, and mistreating children and youth. Trau-
matized children and youth may seem emotionally out of control, avoid taking
responsibility, and appear disruptive or withdrawn (Hodas, 2006). Providers may
label these children as “oppositional” or “spacey” (Guarino & Bassuk, 2010), or
misdiagnose them as having ADHD, bipolar, or oppositional-defiant disorders
(Cook et al., 2005; D’Andrea et al., 2012). Viewed on the basis of presenting symp-
toms alone, providers are likely to overlook the underlying traumatic experiences
that may be the source of dysfunction (Cook et al., 2005; D’Andrea et al., 2012).
With training in trauma-informed care, providers and organizations can shift
their perspectives and practices from the traditional to trauma-informed. For ex-
ample, children’s responses once viewed as disruptive are now understood as
survival skills developed in response to earlier traumatic experiences. Changes in
policies and practices may include (a) providing regular staff training on trauma
and its impact; (b) reducing potentially triggering or retraumatizing practices such
as restraint; (c) creating physical and emotional safety in relationships and in the
environment; (d) using questions about trauma in all assessment protocol; and (e)
giving survivors a voice and choice in all aspects of treatment (Guarino et al., 2009;
Hopper et. al., 2010; SAMHSA, 2014). Finally, a trauma-informed approach takes
into account the impact that working with trauma survivors has on providers (e.g.,
secondary traumatic stress) and includes practices to create a culture that supports
provider self-care.
Implementing trauma-informed care is not without its challenges. The service
delivery context, organizational values, and characteristics of providers and clients
can affect training effectiveness and service delivery. In many health and human
service organizations, delivery of quality services is often hampered by high staff
turnover, resistance to change, limited resources, inadequate training opportuni-
16 Journal of Child and Youth Care Work

ties, limited career ladders, and uninformed provider work attitudes (Atkins et al.,
1998; Glisson et al., 2008a, 2008b; Lorenzi & Riley, 2000; McKay et al., 2006; Sex-
ton & Kelley, 2010). Limited time for staff to attend trainings and limited supervi-
sory and clinical capacity can present real barriers to delivering trauma-informed
care. Additionally, many providers in community agencies view the initiation of
trauma-informed care as akin to opening Pandora’s Box. They fear creating needs
that cannot be met (Moses et al., 2003), and many express fear of having to deal
with difficult topics like sexual abuse. Resistance to creating trauma-informed ser-
vices, however, often stems from a lack of knowledge about the impact of trauma,
uncertainty of appropriate service responses, and for some providers, unresolved
personal traumas.
Despite these challenges, trauma-informed care represents a relatively low-
cost and high-yield investment to address the high rates of trauma for children,
youth, and families. The primary investment in staff training and workforce de-
velopment ensures all those working with children and families have knowledge
of trauma. Systems change demands commitments by leadership to set clear ex-
pectations of how organizations will and will not operate and to ensure staff have
the resources they need to do the job. Current research suggests that the potential
benefits to children, youth, and families far outweigh the cost of system change.

Evaluation and Outcomes of Trauma-Informed Care

Evaluation and Measurement

Currently, there is not one standard of measurement to assess to what degree
an organization is trauma-informed and if an organization providing comprehen-
sive trauma-informed care produces better outcomes for the children and families
served. As an organizational framework, trauma-informed care encompasses ev-
erything from the physical environment to the quality of client interactions with
staff. Without a standard of measurement, it is difficult to definitively link the de-
gree of “trauma-informedness” of an organization (e.g., high or low trauma-in-
formed) to indicators of well-being for children and families, (e.g. PTSD symptom
reduction, a decrease in child welfare or justice involvement, and an increase in
residential stability).
Over the years, research utilizing various organizational climate scales has
been done to identify factors within the environment that affect staff attitudes and
behaviors, as well as treatment outcomes (Friedman, Clickman, & Kovach, 1986;
Holahan & Moos, 1982; Moos & Moos, 1983; Lemke & Moos, 1987). One of the
most well-known social climate scales is the Community Oriented Programs En-
vironment Scale (COPES) (Moos, 1974). Developed by Rudolph Moos to evaluate
the social environment of residential treatment facilities for emotionally disturbed
children, this standardized social climate scale assesses a program’s internal func-
tioning and allows for comparison across programs. The Survey of Organizational
DeCandia, Guarino 17

Functioning (SOF) measures organizational climate and culture, motivation for

change, and staff attributes (Lehman, Greener, & Simpson, 2002). The Center for
Disease Control’s (CDC’s) questionnaire, the KABB, measures the effectiveness
of a training program on intimate partner violence (IPV) by focusing on health
professional staff’s knowledge, attitude, beliefs, and behaviors (Gadomski et al.,
2001; Soliman, 2001).
Although organizational climate scales can be used to assess an organiza-
tion’s culture, to date none of these have been adapted or tested to specifically
measure the degree and effectiveness of trauma-informed care. Process tools that
help organizations become trauma-informed provide benchmarks for organiza-
tional change, but these tools are not validated, standardized instruments with
psychometric properties. A review of literature suggests that no standardized in-
struments of trauma-informed care currently exist.

Outcomes
In 2010, Hopper, Bassuk, and Olivet conducted a comprehensive review of the
field to assess the level of trauma-informed care as an emerging, promising practice.
Their review included a synthesis of published quantitative and qualitative studies,
community-based program evaluations, and unpublished pilot studies. They also
made contact with programs that were utilizing trauma-informed care models, and
gaps in the field were identified. A variety of promising outcomes were found.
The most studied model to date is Sanctuary (Bloom, 1997). A series of studies
have been conducted to assess the extent to which programs using Sanctuary were
operating as therapeutic communities, as compared to traditional residential treat-
ment units (Rivard et al., 2003; Rivard et al., 2004; Rivard, Bloom, McCorckle, &
Abramovits, 2005). Assessed using various combinations of organizational scales,
such as COPES, youth measures (for example, Rosenberg Self-esteem Scale and
the Child Behavior Checklist), and focus groups, positive changes in residential
treatment environments serving youth have been noted (e.g., greater empathy by
staff and greater sense of safety in environment). Focus groups indicated a growing
awareness and understanding among staff of trauma and its impact, however only
minor effects were noted on individual client behaviors.
Overall, preliminary outcomes associated with trauma-informed care include
decreased emotional reactions for program participants, decreased crises in pro-
grams, enhanced sense of safety, and greater collaboration among service provid-
ers (Community Connections, 2002; Cocozza et al., 2005; Morrissey, Ellis, & Gatz,
2005; Noether et al., 2007). A few pilot programs have demonstrated some im-
provement in client functioning in trauma-informed service settings (Morrissey,
Jackson, & Ellis, 2005; Kramer, unpublished), suggesting that trauma-informed
care is a cost-effective approach to addressing trauma as compared to standard
or traditional programming (Domino, Morrissey, Chung, Hunington, Larson, &
Russell, 2005).
18 Journal of Child and Youth Care Work

Implications and Next Steps for the Field

The study of traumatic stress evolved alongside significant cultural and po-
litical shifts that brought trauma into society’s consciousness. This context sup-
ported the rights of the victimized, prioritized the need for healing relationships
and recovery-oriented environments, and politically gave “voice to the disempow-
ered” (Herman, 1992, p. 9). The concept of trauma-informed care emerged from
this ever-evolving recognition and understanding of trauma and the role of the
broader environment in addressing this public health issue.
Despite the recent calls for trauma-informed care across service sectors, the
current discourse indicates a lack of clarity. Providers, policymakers, funders,
and researchers vary widely in their understandings of the concept and use of
the term, and may disagree about the relative efficacy of trauma-specific services
versus trauma-informed care. Trauma-specific services refers to clinical interven-
tions that treat symptoms of PTSD. Trauma-informed care refers to practices and
policies that can be implemented by entire organizations, not just clinical staff, and
involves modifications to organizational culture and practice (Guarino et al., 2009;
Harris & Fallot, 2001; SAMHSA, 2014). Despite the distinction, sometimes the
terms are used interchangeably, which confounds the evidence base.
Currently, the field has an array of process tools that assist organizations in
becoming trauma-informed, but data are lacking about the effectiveness of trau-
ma-informed environments (Hopper et al., 2010). To move forward, the evolution
of trauma-informed care will require (a) a clear consensus on the definition, prin-
ciples, and components of trauma-informed care to create a uniform set of practice
guidelines; (b) instrumentation to measure its effectiveness and assess organiza-
tions to capture their degree of trauma-informed care and its link to client-level
indices of well-being; (c) methodologically rigorous studies to build the evidence
base of trauma-informed care as a framework and complement to trauma-specific
services, and; (d) public and private support, at the federal, state and local levels, to
fund research and implementation.
Taking these next steps will require a shift in priorities and a commitment by
leaders at all levels to invest in developing the human service workforce. In this time
of shifting paradigms, we have a choice. If we simply react to its current popularity
only to lapse back into more comfortable and familiar patterns, we run the risk of
trauma-informed care being nothing more than a passing fad. However, if we re-
spond by acknowledging the extent of trauma in the lives of children and families,
we can transform our systems to be more responsive to all. Compared to the human
and economic toll of unaddressed trauma, trauma-informed care implemented across
service systems represents a relatively low-cost approach to address human suffering.
DeCandia, Guarino 19

Conclusion
Given the widespread prevalence of violence and trauma in the lives of chil-
dren and families, there is a consensus that all service systems become “trauma-
informed” (Report of the Federal Partners Committee on Women and Trauma,
2011; SAMHSA, 2014). However, there remains a lack of clarity about the concept
and inconsistency in its implementation (Hopper et al., 2010). Shifting from the
dominant paradigm is no small feat. Professionals are often reluctant to let go of
accepted models or theories that are familiar, and systems are strongly resistant
to change (Lorenzi & Riley, 2000). Are we ready to shift our public service sys-
tems and respond to trauma in coordinated, evidence-based ways? Are we ready
to invest in the human service workforce, many of whom are paraprofessionals, to
make trauma-informed care a standard of care? If we don’t make this investment,
it is likely that the current wave of interest will crest and eventually succumb to the
forces of history as we once again deny the extent of trauma in the lives of children
and families. When we look into the eyes of a child who has experienced trauma,
the real question we must ask ourselves is: how can we not?

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