Evaluation of Trauma Systems Therapy
With funding from the Annie E. Casey Foundation, Child Trends conducted a comprehensive five-year implementation and outcomes evaluation of Trauma Systems Therapy (TST) at KVC Kansas, a large child welfare and behavioral healthcare agency providing out-of-home care to children served by the Kansas Department for Children and Families. TST is a research-based therapeutic model developed by Glenn Saxe, M.D., to improve the functioning of children exposed to trauma. The purpose of the evaluation was to discover:
- how TST was integrated into the full continuum of care at KVC; and
- whether TST led to improvements in outcomes, including well-being, placement stability, and permanency, for the nearly 1,500 children who entered out-of-home care during the study period of 2011 to 2014.
Summary of findings
Incorporating trauma-informed care throughout KVC’s system of care was an intensive and iterative process carried out over multiple years. The effort was not viewed as a one-time initiative or one that would get subsumed by new priorities.
- KVC provided training to over 90 percent of their staff (including case managers, case manager supervisors, therapists, behavioral health technicians, and family service coordinators) and close to 70 percent of almost 400 foster parents. In addition to the large in-person trainings, an array of extended learning opportunities (for example, coaching, consultations, and web-based trainings) was offered.
- Multiple strategies were used to integrate TST into practice. KVC, in collaboration with the developers of TST, developed new tools, specific to a child welfare setting, that integrated knowledge of trauma and how it impacts children’s lives into the daily care of children.
- KVC staff’s fidelity to the TST model improved over time.
- The comprehensive, iterative, and inclusive nature of KVC’s implementation of TST resulted in the use of a common language within the system of care. Across KVC, staff now use the same terminology (for example, triggers, emotional regulation), which has created a more unified, supportive and productive environment.
We found that children’s exposure to TST (as measured by staff members’ implementation fidelity and foster parents’ exposure to training) is associated with improvements in children’s well-being and placement stability.
- Improvements in functioning and behavioral regulation are gained by sustained exposure to trauma-informed care over time.
- Improvements in emotional regulation are gained after exposure to trauma-informed care during children’s early days in care (first three months).
- Exposure to trauma-informed care promotes placement stability.
- It is unclear how, if at all, TST dosage is related to children’s permanency outcomes, perhaps because permanency is not solely determined by the child’s behavior.
Results of analyses examining the effects of individual members of children’s care teams implementation of TST (such as case managers, case manager supervisors, therapists, foster parents) suggest that, while professionals and caregivers may play unique roles in enhancing children’s well-being, no one individual is central to providing trauma-informed care.
- Trauma Systems Therapy, previously found to be effective in a clinical setting, can be effective in a large child welfare agency setting.
- Children’s emotional regulation, behavioral regulation, functioning, and placement stability can be enhanced by implementing TST across all levels of a foster care organization.
- Non-clinical staff—and, most importantly, foster parents—were open and willing partners in the provision of trauma-informed care, putting the training they received and tools they learned to use.
- No single individual is the cornerstone for improved child well-being.
Evaluation of Trauma Systems Therapy in Different Settings
Based on promising results from the KVC evaluation, The Annie E. Casey Foundation funded an adaptation of TST for implementation in a public child welfare setting— Trauma Systems Therapy-Foster Care (TST-FC). TST-FC was developed by Kelly McCauley with support from Glenn Saxe and Adam Brown, and was implemented along with TST clinical services in two child welfare agencies in different states. Child Trends conducted an implementation evaluation of TST-FC to address the following questions:
- How well and with what degree of fidelity was TST-FC implemented?
- Does TST-FC increase knowledge of staff and foster parents on impact of trauma on children, and improve their skills and approaches to caring for children who have experienced trauma?
- Is TST-FC associated with improvements in placement stability and resource home retention?
The evaluation sample included 111 foster parents and kinship caregivers (resource parents), 117 child welfare staff, 21 mental health providers, and 52 children placed in TST-FC trained foster homes, 25 of whom received TST-clinical services.
Summary of findings
Findings on TST-FC implementation included these:
- TST-FC was implemented with a high level of fidelity to the model.
- Both resource parents and child welfare staff had positive perceptions of the training and benefited from sharing a new language for talking about child trauma.
- Training for staff was less prescriptive and its implementation varied.
- Resource parents significantly increased their knowledge and skills about trauma and trauma-informed parenting, as well as their sense of parenting efficacy.
- Resource parents made significant gains in tolerating children’s misbehavior, praising children for positive behavior.
A preliminary investigation of child outcomes showed better resource home retention and placement stability among children living with resource parents who were trained in TST-FC, compared to those who were living with resource parents who did not participate in the training.
Findings from these recent evaluations suggest that TST is a promising approach for integrating trauma-informed care into child welfare systems. In particular:
- Resource parents and child welfare staff benefit from practical approaches and a common language for communicating about child trauma.
- Children who reside with resource parents trained in TST-FC had more stable placements.
- Resource parents who received training in TST-FC were less likely to close their homes to children in the foster care system.