Enablers and barriers to trauma-informed systems, organisations and workforces: evidence review

Section 3: Key findings – Enablers

Nine key enablers of successful trauma-informed approaches were identified:

• Workforce development
• Organisational readiness / pre-intervention strategies
• Trauma-informed leadership
• Training and education for parents, carers and people with experience of trauma
• Use of trauma screening or routine enquiry (where appropriate)
• Adoption of strengths-based approaches
• A flexible approach
• Promoting involvement, positive relationships and effective communication with stakeholders
• Extended implementation periods

3.1 Workforce development

Professional or workforce development is often described as a driver for change, essential when it comes to implementing trauma-informed practices within different systems. Different aspects of trauma-informed workforce development that have been described in the literature as effective are set out below.

Education – staff training

Staff training has been identified as an essential element of trauma-informed approaches that helps staff understand difficult behaviours and regulate their own performance, leading to a decrease in reactive and punitive responses helping avoid escalation (Avery et al., 2021).

In Diggins' (2021) study, staff received a 2-day group training on the Sanctuary Model at the beginning of their employment in an Australian specialist school for emotional and behavioural difficulties. This training addresses the four core areas of the model, which include:

• trauma theory,
• the Sanctuary commitments of organisational practice,
• the Safety; Emotion; Loss; Future framework (focused on shared language)
• the Sanctuary toolkit (community meetings, self-care plans, and individual safety plans for all members of the institution).

The Sanctuary model promotes understanding of the effects of trauma and coping strategies at the organisational level. Similarly, the ReLATE model (see Diggins, 2021) offers training on Therapeutic Crisis Intervention (TCI) to staff at the beginning of the trauma-informed intervention. The training is delivered in group sessions over two days, with lectures and individual coaching focusing on management of critical incidents, recovery and behavioural tools and strategies, and motivational interviewing. This was provided together with practice-based instruction of de-escalation, crisis management, injury reduction, or stress handling.

TIES (Trauma-Informed elementary Schools), a program based on the Attachment, Self-regulations, and Competency (ARC) framework, focused on delivering trauma-informed services within primary education and offering early intervention to children who have experienced trauma (Tabone et al., 2020). The main aims of TIES are providing trauma identification training for school staff and developing trauma-informed school environments through training for parents and teachers, and classroom consultation including the provision of a liaison figure (therapist) to help teachers identify and address signs of trauma.

In their literature review of school-based trauma-informed approaches implementation, Avery et al. (2021) conclude that allowing teachers to have an active role in training planning and delivery, together with creating space for them to share the systemic challenges they face was a key element of service design and delivery.

Child welfare – staff training

Murphy et al. (2017) consider that all members of care teams working within child welfare systems must be trained for certain trauma-informed strategies (such asTrauma Systems Therapy) to be successful, regardless of how closely they work with the children. All, from caregivers and therapists to service co-ordinators, influence the child's experience and are essential.

Other studies considered trauma-informed training as part of wider strategies such as CONCEPT, a programme implemented state-wide in Connecticut (Connell et al., 2019; Lang et al., 2016). Here, trauma-focused training was delivered pre- and in-service at a system-wide level to all the child-welfare workforce and was one of the best rated aspects of the programme. Staff training was supported by the development of a group of trauma champions, who acted as liaisons with relevant staff.

Several studies adopted a more complex training strategy providing post-delivery support and advanced training to certain members of staff. in their state-wide trauma-informed care (TIC) implementation, Jankowski et al. (2019) provided training on TIC principles and its implementation within the child protection and justice systems. They also provided training in using the Mental Health Screening tool (MHST), which is used to assess child wellbeing and exposure to trauma. Post training support was also available three months after delivery to help staff interpret and communicate the results of MHST and to guide them in effectively adopting this screening strategy. Advanced training was provided to trauma specialists or champions to support the implementation of TIC.

Lang et al. (2016) described the mandatory training that was part of the adoption of the CONCEPT project. This training was delivered pre- and in-service for child welfare staff. It followed a "train-the-trainer" format and was based on the National Child Traumatic Stress Network (NCTSN) Child Welfare Trauma Training Toolkit (see Lang et al., 2019). The toolkit's curriculum focused on enhancing staff's child-trauma related knowledge and on the promotion of trauma-informed practice across different levels of the child welfare system.

Akin et al. (2017) highlight the significance of providing training to staff while considering their workload and the importance of their jobs. They highlighted the need to consider and use established systems and processes to integrate and deliver training. Considering a hybrid delivery method (web-based and in-person activities) could also be a facilitator to promote effective and efficient training.

Community-based interventions – staff training

Training all staff was a priority in the study conducted by Hales et al. (2019). These authors implemented a TIC intervention within a non-profit organisation which provided services for people experiencing problematic substance use, mental health difficulties and homelessness. Mentors and trainers were recruited from senior staff and programme directors in the organisation; staff across the agency could volunteer to become mentors as well. After receiving a three-hour "Trauma 101" session, a team comprised of the mentors, a programme director and a counsellor delivered the training. Having all staff receive the initial training helped create a common trauma-informed language and knowledge, sharing across the agency.

Health – staff training

Racine et al. (2021) aimed to help tackle the gap in the literature exploring the association between TIC approaches and health outcomes for mothers and new-borns. They implemented a multi-layered TIC initiative in a maternity clinic to evaluate the impact of adopting a TIC for women whose pregnancies were considered low-risk. Training played a key role in this intervention since some of its core components included training a peer champion or training physicians and staff offering primary care. The peer-champion, who was a physician, received trauma training and followed a model (Awareness, Desire, Knowledge, Ability and Reinforcement; ADKAR) to manage change and resources. They then delivered training to staff via voluntary retreats or online learning activities, which were attended by most staff. The aim of these training and educational activities were to understand the impact of trauma on those who experience it, and on the need to cultivate empathy and understanding towards them. The training strategy also targeted staff skills building, including motivational interviewing and trauma screening techniques.

Azeem et al. (2017) delivered training to staff working at a child and adolescent psychiatric hospital in the US with the aim of assessing the effectiveness of trauma-informed strategies in reducing the use of seclusions (where patients are temporarily segregated from other patients) and restraints. The training was based on six core trauma-informed and strength-based care strategies, which focused on principles of primary intervention (see Azeem et al., 2017). These were developed by the National Association of State Mental Health Program Directors (NASMHPD) and included: leadership towards organizational change, use of data to inform practice, workforce development, use of restraint and seclusion reduction tools, improve consumer's role in inpatient setting, vigorous debriefing techniques.

Regarding curriculum content, there seems to be a deficit of trauma-informed primary care providers (PCPs), despite the high prevalence of trauma and trauma-related symptoms amongst the general population. Gundacker et al., (2021) conducted a literature review to identify trauma-informed curricula for PCPs, considering their effectiveness and research gaps. The most common topic addressed by the different curricula was "understanding the health effects of trauma". Additionally, they identified different methods and modes of training delivery such as online, within the setting, or hybrid. However, there is a need to expand the research to determine the most beneficial elements of online versus on-setting delivery. The main educational elements identified in this review included "tangible resources for providers to refer to during the clinical encounter", or "continuing medical education credit for the training", which incentivises participation in the training (p. 854). It was followed by 71% of the investigations focusing on patient-centred communication and care. Additionally, 53% of the studies reviewed discussed Kirkpatrick level 3 behavioural changes in assessment outcomes with higher rates of trauma screening and communication. However, no changes were reported in referrals.

Gundacker et al. (2021) concluded that trauma-informed curricula improved PCPs confidence and abilities to deliver TIC, increasing their knowledge about the impact of trauma on health outcomes (Kirkpatrick's level 2). Their attitudes towards patients who experienced trauma improved as well, and changes on the PCPs behaviour were also reported (Kirkpatrick's level 3). Therefore, the authors conclude that other organisations looking to deliver trauma-informed training to PCPs could use or adapt the curricula they describe in their review. The TIC framework they describe together with the Kirkpatrick levels can also be used, depending on the needs of their programme. However, this review has to be understood considering that it was mainly based on small pilot studies. More research is necessary to understand the impact of trauma-informed training on short- and long-term results (Kirkpatrick's level 4) (Gundacker et al., 2021).

Youth Justice – staff training

Baetz et al. (2021) assessed the impact of a trauma-informed intervention on violence rates at two juvenile detention institutions in the US. It focused on delivering trauma-informed training for staff and a skills development programme for the young people in these facilities. The curriculum delivered to staff was known as Think Trauma (see Baetz et al., 2021) and focused on developing a shared knowledge and language related to exposure to trauma and its impact on the behaviours of young people, as well as staff wellbeing and organisational outcomes. A "train-the-trainer" approach was used, and the key components of this curriculum included the impact of trauma on young people involved in the juvenile justice system, trauma and the development of children and adolescents, supporting young people develop healthier coping strategies, as well as secondary trauma, self-care and stress at the organisational level. Training sessions took place over a period of eight weeks.

Multi-Agency – staff training

Damian et al. (2017) studied the impact of a training-based, nine-month TIC strategy implemented at city-wide level in Baltimore (USA). The goal of the training delivered was to promote the implementation of the six trauma-informed principles described by the USA Substance Abuse and Mental Health Services Administration (SAMHSA): "1) Safety, 2) Trustworthiness and Transparency, 3) Peer Support, 4) Collaboration and Mutuality, 5) Empowerment, Voice and Choice, and 6) Cultural, Historical and Gender Issues" (p. 3). This training was delivered to professionals working in the areas of Law Enforcement, Social Services, and Health and education who interacted with people with experience of trauma. Different activities such as coaching sessions, feedback from trauma experts about implementing TIC in their workplaces were used to deliver that training. This project was based on multi-agency collaboration.

Barnett et al. (2018) divided their 3-year TIC training-based implementation within a youth residential treatment centre and accompanying special needs school into different phases. These involved: 1) needs assessments involving leaders and administrators to deliver a programme tailored to the agency's requirements, 2) promoting buy-in and strategic planning, 3) delivering voluntary training and coaching sessions to staff, and 4) internal sustainment of training and reflective practice group sessions. For the training delivery, a train-the-trainer approach was taken, and an internal trauma specialist delivered six (voluntary) ongoing training sessions and reflective practice group sessions to staff. Staff involvement in these training sessions was high, and, if they met the criteria, they received a pay increase. This strategy later evolved, and trauma training was embedded in staff orientation for new recruits.

Enhancement of staff capacity (other than training)

Schools: The ReLATE model included staff debriefing in response to critical incidents in schools (Diggins, 2021). These debriefing sessions lasted 90 minutes and involved staff who had witnessed the incident, and school leaders such as the principal and psychologist. The debriefing process included reflective practice and behavioural analysis. This was complemented with additional coaching opportunities during supervision meetings. Teacher coaching was used to translate knowledge into practice, deemed an essential element of successful school-based trauma-informed implementation (Avery et al., 2021). Teacher coaching can be delivered in the form of group sessions (Day et al., 2015, Dorado et al., 2016), workshops, or via specialist support (Perry and Daniels, 2016).

Child welfare: The CONCEPT initiative, implemented at state level in Connecticut (Connell et al., 2019; Lang et al., 2016) considered secondary staff trauma as a way of providing staff support and promote their wellbeing. Staff working within child welfare systems are particularly vulnerable to secondary traumatic stress due to their regular involvement with the consequences of these children's traumatic experiences (see Lang et al., 2016). The CONCEPT project included an employee support and wellness team per office. These teams, who were provided annual funding organised regular meetings and used local resources to promote staff's wellbeing. Some examples include creating a wellness room for staff to use during crises, or workshops delivery on topics such as stress management or physical wellbeing. In the fourth year of the implementation of CONCEPT, state-wide training was delivered for staff, along with follow-up consultation on secondary trauma (Connell et al., 2019).

Community-based interventions: enhancing staff capacity was the focus ofinterventions like Building Connections, which focused on increasing the capacity - through enhanced relational and trauma-informed approaches - of service providers in community-based projects to help them identify and respond to interpersonal violence (Singh et al., 2020). The general goals of the Building Connections initiative were to raise awareness about how to effectively support mothers and their children experiencing interpersonal violence and disseminating and evaluating the implementation of an intervention focused on interpersonal violence delivered to mothers. Additionally, staff coaching was offered in the study developed by Hales et al. (2019), where trauma coordinators observed staff during key points of their routine and provided relevant support about the use of language, promoted team building or helped walk staff through the program.

Culture change

Schools: promoting culture shifts is one of the aims of workforce development described in different school-based interventions. For Perry and Daniels (2016) focused on enhancing staff capacity and developing expertise to provide trauma-informed services to students. Workforce development seems to be crucial for driving trauma-focused changes because it provides staff with a broad understanding of trauma and its impact on learning, as well as with strategies to interact with students (who might have experienced trauma) more effectively. Initial staff training and intensive follow-up training to ensure culture shift, supported by collaborative bespoke training design and continuous opportunities for staff debriefing and discussion, are some of the strategies recommended by Avery et al. (2021).

Reflective practice

Child welfare: while adopting the Sanctuary Model, reflective practice helped staff identify strengths, areas for improvement and ways in which they can address challenges more effectively. Reflective practice encourages continuous learning and critical reflection of staff practices and performance (Galvin et al., 2021).

Community-based interventions: reflective conversations were used in the study conducted by Hales et al. (2019),which focused on the implementation of TIC in a non-profit organisation providing services for substance use, mental health and homelessness. These reflective conversations were implemented during staff meetings, facilitated by senior staff and directors. The aim of these conversations was to critically analyse policy, procedures and practices that could lead to re-traumatisation, and identify areas of focus to strengthen their trauma-informed approach. Additionally, these conversations focused on prompting safety, trust, choice, and empowerment for everyone in the organisation (ibid).

Multi-agency level: Barnett et al. (2018) included reflective practice groups to promote the sustainment of their trauma-informed programme implemented in a youth residential treatment centre and accompanying special needs school. Staff could participate in the reflective practice groups after completing six voluntary training sessions.

3.2 Organisational Readiness / pre-intervention strategies

Organisational readiness should be carefully considered before implementing trauma-informed approaches.

Schools

According to Avery et al. (2021) school readiness and motivation, together with the availability of appropriate systems and resources are essential to guarantee successful TIC implementation. Leadership engagement with and support of the intervention is also crucial in this regard, as is the alignment between the intervention and the needs, values, policies, and practices of the school. Two examples of implementations efforts developed to explore these areas include Perry and Daniels (2016) and Day et al. (2015), who developed implementation workshops and the bespoke co-design of training to meet schools needs to ensure the successful implementation of trauma-informed practices.

Child Welfare

Jankowski et al. (2019) conducted a needs assessment as part of the TIC project in the Trauma-Informed Care Initiative in a State Child Welfare System in New Hampshire, USA. The needs assessment was informed via interviews and focus groups with different stakeholders, including children, families and staff from child welfare services or juvenile justice. The results of this needs assessment were combined with the results of the Chadwick Trauma System Readiness Tool (TSRT) to pilot-test the intervention. The intervention was then modified according to the results of the pilot study.

Akin et al. (2017) describe the benefits of using pre-implementation needs assessment strategies in three US state-wide trauma-informed projects. They highlighted how these approaches can help define the needs of the population, gaps in the service and practice, readiness for change or challenges to implementation. Having a needs assessment phase in TIC implementation can also help promote buy-in, promote change, and plan the intervention.

Multi-agency level: Barnett et al. (2018) conducted a pre-intervention needs assessment before they implemented a TIC initiative within a youth residential treatment centre and special needs school. The researchers met with leaders and administrators in the institution to design a tailored intervention that would meet their needs and requirements, which they consider was part of what led to their successful results.

3.3 Trauma-informed leadership

Strong and committed roles models seem to be essential in the implementation of trauma-informed approaches.

Child welfare

Bunting et al. (2019) identified "leadership buy-in" (promoted via training senior managers, developing implementations plans, etc.) as a key element to promote organisational change within child welfare systems. According to Galvin et al. (2021) "leadership and / or champions were non-negotiable" (p. 4) in the implementation of the Sanctuary Model. These authors add that although some of the managers and coordinators initially only followed the trauma-informed Sanctuary Model because they felt they "had to" (ibid), they sustained doing so because they believed in its benefits.

Seeing those in positions of leadership putting the model in practice and encouraging others to do so was essential for implementation. This is particularly relevant when implementing organisation-wide initiatives, where those in positions of influence and power should be the ones driving change and promoting buy-in at different levels of the organisation. Champions are those people with a higher level of knowledge and understanding of trauma, who are at a privileged position to steer change within the organisation (see Hales et al., 2019).

A key component was introducing Trauma-Informed Leadership Teams (TILTs). These teams focused on developing and supporting the structure for the integration of a community-based TIC system (Bartlett, et al., 2019). The membership of TILTs were formed by a wide range of professionals involved in different areas of the child welfare system, such as education, early intervention or legal services. Their role was to enhance collaboration between the different relevant systems to ensure practices were more responsive to young people and families with lived-experience of trauma. Having a team structure promoted increasing awareness of the impact of childhood trauma and enhanced the sharing of best practices and service gaps across different systems. It also helps reduce obstacles to accessing evidence-based services.

Bartlett et al. (2016), focused on assessing the improvements in TIC reported by clinicians after being involved in the project for a year. After reviewing meeting documentation (content, frequency of meetings, attendance, etc.) and conducting interviews with "key informants" about the first-year of implementation (retention, activities, challenges, etc.), the authors saw that TILTs were involved in a wide range of activities, reaching a varied audience. These activities included self-assessment, organising training about childhood trauma, mental health roles for child welfare staff or delivering wellness classes to address secondary stress within staff. They also provided training to parents and schools and focused on creating a positive and welcoming space for children and families.

Additionally, the learning collaborative model was employed as a key element of the dissemination of information about evidence-based treatment amongst health providers, due to its potential in supporting the implementation of evidence-based treatment (EBT) amongst mental health providers (see Bartlett et al., 2016). The learning collaborative model, considered a tool for developing governance and leadership at different TIC levels, comprises of a 1-year educational strategy based on in-person learning sessions and intensive EBT consultation. Leadership plays a key role in this model, which understands it as a key factor for promoting change and sustaining new initiatives. This is reflected the approach taken, which is based on bringing together teams of health professionals. It is essential that within those teams there is a senior leader with capacity and authority to make decisions about the programme and changes to policy, and who will focus on monitoring EBT and quality improvement (see Bartlett et al., 2016).

The state-wide project implemented by Jankowski et al. (2019) was directed by a leadership team involving administrators from the Division for Children, Youth and Families (DCYF) and several evaluators. This team met monthly to review policies, guide change, it also focused on removing barriers to the implementation of new practices and discussed evaluation activities and findings. Organisation leads then introduced the project to DCYF staff.

In the implementation of the Sanctuary Model, creating relevant teams and structures within the organisation was also seen as an effective driver of change (Galvin et al., 2021). These different teams came together regularly to monitor implementation and quality and challenge each other, which helped embed the Sanctuary Model in their organisation.

In the case of the CONCEPT project (Lang et al., 2016), central teams guided planning and implementation of the programme. These teams were comprised of managers, administrators, project coordinators, trauma experts or members of the evaluation team. The CONCEPT project also included the creation of subcommittees that reported to those central teams, regarding policy changes, implementation of evidence-based practices or workforce development. Additionally, volunteer trauma champions (a total of 40) were selected in the different facilities and offices involved in the project implementation. These trauma champion roles were taken up by different members of staff, including managers, supervisors, or clinical coordinators. Trauma champions were expected to deliver monthly training within their facilities. Some of the activities they develop included delivering training to foster parents, circulating newsletters, or hosting presentations delivered by local trauma-informed mental health professionals.

Community-based interventions

Hales et al. (2019) implemented an intervention within in a non-profit organization delivering services for substance use, mental health and homelessness. In this case, the authors prioritised that senior staff and managers receive trauma-informed training first with the aim of creating a foundation and promoting TIC buy-in at other levels. These senior members of staff and programme directors were then recruited as mentors to deliver training to all staff, which was one of the priorities of the intervention. After delivering the training, these mentors returned to their previous programmes and became TIC champions, acting as role models and points of contact for other staff during the implementation of the TIC programme. All programme directors became trauma champions, receiving additional training to strengthen their specialised trauma knowledge, and their roles and responsibilities, which included providing support and securing the TIC implementation in the organisation.

Justice system

Leadership teams were considered essential in the effective implementation of trauma-informed programmes. Baetz et al. (2021) highlighted that regular check-ins with the leadership team were essential to protect key areas of their multi-layered programme that might have otherwise have been deprioritised. Baetz et al. (2021) also described skill development groups delivered to the young people at the juvenile detention facilities where they implemented a multi-layered trauma-informed strategy aimed at reducing violent incidents.

3.4 Training and education for parents, carers and people with experience of trauma

Schools

Fondren et al. (2020), in their literature review of school-based trauma-informed interventions, identified some studies that delivered what they called Tier 1 prevention strategies, which focused on the promotion of positive behaviours and increasing socioemotional learning (SEL). According to Fondren et al. (2020), the most effective techniques, which were even more effective if delivered by teachers, "(1) involved sequenced activities, (2) provided activities for students to practice using learned skills, (3) emphasized the development of social skills, and (4) targeted SEL skills specifically, such as self-awareness, self-management, social awareness, relationship skills, and responsible decision making.

Parent training and consultation is also a key element of the Trauma-Informed elementary Schools (TIES) intervention, an educational early intervention focused on delivering trauma-informed services within primary education and offer early intervention to children who have experienced trauma. (see Tabone et al., 2020).

Child welfare

Lotty et al. (2020) assessed the effectiveness of the programme known as Fostering Connections, focused on TIC for child welfare agencies in Ireland. Fostering Connections is a trauma-informed intervention, based on psychoeducation with a group and experiential activities (i.e. uses exercises, videos, role-play, discussions, etc.). This initiative was delivered during 6 weeks within a community setting. Fostering Connections focuses on delivering cumulative content, focusing on trauma awareness, attachment, resilience, or collaboration. The principles of this programme, which align with the National Child Traumatic Stress Network (NCTSN), focus on promoting "trauma awareness, knowledge, and skills" of those involved in the child welfare system (Lotty et al., 2020, p. 4). This programme aims to promote trauma-focused awareness amongst foster carers as well as strategies to effectively develop healing connections with foster children. The rationale is for the intervention to reduce the children's trauma and address attachment difficulties.

Youth Justice

Baetz et al. (2019) studied the delivery of a trauma-informed intervention focused on reducing violence at two juvenile detention institutions in the US. This initiative delivered trauma-informed training for staff (see the "workforce development" section above) and a group skills development programme for youth in the facilities known as STAIR. The STAIR programme was based on the delivery of three sessions focusing on trauma education and feelings recognition, coping with difficult feelings, and effective communication. There is no specific order for these sessions, and participants also needed to complete a "trauma-informed safety plan" along with attending the three sessions, allowing participants to identify triggers, dysregulation, and coping skills. These groups were co-facilitated by a mental health professional and a counsellor. This training was offered to all youths in both settings.

Community-based interventions

Some initiatives share TIC information with their clients to ensure they are aware of the trauma-informed organisational changes and their purpose (Hales et al., 2019), and others (Racine et al., 2021) promoted patient awareness of mental health and trauma within a maternity clinic as part of the implementation of a multi-layered TIC initiative. Racine et al. (2021) also included the promotion of trauma awareness amongst the patients of the low-risk maternity clinic where they implemented a TIC strategy. With this aim, posters, brochures and online information on the clinic's website was facilitated, also with the objective of promoting mental health.

3.5 Use of trauma screening or routine enquiry where appropriate

Child welfare

In their literature review, Bunting et al. (2019), observed that trauma screening was a common strategy implemented in different studies, generally the result of trauma-informed training. Trauma screening can be used to identify children and young people who might need further assessment, support or treatment from trauma-informed services (ibid). According to Bunting et al. (2019) there are different ways of adopting trauma screening i.e. screening children in all child-welfare related cases, or only screening those going into care, or using the Trauma Screening Checklist to identify children and adolescents who needed trauma specialist services. However, independently of the strategy, trauma screening was positively perceived by child welfare and mental health staff.

Jankowski et al. (2019) describe the implementation of the Mental Health Screening Tool (MHST) as one of the main components of their project that implemented TIC in a state child welfare system. MHST is an online tool used to assess general child wellbeing and exposure to traumatic and post-traumatic experiences leading to stress symptoms. Specialist training and guidance was offered to staff to ensure the effective implementation of this screening strategy.

Community-based interventions

Racine et al. (2021) used standardised screening of ACEs and mental health symptomatology in their implementation of a multi-layered TIC strategy within a low-risk maternity clinic to evaluate the impact of TIC on mother and offspring outcomes. The first step toward the implementation of this strategy was delivering training to ensure staff had the skills to effectively use a trauma screening questionnaire and provide follow-up. When it came to the ACEs screening process itself, a handout was given to patients during their second prenatal visit with the aim of explaining the reason to ask about childhood trauma. After this, patients could voluntarily complete a 10-item version of the ACEs questionnaire. The results of ACEs screening were reviewed by the physician, focusing on the patient's mental health needs and available supports; referrals for follow-up were processed if needed.

3.6 Adoption of strengths-based approaches

Schools

Strategies with the aim of increasing connection, self-regulation skills or empathy were crucial organisational changes in the school-based studies reviewed by Avery et al. (2021). Replacing a punitive and reactive approaches for a healing, "strength-based and skill-building approaches" (p. 13) is supported by research exploring evidence-base trauma-informed care and practices.

Studies such as the programme implemented by Diggins (2021) included strategies to respond to critical incidents. In this case, the ReLATE model included the Life Space Interview (LSI) as a response to every critical incident that happened in the school (for instance, dangerous behaviours, injuries, physical assault). LSI included a structured staff-student discussion focused on self-regulation to avoid violent behaviours. Steps include empathic listening and helping the student identify adaptive behaviours. These interviews were adapted to the children's developmental stage, using storybooks and drawings to work with primary students, and conversational approaches with secondary students.

Additionally, the ReLATE program created individualised safety plans for each student, something they could use whenever they did not feel safe in the classroom. These safety plans were developed at the beginning of an academic year and included triggers and were adapted to the children's cognitive level (images for children in primary education and written language for secondary students (see Diggins, 2021). A key components of the Trauma-Informed Elementary Schools (TIES) programme is the provision of therapeutic interventions for children and their families. This includes the creation of comprehensive intervention plans developed by the schools' behavioural health services and children's families (Tabone et al., 2020).

Child-welfare

After reviewing relevant policy and practice manuals, a policy workshop developed a review tool stemming from Chadwick's essential elements of a trauma-informed system. This led to the change of 22 policies and practice guidelines and the production of a guide for trauma-informed resources to support these types of policies and practices. For example, the family Assessment and Response guidelines were updated to ensure it assessed signs of traumatic stress in the children, their caregivers' trauma history and the impact it might be having on their ability to care for the child (see Bunting et al., 2019). In the study conducted by Jankowski et al. (2019), a change of system-level policies and practices was promoted through the establishment of formal protocols to help integrate the new approach including new screening guidelines, case planning, and progress monitoring within the overall structure of the child welfare system.

3.7 A flexible approach

Child welfare

Creativity and flexibility as key elements of a trauma-informed approach ensure that model(s) can be adapted to the of service users and organisations. In the case of the Sanctuary Model (Galvin et al., 2021), ensuring young people had flexibility in the ways they could engage with the different programmes and initiatives related to the model, and allowing staff to creatively implement the model's principles worked particularly well. Initiatives like the MCTP are also characterised by its flexibility, which according to Barto et al. (2018) allowed for tailored service delivery, adapting to the individual needs of children and families.

According to Akin et al. (2017) inflexible work plans and protocols can prevent or limit the implementation certain initiatives. However, they report flexibility and continuous evaluation promoted the adjustment of practices, when needed, and the development of supports to promote successful adoption of trauma-informed approaches.

Multi-agency level

Damian et al. (2017) reported that TIC training led to more flexible and lees punitive policies towards clients. As a result of the training received, the government and non-profit professionals involved in this city-wide initiative mentioned changing their views regarding labelling youth and adopting a less rigid approach to working with service users. Additionally, they reported increased capacity to listen and pay more attention to the clients' needs.

3.8 Promoting involvement, positive relationships and effective communication with stakeholders

Schools

In Perry and Daniels' (2016) study of a school-based trauma-informed intervention, clinical services gave relevance to building relationships across all organisational levels. Rather than focusing on referral to external trauma-based services, the focus was on working with existing resources and building positive relationships within schools by delivering relevant workshops. More specifically, the aim was to identify and assess existing needs and supports already available at the school, strengthening relationships between staff and students, providing workshops at classroom level and trauma screening and clinical interventions for students. Perry and Daniels (2016) created Care Coordination teams, which helped establish supportive relationships with families, providing resources and coordinating care to address their overall needs. The constant communication facilitated by this strategy helped close a frequent gap in the interactions between families and schools. Additionally, in this school-based intervention, the focus was ensuring that the efforts to promote academic achievement did not outshine the specific support needs of students and families. Therefore, the intervention included personalised care guided by collaboration with the family and individual with the aim of covering the families' complex needs. Avery et al. (2021) reported that, together with care coordination teams, revising communication guidelines with stakeholders (staff, families, students, sider community) and interagency collaboration were enablers of the implementation of trauma-informed approaches.

The ReLATE intervention includes daily community meetings, at the beginning and end of the school day.. These meetings focused on three questions: "How are you feeling? What is your goal for today? and Who can you ask for help?" (Sanctuary Model, 2012, as cited in Diggins, 2021 p. 196). The aim of these questions was to increase emotional communication, supporting help-seeking behaviour and goal setting. These community meetings, which created a predictable daily routine for students, promoted a feeling of safety, which can support students who benefit from having clear structures (see Diggins, 2021).

TIES (Trauma-Informed elementary Schools) is a program aimed at offering trauma-informed early intervention to primary school children who have experienced trauma (Tabone et al., 2020). TIES is delivered at classroom level. The needs of children who have experienced trauma are addressed by developing healthy classroom environments facilitated by the collaboration between schools and families.

Avery et al. (2021) described that some of the studies in their literature review were interested in understanding students' views (see Day et al., 2015; Dorado et al., 2016). Considering students and their families' cultural values and needs was understood to promote empowerment, safety and the promotion of relevant cultural and gender principles of care, while strengthening the commitment to avoid re-traumatisation.

Child welfare

Several programmes developed within child welfare systems considered promoting engagement amongst service users as a key element of TIC implementation (Bunting et al., 2019). Some of the initiatives included trauma-informed training for parents and carers, promotion of community engagement or involvement in leadership teams. In the case of more grassroots approaches such as the Michigan Children's Trauma Assessment Centre, the emphasis was put on the development of community partnerships and on promoting community collaboration assessments including foster and birth parents. This particular initiative included using an assessment of TIC policies and practices, which helped develop the principles to implement TIC plans, something that was supported by consultation with the appropriate stakeholders. However, these initiatives were discussed in a mainly descriptive way, and they seemed to have targeted parents and carers, but not children and young people (ibid). Bartlett et al. (2016) conclude that the simultaneous, comprehensive implementation of TIC within the child welfare system and associated mental health services improves the inter-systems collaboration that is understood to be essential for the success of these initiatives.

In their description of three state-wide projects that implemented trauma-informed and evidence-based initiatives, Akin et al. (2017) discuss the efforts made in those projects to promote cross-agency and cross-system engagement. In this regard, they mention that different activities (e.g. training) were developed to promote stakeholder engagement and collaboration at all stages of implementation, including planning. These efforts promoted buy-in and helped address challenges. Additionally, establishing inter- and intra- agency teams seemed to be another essential part of TIC implementation. Having several of these teams can help deliver change, promote buy-in and engagement, and guide project implementation. These teams can also help address and prevent challenges, solve problems. However, it is important to consider their already high workload and ensure the intervention did not become a burden.

3.9 Extended implementation periods

Schools

Avery et al. (2021) reported a strong relationship between the longer length of implementation and reduction in behavioural difficulties.

Child welfare

Zhang et al. (2021), concluded that child-welfare TIC interventions had the largest effect size when implemented for a longer time (7 to 12 months), in comparison to those implemented for shorter periods. Murphy et al. (2017) maintained that longer implementation periods are a factor that helps observe certain changes that only take place over time, as is the case of changes in emotional difficulties.