A Realist Systematic Review of Trauma Informed Practice in Inpatient and Residential Child and Adolescent Settings

Background: Many young people who receive psychiatric care in inpatient or residential settings in North America have experienced various forms of emotional trauma. These settings can exacerbate trauma sequelae. Common practices, such as seclusion and restraint, put young people at risk of retraumatization, development of comorbid psychopathology, injury, and even death. In response, psychiatric and residential facilities have embraced trauma-informed care (TIC), an organizational change strategy which aligns service delivery with treatment principles and discrete interventions designed to reduce rates of retraumatization through responsive and non-coercive staff-client interactions. After more than two decades, a number of TIC approaches have shown favorable results. Largely unexamined, however, are the features that lead to successful implementation of TIC, especially in child and adolescent inpatient psychiatric and residential settings.

Methods: Using methods proposed by Pawson et al. (2005), we conducted a modified five-stage realist systematic review of peer-reviewed TIC literature. We rigorously searched ten electronic databases for peer reviewed publications appearing between 2000 and 2015 linking terms “trauma-informed” and “child*” or “youth,” plus “inpatient” or “residential” plus “psych*” or “mental.” After screening 693 unique abstracts, we selected 13 articles which described TIC interventions in youth psychiatric or residential settings. We designed a theoretically-based evaluative framework using the active implementation cycles of the National Implementation Research Network (NIRN) to discern which foci were associated with effective TIC implementation. Excluded were statewide mental health initiatives and TIC implementations in outpatient mental health, child welfare, and education settings. Interventions examined included: Attachment, Self-Regulation, and Competency Framework; Six Core Strategies; Collaborative Problem Solving; Sanctuary Model; Risking Connection; and the Fairy Tale Model.

Results:  We  hypothesized that ideal implementation would involve: 1) community inclusion; 2) leadership commitment; 3) model selection; 4) workforce transformation; 5) outcome orientation; and 6) shared maintenance. We found two large discrepancies between our original program theory model and the data we analyzed systematically: 1) the sequence of implementation activities undertaken, particularly activities to ensure patient and family participation; and 2) the importance of choosing a particular program model. Ultimately, we found five factors that were instrumental in successful implementation of TIC across a spectrum of initiatives: 1) senior leadership commitment; 2) sufficient staff support; 3) amplifying the voices of patients and families; 4) aligning policy and programming with trauma informed principles; 5) and using data to help motivate change.

Conclusions:  This review suggests that TIC initiatives which are comprehensive, theoretically grounded, and developmentally-informed may reduce seclusion, restraint, and staff and patient injury rates. They may also add value by improving clinical outcomes. Although not definitive, a train-the-trainer rather than purveyor model may produce financial efficiencies and generate longer term change in organizational culture. Importantly, quality assurance efforts explicitly focused on reducing potentially injurious and coercive physical interventions may also result in significant positive changes. Given the broad array of age, developmental needs, and clinical presentations in child and youth inpatient and residential settings, TIC may best be implemented on a unit-by-unit or agency-by agency basis.