Child Welfare,Juvenile Justice,Mental Health,and Education Providers’ Conceptualizations of Trauma-Informed Practice

Abstract

This study systematically examined child-service providers’ conceptualizations of trauma-informed practice (TIP) across service systems, including child welfare, juvenile justice, mental health, and education. Eleven focus groups and nine individual interviews were conducted, totaling 126 child-service providers. Conventional content analysis was used to analyze the qualitative data with interrater reliability analyses indicating near perfect agreement between coders. Qualitative analysis revealed that child-service providers identified traumatic stress as an important common theme among children and families served as well as the interest in TIP in their service systems. At the same time, child-service providers generally felt knowledgeable about what they define TIP to be, although they articulated wide variations in the degree to which they are taught skills and strategies to respond to their traumatized clients. The results of this study suggest a need for a common lexicon and metric with which to advance TIP within and across child-service systems.

Keywords

child PTSD/trauma child welfare definitional issues juvenile justice qualitative research service delivery

The Need for Trauma-Informed Practice (TIP) in Child-Service Systems

Over the last 20 years, studies have estimated that between 25% (Costello, Erkanli, Fairbank, & Angold, 2002) and 60% (Finkelhor, Turner, Ormrod, & Hamby, 2009) of youth in the United States are exposed to child maltreatment or other traumatic events. Although many youth demonstrate resilience after trauma exposure (Cicchetti, Rogosch, Lynch, & Holt, 1993), other youth who have been exposed to traumatic events demonstrate disruptions in their healthy development, and these concerns may continue into adolescence and adulthood (Kaplow & Widom, 2007; Lansford et al., 2002). After experiencing traumatic events, youth and their families may become involved with a number of different child-service systems, including the child welfare (Garland et al., 2001), juvenile justice (Abram et al., 2004), and mental health (Burns et al., 2004) systems. However, these systems have historically provided services without regard to, or conscious practice associated with, the high rates of trauma exposure of youth served.

In the United States, the child welfare (U.S. Department of Health and Human Services, 2015) and juvenile justice systems (Abram et al., 2004; Dierkhising et al., 2013) encounter large numbers of trauma-exposed youth. While all child-service systems aim to improve outcomes for youth, including those exposed to traumatic events, each system is differentially equipped to recognize and respond to the impact of trauma on youth, families, and service providers (Ko et al., 2008).

Child welfare

During the 2013 fiscal year, approximately 3.9 million children and adolescents were the subjects of at least one Child Protective Services report in the United States; approximately one-fifth of these reports (679,000) were substantiated (U.S. Department of Health and Human Services, 2015). Providers in the child welfare system are keenly aware of the traumatic event(s) that bring youth to the attention of Child Protective Services, but they may be less informed about the youth’s trauma history or its impact on the youth’s emotional or behavioral functioning (Conners-Burrow et al., 2013; Ko et al., 2008). Traditional child welfare practices, such as removal from the home, multiple placements in out-of-home settings (e.g., foster homes, group homes, residential treatment facilities), transfers to new schools, and separation from existing social support networks, may exacerbate the effects of the original trauma(s) (Cook et al., 2005; Ko et al., 2008).

Increased awareness of the pervasiveness of trauma has propelled the child welfare system to explore ways to ensure their services are more sensitive to trauma-exposed children and families (Conners-Burrow et al., 2013). In order to accomplish this, changes at the frontline, supervisory, and administrative levels can provide child welfare workers with the knowledge, skills, and tools to support trauma-exposed children through sensitive trauma-informed screening, evidence-based assessment and treatment, and other strategies (Fraser et al., 2014; Ko et al., 2008; Kramer, Sigel, Conners-Burrow, Savary, & Tempel, 2013). Moreover, high rates of secondary traumatic stress among child welfare workers lead to high rates of burnout and turnover among child welfare workers (Pryce, Shackelford, & Pryce, 2007; Sprang, Craig, & Clark, 2011). Such challenges further strengthen the rationale for the implementation of an approach to working with trauma-exposed youth in the child welfare system (Fraser et al., 2014).

Juvenile justice

Similar to the child welfare system, an overwhelming number of justice-involved youth report extensive trauma histories (Abram et al., 2004; Dierkhising et al., 2013). While trauma exposure and traumatic stress are recognized among youth within the juvenile justice system, the implementation of any system-wide approach to working with those youth is directly impacted by the complexity of the system. In fact, the juvenile justice system has been described as a “multifaceted array of interconnecting organizations,” including law enforcement agencies, courts, school, detention centers, and community rehabilitation programs, with each organization endorsing competing goals and directives (Ko et al., 2008, p. 400). The competing directives of public safety and rehabilitation may limit the ease with which juvenile justice workers may adopt and implement strategies for responding to trauma-exposed youth. For example, correctional facilities have traditionally operated from a public safety lens, using force, solitary confinement, and punitive disciplinary systems to manage the behavior of justice-involved youth (Burrell, 2013). Further, justice-involved youth are often retraumatized during routine entry into the juvenile justice system when exposed to arrest, detention, juvenile processing, and placement out of the home (Ko & Sprague, 2007). Therefore, if efforts are not made to address youth trauma within the juvenile justice system, the aforementioned practices may continue to contribute to increasingly deviant behavior, retraumatization, and chronic justice involvement (Ko et al., 2008).

Conceptualizing TIP Across Child-Service Systems

While all child-service systems aim to improve outcomes for youth exposed to traumatic events, each system is likely to approach trauma differently, with providers having varying levels of knowledge, skills, and capacities to assess for, and treat, traumatic stress (Ko et al., 2008). In response to such systemic disparities, researchers, practitioners, and policy makers have articulated the need for a comprehensive approach to service provision in child-service systems in which all programmatic practices, cultures, and policies are responsive to the impact of trauma (Harris & Fallot, 2001; National Child Traumatic Stress Network [NCTSN], 2012; Wilson, Fauci, & Goodman, 2015). We refer to this approach as TIP, although it is variably known as trauma-informed care (Conners-Burrow et al., 2013; Wilson et al., 2015), trauma-informed systems (Conradi & Wilson, 2010; Ko et al., 2008), or trauma-informed services (Elliott, Bjelajac, Fallot, Markoff, & Reed, 2005). The Substance Abuse and Mental Health Services Administration (SAMHSA, 2014) defines the approach to TIP as follows:
A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization. (p. 9)
As such, TIP represents far more than the sum of specific trauma-informed services offered, including trauma-informed evidence-based practices (Harris & Fallot, 2001). As articulated by Harris and Fallot (2001), TIP promotes the dissemination and implementation of evidence-based treatment and is not considered to be a treatment model or program.

Despite a decade of discussion on TIP (Hopper, Bassuk, & Olivet, 2010), there remains a dearth of empirical research on the how TIP is perceived by providers within child welfare, juvenile justice, mental health, and education systems. Research and conceptual frameworks developed to date have proffered the contours of TIP (i.e., its definition and key elements) as well as case examples of statewide TIP efforts. Gathering data on how frontline, supervisory, and administrative providers perceive TIP, and what they need and want to achieve desirable outcomes for themselves and their clients, allows for an understanding of key facilitators and barriers to TIP, as it is applied in child-service systems. Data from providers offer a unique perspective on the details of how TIP is viewed. The use of such data could inform TIP training efforts (e.g., NCTSN’s Child Welfare Trauma Training Toolkit; Child Welfare Committee, 2008) and eventually further the field by advancing a common conceptualization of TIP across diverse child-service agencies.

State-Level Initiatives to Develop Trauma-Informed Child-Service Systems

State agencies are in a unique position to accelerate progress in TIP, as prevention and intervention efforts are often developed and funded through county- and state-level systems (Bruns et al., 2008; Bumbarger & Campbell, 2012). However, research suggests that the field of implementation and dissemination is in a nascent state with regard to transporting trauma-informed evidence-based practices into public sector systems of care (Rukez & Rosen, 2009; Self-Brown, Whitaker, Berliner, & Kolko, 2012). Furthermore, the organizational climates and cultures in such systems are often not conducive to rapid programmatic innovation based on scientific evidence (Aarons & Sommerfeld, 2012; Green, Albanese, Cafri, & Aarons, 2014). State-level exploration and adoption may be further complicated by the absence of common language and definitions for key terms such as “evidence-based practice” (Self-Brown et al., 2012) and “trauma-informed systems” (Conradi & Wilson, 2010).

Despite the barriers, state-based models for the dissemination and implementation of effective practices are emerging (Becker, Stice, Shaw, & Woda, 2009; Bumbarger & Campbell, 2012; Rukez & Rosen, 2009). Optimally, these are community–state partnerships that promote a sharing of power and decision-making to create community-specific solutions to dissemination and implementation questions (Becker et al., 2009). For example, Arkansas, New York, and Maine are implementing TIP efforts in the child welfare (Kramer et al., 2013; Kramer et al., 2015), juvenile justice (Ferone, Salsich, & Fratello, 2014), and mental health systems (Maine Department of Health and Human Services, 2012). Efforts in Massachusetts are underway to implement TIP across mental health and child welfare systems (Fraser et al., 2014).

A similar initiative is underway in Minnesota. This initiative, known as the Ambit Network, aims to improve access to quality care for traumatized youth by establishing TIP across multiple child-service systems statewide and by creating a continuum of care linking providers in those systems to trauma-trained clinicians. In line with best practice standards in the cultivation of effective community-state partnerships (Bumbarger & Campbell, 2012), a needs assessment process was undertaken to gain an understanding of child-service providers’ conceptualizations of TIP and to build a statewide consensus for the need for TIP and its operationalization. The current study reports findings from that process.

The Present Study: Eliciting Conceptualizations of TIP Across Child-Service Systems

The purpose of the present study was to give child-service providers the agency to conceptualize and define what TIP means to them by soliciting knowledge about TIP, perceptions regarding the resources needed, and anticipated barriers to TIP implementation. Providers were also encouraged to reflect upon the outcomes desired to determine whether TIP is making a difference, and how service providers address secondary traumatic stress.

Method

The present study is embedded within a larger SAMHSA/NCTSN-funded project. Qualitative data collection, in the form of focus groups and individual interviews, was the third step in a six-step process to disseminate knowledge on TIP and secondary traumatic stress through workforce training initiatives. The focus groups and individual interviews followed the elicitation of support through the signing of a Memorandum of Understanding between state- and county-based child-serving systems and Ambit, as well as the identification of regional teams representing multiple child-serving systems and decision makers, hereafter referred to as leadership teams.

Participant Selection

The target population for this study was service providers within the child welfare, juvenile justice, mental health, and education systems of a large Midwestern state. Focus group participants were identified by the leadership team through purposive sampling methods (Palinkas et al., 2015). Each team had a champion who served as convener and acted as the liaison between the researchers and the target population in the region. Typically, this convener requested focus group participants through an e-mail sent to agency-level supervisors describing the research process, listing the interview questions, specifying the amount of time needed (i.e., 90 min), and indicating that participation was voluntary. The composition of each focus group varied depending on the needs of the region in which they were gathered. Leaders from one region elected to use individual interviews because of concerns that focus groups would not bring in the numbers of participants needed.

A total of eleven focus groups and nine individual interviews were conducted. Each focus group consisted of approximately 11 participants (µ = 10.6). All participants worked in service settings with youth who were likely to have experienced trauma exposure. The racial and ethnic makeup of participants was a reflection of the workforce. As such, participants were primarily Caucasian with the exception of participants from a region whose population included a tribal nation.

Sample

The overall sample was 126 individuals, 117 of whom were gathered in focus groups, and 9 of whom participated in individual interviews. In total, 56% of participants worked within the child welfare system (n = 71), 21% within the juvenile justice system (n = 27), 20% within the mental health system (n = 15), 6% within the education system (n = 8), and 3% within other systems (n = 4), including public health and law enforcement systems.

Data Collection Procedures

Recommended procedures for focus group data collection were followed (Krueger, 1994). A uniform set of focus group questions were developed in consultation with each leadership team and based on a review of regional needs assessments conducted for similar purposes (Allred et al., 2005; Hendricks, Conradi, & Wilson, 2011; Richardson, Coryn, Henry, Black-Pond, & Unrau, 2012). Focus groups began with introductions, after which the purpose of the focus group was explained along with the process for aggregating and distributing the deidentified information. Two facilitators and two recorders were trained to conduct and record, respectively, the focus groups. Nine individual interviews were also conducted and the resulting data were integrated into the focus group material. The interviews were conducted over the phone for convenience purposes and used a similar protocol to focus group data collection.

Each focus group and individual interview covered several areas. This study reports data from the following questions: (1) What is TIP? What does it mean in your system of care? (2) What are the barriers to TIP, and what are the resources you need to provide it within your system? (3) What do you want to learn about TIP? (4) What outcomes do you want to see to show that TIP is working? (5) How do you (or do you) address secondary traumatic stress in your service system or agency?

Data Analysis

A conventional content analysis approach (Hsieh & Shannon, 2005) was used to analyze the focus group and individual interview transcriptions. Given the semistructured nature of the data, line-by-line coding informed the development of a codebook for each of the five questions (Morse, 2015). Line-by-line coding was conducted through the use of ATLAS.ti software (Version 1.0.16 [82], 2013), allowing the coders to organize the data by question and child-serving system. Emic, or inductive, terms were preserved and incorporated into the analysis whenever possible (Maxwell, 2008). For example, when asked about ways to address secondary traumatic stress within their respective systems, some providers referred to system-specific strategies, such as “reflective practices” in mental health and “employee assistance programs” in juvenile justice. System-specific codes were preserved, sorted into categories based on existing relations, and these emergent categories were used to group codes into meaningful themes (Hsieh & Shannon, 2005). After the lead coder completed coding, one of the facilitators reviewed the codebook to confirm that the codes were an accurate representation of the data.

Next, 20% of the data (i.e., four separate focus groups or interviews) were randomly selected for interrater reliability analyses. A second coder received about five hours of training and subsequently coded the random sample of data with the codebooks described above. Similar semistructured qualitative research suggests that Cohen’s (1960) κ was an appropriate index of interrater reliability, or the degree to which coders consistently assign codes to similar segments of text (Morse, 2015). The resulting κs for each question indicated near perfect agreement (Landis & Koch, 1977): Question 1, κ = 0.93, SE(κ) = 0.05; Question 2, κ = 0.98, SE(κ) = 0.01; Question 3, κ = 1.0, SE(κ) = 0.00; Question 4, κ = 1.0, SE(κ) = 0.00; and Question 5, κ = 1.0, SE(κ) = 0.00.

Ethical Considerations

All facilitators and recorders were trained and certified in ethical procedures with human participants. Focus group and individual interview transcripts were deidentified and kept in password protected computer software, available only to the researchers. Identifying information was destroyed after the completion of the project.

Results

The following themes emerged through conventional content analysis of the eleven focus groups and nine individual interviews conducted across child-service systems. In general, overarching themes were common across systems. We have highlighted differences among system providers when they were evident and meaningful. Quotations (in italics) are used to illustrate common themes or motifs.

Question 1: What Is TIP? What Does It Mean in Your System of Care?

When child-service providers were asked to define TIP within their systems, three prominent themes emerged from data analysis: (1) TIP represents trauma knowledge, recognition, response, and skills; (2) TIP differs by system; and (3) TIP is an evidence-based practice that has been shown to support recovery for youth and families. However, there appeared to be varying levels of knowledge of TIP across child-service systems. In some systems, providers had attended trainings on trauma and how to appropriately intervene with trauma-exposed youth and families. In other systems, providers reported receiving few, if any, trainings on trauma and its impact on youth. Within the child welfare system, specifically, providers generally understood TIP as a “philosophy,” an “approach,” or an alternative way to think about the practice of intervening with trauma-exposed youth and families:
We need workers to understand [TIP] as practice instead of an event. It is a struggle to get workers to think this way; it is a different way of thinking.

Trauma knowledge, recognition, response, and skills

Data analysis revealed a host of themes in the characterization of TIP among child-service providers, including the idea that TIP represents a family-oriented perspective (i.e., “multigenerational approach to trauma,” “identifying family trauma history”), embodies a systems approach (i.e., “change across systems,” “cross-system collaboration”), and underscores a general understanding of evidence-based practices.

Looking more closely at the themes, providers within the child welfare and juvenile justice systems acknowledged that TIP is the embodiment of trauma awareness as well as trauma-informed skills that may be used when working with children and families exposed to trauma:
It’s about meeting families where they are, trying to understand what they’ve been through. You may need to tailor how you work with them, what they can handle, or how fast or slow you work with them. All of this is taken into account in trauma-informed practice.
In contrast, in other child-service systems, providers were introduced to the concept of TIP while participating in the focus groups and individual interviews. These providers often reported concerns about the community-wide awareness of TIP, and the inherent ambiguity of the term:

There’s no awareness of trauma-informed care and practice … The term ‘trauma-informed care’ is ambiguous, so it means different things to all of us.

System differences

Child-service providers also expressed concern that each system conceptualizes TIP differently. One mental health provider underscored the idiosyncrasies of TIP across various child-service systems:
People have different viewpoints on what trauma-informed practice is. I think my definition is probably different from someone else’s.
Alternatively, providers within the education system discussed the importance of differentiating TIP from other initiatives, and ensuring that community-wide TIP efforts are carefully planned with appropriate resources for integration into existing programmatic processes and policies:
People might not understand trauma-informed practice, and just hear that this is the new “whatever.” What does trauma-informed practice mean? We are in “initiative overload” and if people think this is just the next initiative, there would be pushback from all levels.

Use of evidence-based practices

When conceptualizing TIP more broadly, providers within the juvenile justice system articulated a need for evidence-based practices to become “best practice standards”:
Whatever we do, the model or practice needs to hold true to the best practice standard. Money is tight, and time is tight, and sometimes we take [best practices] and create things that work best for us.
This comment highlights the value placed on evidence-based practices, and the recognition that service providers often tailor programs and practices to better fit the context of the system (e.g., availability) as well as the specific needs of clients, families, agencies, and communities.

Question 2: What Are the Barriers to TIP, and What Are the Resources You Need to Provide It Within Your System?

Across child-service systems, providers expressed significant concerns about the potential resources needed for TIP. Specifically, four themes emerged during conventional content analysis: (1) resource barriers, (2) treatment barriers, (3) lack of a general trauma training, and (4) political and/or administrative barriers.

Resource barriers

Although providers from all child-serving systems articulated concern regarding a lack of funding and time when implementing TIP in their respective organizations, child welfare providers expressed the greatest concern. Specifically, child welfare providers reported a significant lack of funding within their system to implement initiatives like TIP. Many providers referred to high caseloads, limited staff time, and a lack of familial transportation to trauma-informed services (e.g., “neuropsychological evaluations,” “trauma-informed therapy”).

Treatment barriers

Other providers felt that their communities lacked appropriate trauma treatment. For instance, within the child welfare and public health systems, many barriers were related to the affordability and accessibility of trauma-informed treatments. Further, the majority of service providers reported that many families lacked appropriate insurance coverage and that even in cases in which families have insurance coverage, there are often few trauma-informed mental health providers within their communities:
We have had more awareness of trauma-informed treatment recently; however, we still lack providers. In other words, providers and clinicians [who] really provide trauma-informed services.

Given the dearth of trauma-informed treatments within their communities, many child-service providers expressed a lack of knowledge of appropriate community referrals for the treatment of youth trauma.

General trauma training

When asked to identify specific resources, or additional supports needed to implement TIP within systems, providers reported an overarching need for foundational cross-system trauma training. For instance, one mental health professional described a universal lack of education about trauma within the community:
Every department, every program, every community member feels trauma and can see it, but doesn’t have the education or awareness to put a label on it.
Across systems, child-service providers called for a foundational trauma training to provide a common language, while also establishing collaborative processes across systems:
It would be nice to have everyone at the same table, saying the same thing, have the collaboration right there. Have everyone going to training, so they all hear the same thing.

Political and/or administrative barriers within and across systems

A final theme that emerged from data analysis was a profound awareness that TIP implementation would be influenced by political and administrative barriers within and across service systems. One service provider articulated the idea that lasting internal changes must start from the administrative level:
We need leaders who are willing to make these trainings available for all of us, schedule times to consult, allow for the sharing of practice. They all have good intentions, but with “too many cooks in the kitchen,” or too few, things will crumble. We need the infrastructure set up to support trauma-informed practice and care as it moves along.

Question 3: What Do You Want to Learn About TIP?

Three prominent themes emerged from conventional content analysis with respect to child-service providers’ prominent learning interests, including (1) knowledge of specific TIP skills, (2) the implementation of trauma screening and assessment, and (3) specific trauma treatment training.

Specific TIP skills

Throughout the focus groups and interviews, providers reflected upon the utility of understanding TIP as an “ideology,” versus a “process” or planned procedure for care:
We not only need to present a theme, but we need to have a plan so [providers] know what they need to do and how to do it. Ideologies are not the best way for [providers] to talk about something. They need a laid-out process.

Further, providers from both child welfare and juvenile justice expressed a clear desire for trainings that could impart concrete, specific skills to be used when working with children and families exposed to trauma:
The hardest thing to do is put [TIP] into practice … If providers are going to come to a training, they want to leave the trainings with tools they can use in their practice.
Similarly, a provider from the juvenile justice system stated:
I’m a nuts and bolts kind of guy. I need something that says, “This kid has this kind of trauma and here are things you can use to help that kid.” Basically, I need a written recipe that states, “This is the way to address it,” or something that staff can use on the job.

Trauma screening and assessment

In addition to the call for trainings that address utilitarian skills and tools that can be used in everyday practice, both child welfare and juvenile justice providers identified trauma-informed screening and assessment as a second limitation when implementing TIP in their systems. For instance, one child welfare worker stated:
We need a generalized screening tool so kids can get where they need to go faster. Something that sends up a red flag right away. [We] also [need] a decision tree for really complex cases …

Trauma treatment training

In contrast to TIP trainings that impart a specific skill set, child welfare providers shared that they are in need of a series of trainings about evidence-based trauma-informed treatments, and their availability within the community. Child welfare providers were also interested in knowing “what makes trauma-informed treatment or therapy better than other types of therapy?” For example, one child welfare worker stated:
[We need] a series of ongoing trainings about what is available and what is going on in trauma-informed care.
This pervasive sentiment is likely related to child welfare providers’ concerns about limited referral options within their respective communities. In contrast, mental health providers expressed a desire for increased accessibility to trainings addressing the treatment of specific types of trauma (e.g., “sexual abuse,” “physical abuse”).

Question 4: What Outcomes Do You Want To See to Show That TIP Is Working?

Providers identified four key outcomes if TIP were to be implemented within their agency or system. These outcomes are at the level of (1) children and/or adolescents, (2) families (i.e., biological or foster), (3) child-service providers, and (4) child-service systems and/or the community.

Children and/or adolescents

Across systems, providers uniformly spoke to desirable system-specific outcomes. For instance, within the child welfare system, providers reported a strong interest in observing the following child-level outcomes: decreased mental health symptoms, drug use, recidivism, and increased engagement and satisfaction within treatment programs. Providers from the juvenile justice system similarly identified system-specific outcomes, including decreased emotional and behavioral difficulties along with decreased recidivism. They also acknowledged increased academic success and community functioning as favorable outcomes within the juvenile justice system.

Families (i.e., biological and foster parents)

When discussing family-level outcomes after the implementation of TIP, child welfare providers hoped to observe improved family health, increased caregiver satisfaction, as well as decreased familial recidivism in the child protection system. In contrast, juvenile justice providers mainly spoke to increased parental engagement and satisfaction.

Child-service providers

Child welfare providers were some of the only professionals to describe provider-level outcomes with respect to TIP success. Providers reported an interest in seeing TIP benefit staff members through “lower caseloads,” and increased knowledge about which mental health professionals use evidence-based treatments for trauma.

Child-service systems and/or the community

Across all child-service systems, providers reported that the most demonstrable community outcome would be increased access to trauma-informed therapy. In other words, providers acknowledged that there are not enough community practitioners trained in trauma treatment or trauma-informed evidence-based practices.

Question 5: How Do You (or Do You) Address Secondary Traumatic Stress in Your Service System or Agency?

Child-service providers from all systems reported the limited existence of resources for secondary traumatic stress and, in general, providers felt that additional resources would be beneficial (e.g., “supervision,” “trainings,” and “system acknowledgment”). While mental health providers felt the most supported to disclose the effects of secondary traumatic stress in their workplace, juvenile justice providers were the most hesitant about training in, or additional resources for, secondary traumatic stress. For example, a juvenile justice provider stated:
I think the workforce would be resistant [to addressing secondary traumatic stress]. Staff do not necessarily feel they have permission or an invitation to have that conversation.
However, one provider in the juvenile justice system acknowledged the critical importance of secondary traumatic stress in his or her work:
I love the idea of trauma-informed practice, but it is more important to start with secondary trauma. How are we going to go out and ask these questions? … What is the information I am gathering and how is that impacting me? [I] need to be able to tell someone that this case is hitting me in a way I didn’t expect. [I] need to be able to say I can’t do this case.
In contrast, when child welfare providers were asked if they think secondary traumatic stress is an important issue among workers, the majority of providers shared that although secondary trauma was addressed in occasional trainings, the most effective ways to process secondary trauma is through regular case sharing and/or debriefing practices as well as self-care practices. For example, one child welfare provider stated:
Over the years, and from experience, you learn how to address secondary trauma, and you develop your own self-care practices.
Overall, the extent to which secondary traumatic stress is acknowledged and addressed differs substantially by service system. In general, mental health providers reported the most support for secondary traumatic stress, while juvenile justice providers felt inadequately supported.

Discussion

This study is the first that we know of to systematically examine conceptualizations of TIP across a large number of child-service providers in multiple systems across a state. The data demonstrate that both within and across service systems, providers appear to be acutely aware of the importance of TIP, and the need for a coherent plan for its implementation. In some ways, the discussion about TIP appears to have united child-service providers by providing a language with which to discuss and articulate the need for support for their most vulnerable clients. On the other hand, the results also demonstrate differences across the systems in awareness of the impact of trauma on children as well as differences in the degree to which tools are available to identify, screen, and refer traumatized children for services. Indeed, as we expected, participants noted varying definitions of TIP, even within their own system. This finding calls attention to the need for common definitions and the operationalization of TIP (Elliott et al., 2005; Ko et al., 2008; Wilson et al., 2015). However, the same finding also presents a limitation in this study—and any study that allows participants to bring their own definitions to a discussion—that responses are based on varying definitions of the concept of TIP.

Regardless of their service system, providers identified secondary traumatic stress as a concern that requires attention—through training, case consultation, or individual emotional support. Participants indicated that their systems differed in the degree to which secondary traumatic stress was identified as a real concern to which providers and supervisors pay attention. Not surprisingly, mental health providers reported the most support and resources for addressing secondary traumatic stress. On the other hand, juvenile justice providers reported the least, citing a lack of awareness and/or unwillingness to discuss the topic.

Overall, our data suggest that, while providers all identified traumatic stress as an important common theme among families served, and TIP as necessary, there are wide variations in the degree to which providers in different systems feel knowledgeable about TIP and possess the skills and strategies to respond to their traumatized clients. Our findings resonate with the literature on TIP—the varying terms, lack of a common lexicon, and differences across systems in knowledge and skills related to TIP. For example, some literature inextricably links TIP with evidence-based treatments (Fraser et al., 2014), while other literature discusses TIP as a concept that is distinct from the implementation of evidence-based trauma treatment (Conradi & Wilson, 2010; Harris & Fallot, 2001; Wilson et al., 2015).

Placed in the larger context of the TIP literature, our findings suggest that it is time for a unified conceptualization and operationalization of TIP; one that is as applicable to educators as it is to juvenile justice, child welfare, and other child-service professionals. Such an approach should be measurable, with accompanying research to examine its effectiveness in improving child, family, provider, and system-level outcomes. Broad frameworks have been put forth (e.g., Harris & Fallot, 2001; NCTSN, 2012; SAMHSA, 2014); however, details and measurable outcomes are needed. Key challenges are the disparate organizational goals, cultures, and climates of child-service systems, as well as the potential unintended consequence that providers may expect TIP to be the “magic bullet” enabling them to solve all their client challenges (Wilson et al., 2015).

Limitations and Conclusions

This study was conducted with providers in a Midwest state, and thus findings cannot necessarily be generalized to other states or to the nation as a whole. The findings may have been influenced by the overrepresentation of participants from the child welfare system—and underrepresentation from participants in the education system—and the presence of just a few individuals from the corrections and public health systems. We combined findings from two different data collection strategies (i.e., individual interviews in one region vs. focus groups in others), and the data collection strategy (e.g., presence or absence of others in the room) may have confounded some of the results. Finally, as noted above, the fact that we asked participants to answer questions with regard to their own definition of TIP means that their responses may not necessarily be comparable. Nonetheless, the goal of this study was to learn from the perspectives of participants, rather than to have them react to a definition provided to them. We also did not include trauma-exposed youth and families in this study. A full conceptualization of TIP should include those voices, as researchers and program developers continue to develop and implement TIP (Wilson et al., 2015).

Our findings demonstrate the feasibility of starting a statewide TIP initiative by first reaching out to providers to yield a common understanding and, eventually, a common metric for TIP. We argue that although interpreting participant responses in this process may sometimes be messy, as participants bring their own definitions and understanding to their responses, generalizability and utility are expanded by working across systems, rather than developing individual within-system lexicons for TIP. We view this study as the beginning of a process to develop a common and standardized approach to TIP. The critical next step is to integrate the disparate frameworks that have been put forth to encompass TIP (i.e., Harris & Fallot, 2001; Ko et al., 2008; NCTSN, 2012; SAMHSA, 2014) and conduct research testing the effectiveness of TIP on child, family, and organizational outcomes. TIP will only provide added value if it is shown that the investment in trauma-informed knowledge, skills, and service delivery results in meaningful improvements in the lives of children, and families, and in the work of those who serve them.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Substance Abuse and Mental Health Services Administration, grant number SM056177.

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