Commentary
Child Maltreatment
Trauma Informed Care: A Commentary
and Critique
Lucy Berliner1 and David J. Kolko2
We appreciate the invitation to offer some comments regarding
the methods and implications of the six papers included in this
special series devoted to understanding and applying the topic
of trauma-informed care (TIC) in diverse human service orga-
nizations and would like to acknowledge Drs. Hanson and
Lang for their initiative in proposing and organizing the series.
The concept of TIC appears to have emerged out of increasing
awareness of the prevalence and implications of childhood
trauma in clinical contexts (mental health, child welfare,
juvenile justice) as well as the general population (Finkelhor,
Turner, Shattuck, & Hamby, 2015; Saunders & Adams, 2014).
Awareness of the ubiquity of traumatic experiences and their
impact arose in tandem with widespread dissemination of the
results of the adverse childhood experiences study by the
Centers for Disease Control and Prevention (see Felitti et al.,
1998). Such adversities comprise a range of harmful or
stressful life experiences, of which some are traumas. For
example, among the original 10 adversities were four forms
of abuse (i.e., physical, sexual, emotional, and witnessing one’s
mother treated violently) as well as two forms of neglect and
several forms of household dysfunction (household mental
illness, household substance abuse, parental separation or
divorce, incarcerated household member parental incarcera-
tion). These two strains of research have oriented our society
toward greater recognition that many children are exposed to
trauma and adversity at an early age and that exposure can
confer significant risk for poor health and mental health
outcomes.
The victimization, trauma, and adversities literature has
documented not only that these experiences are common but
also that many children suffer from more than one such expe-
rience. Finkelhor, Ormrod, and Turner (2009) call this poly-
victimization. The literature has documented that cumulative
burden of adversity increases risk for many negative outcomes.
McLaughlin et al. (2012) reported that the population attribu-
table risk of childhood adversities accounts for 47% of child-
hood onset of psychiatric disorders, 32% of adolescent onset,
29% of early adulthood, and 39% of later adulthood onset.
All this awareness has had the effect of galvanizing institu-
tions and policy makers in many service sectors to consider
invoking the concepts of trauma and adversities in policy and
practice. There is a genuine desire to encourage the community
2016, Vol. 21(2) 168-172
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and professionals to develop more helpful responses to the
affected children and their families when they enter child-
serving systems. At the federal level, the Substance Abuse and
Mental Health Services Administration (SAMHSA) has taken
the lead in defining and promoting trauma-informed
approaches (see http://www.samhsa.gov/nctic/trauma-inter-
ventions). As defined by SAMHSA, a trauma-informed
approach broadly incorporates awareness of trauma and its
impact into all aspects of organizational functioning and is
reflected in certain general principles. SAMHSA explicitly
distinguishes a trauma-informed approach from trauma-
specific clinical interventions. The federal Administration for
Children and Families has supported many states and tribal
agencies to implement trauma-informed initiatives for child
welfare and mental health. In addition, TIC classes, seminars,
webinars, and other educational activities are now ubiquitous.
Federal and local governments are making substantial invest-
ments to support the efforts with grants or training mandates. It
is an idea that has taken off in many directions.
It is heartening that there has been so much enthusiasm for
efforts to be more trauma informed. Increased awareness that
so many children suffer victimization and adversities is good.
Society at large, as well as its institutions and professionals
working with children, should be knowledgeable about the
prevalence of hardship in the lives of children. However, ulti-
mately the value of increased awareness lies in whether it
actually benefits the children. After all, the children already
know all about the trauma and the adversities they have expe-
rienced because they are living with them. The challenge for
the movement to instill TIC across institutions is to demon-
strate that awareness or the implementation of other activities
associated with TIC initiatives actually makes a difference,
which improves the lives of the children.
1
Harborview Center for Sexual Assault and Traumatic Stress, Seattle, WA,
USA
2
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
Corresponding Author:
Lucy Berliner, Harborview Center for Sexual Assault and Traumatic Stress, 325
Ninth Ave., MS 359947, Seattle, WA 98104, USA.
Email: lucyb@uw.edu
Berliner and Kolko
This special section attempts to address some of the key
issues associated with various aspects of the implementation
of diverse and creative activities designed to increase trauma
informedness. The aforementioned SAMHSA definition is pri-
marily about awareness but as well describes what are consid-
ered basic principles related to trauma. However, these
principles are essentially principles of good care and are not
specific to trauma per se. For example, safety, trustworthiness,
collaboration and mutuality, empowerment, voice, and choice
should characterize all systems-level responses. Or, to take a
common example for how being trauma informed has a value at
the individual level, it is often recommended that instead of
characterizing children with problems as intentionally misbe-
having, it is important to consider that the behaviors may be
adaptive or understandable responses to adversity or other his-
torical influences. Again, this is good care and should not be
reserved only for those children who may have been affected
by trauma.
This discussion then raises the question—what defines TIC
beyond good practice principles and trauma awareness. In other
words, how would institutions, organizations, or individual
providers know if they were delivering TIC? Some progress
toward answering these questions can be found in the papers
from this series. For example, the Donisch et al.’s paper (this
issue) nicely reflects the definitional dilemma. Focus groups
and interviews with professionals in various child-serving sys-
tems (child welfare, juvenile justice, mental health, education)
revealed that participants were generally familiar with and
endorsed the importance of traumatic stress and the need for
trauma-informed practice (TIP) in their systems. But when it
came to the operationalization of the concept, there was diver-
sity of response and considerable uncertainty, especially in
terms of the extent to which they were taught the skills and
strategies needed to respond to traumatized youth. Respondents
in the different systems noted variations in the availability of
tools to help them identify, screen, and refer traumatized chil-
dren for services. Of note, a number of respondents explicitly
commented that direction is lacking about the operationaliza-
tion from the big idea to every day practice. As the authors
conclude:
. . . our findings suggest that it is time for a unified conceptualiza-
tion 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 measur-
able, with accompanying research to examine its effectiveness in
improving child, family, provider, and system-level outcomes.
(Donnish et al., p. 22)
This conclusion argues for the need to develop a common
definition that can be operationalized across different systems
to address the implementation of TIC versus trauma-specific
interventions.
Awareness training with the goal of changing knowledge,
attitudes, and behaviors of professionals or others is a com-
monly used strategy in the TIC movement. Two papers assess
169
the impact of training programs designed to assess knowledge
and/or attitude change and self-reported behavior change.
Kerns et al. (this issue) evaluated two different child welfare
trainings, one is designed to evaluate training on the use of a
new trauma impact screening tool with foster children and the
other is a child welfare workforce training program. Attitudes
and self-reported behavior changes were mixed on the use of a
new tool to assess impact of trauma, even though the partici-
pants were already skilled at administering a general behavior
measure. Almost a third did not see value in using a trauma-
specific tool, and another third were not sure whether there was
value. The ambivalence about the addition of a trauma impact
tool in this study may be a local artifact or it may relate to the
larger issue of why trauma exposure or impact screening has
been slow to take hold as a routine practice, despite the fact that
it is the necessary prerequisite to identifying children in need of
trauma treatment. Anecdotally, the authors noted that some
caseworkers were uncomfortable at the thought of asking chil-
dren to discuss traumatic events and experiences, which is a
common reaction among practitioners. Importantly, the study
does not report how the training affected caseworker rates of
referral to appropriate treatment services as a result of the
added trauma impact screening even though it is now the stan-
dard practice. So, we recognize that screening for trauma is not
a simple or neutral function. The workforce training addressed
several topics, including trauma-related impact on children
served in the child welfare system, principles of evidence-
based treatments, and matching treatments to problems.
Knowledge gains occurred across the workforce trainings as
did self-reported competence. But actual use of the skills was
not reported.
Sullivan, Murray, and Ake (this issue) tested a curriculum to
promote awareness of trauma among resource parents (caring
for children who have experienced trauma, also known as the
resource parent curriculum, see National Child Traumatic
Stress Network, http://learn.nctsn.org/enrol/index.php?id¼67)
for foster parent/kinship caregivers. The workshop was
designed to improve caregiver responses to foster children
affected by trauma. Interestingly, again, many of the specific
behaviors that are included in the curriculum are not trauma-
specific but promote general principles that should characterize
responses to all foster children regardless of a trauma history
(‘‘help your child to feel safe,’’ ‘‘help your child understand
and modify problem behaviors’’). A main goal of the curricu-
lum was to increase awareness of the impact of trauma on
children and show how the concepts can be applied to parent-
ing. Not surprisingly, immediately following the class care-
givers reported increases in knowledge and beliefs, along
with high satisfaction for the program. At the same time, it is
important to recognize that the level of change was modest, the
design did not include a comparison condition, and the absence
of follow-up data precludes documentation of the maintenance
of these attitudes. Interestingly, the evaluation included two
additional measures that could bear implications for under-
standing the potential for actual behavior change. One mea-
sured parenting efficacy and the other tolerance of
170
misbehavior. Tolerance for misbehavior is an especially rele-
vant construct in foster care because child behavior problems
are a common cause of placement disruption (Hurlburt, Cham-
berlain, DeGarmo, Zhang, & Price, 2010). Findings showed an
increase over time for parenting efficacy across both groups,
but tolerance for misbehavior only increased in the kinship
caregiver group. This finding could be useful in conjunction
with a recent paper reporting that kinship care is only more
stable when the kin are especially empathic to the children
(Anderson & Falleson, 2015).
A macro strategy to promote TIC involves the use of feder-
ally funded state initiatives that focus on this topic. Typically,
they include multiple layers of activities including increasing
awareness, enhancing cross system collaboration, installing
more routine screening, and increasing access to trauma-
specific evidence-based treatment (EBT). Lang et al. (this
issue) and Bartlett et al. (this issue) describe the various activ-
ities in two statewide initiatives that included a variety of stra-
tegies. At the system level, both papers report increased levels
of appreciation for the importance of being trauma informed,
awareness of the impact of trauma on children, a commitment
to cross system collaboration, and changes in how cases are
handled. Lang et al. (2016) measured system-level change via a
survey of caseworkers and find increases in all constructs mea-
sured including self-reported knowledge, attitudes, and prac-
tices. These improvements were found across most of the
domains assessed (e.g., knowledge about trauma, foster care,
supervision, addressing trauma needs of birth families, access
to trauma-focused EBTs for behavioral health), highlighting
greater organizational support for TIC 2-years after the initial
training program. Although statistically significant, some of
these changes appeared to be minimal and it is unclear by how
much a nontrained comparison group would improve, given
that the concepts around TIC have been widely promulgated
and that many of the constructs are not trauma-specific per se.
Bartlett et al. (this issue) examined system change though
interviews with members of multidisciplinary teams devoted to
enhancing awareness and trauma-informed activities. A broad
range of programs was targeted, such as trauma-informed lead-
ership teams (TILT), senior leaders in a learning collaborative,
clinicians and children who were enrolled in one of the three
recommended EBTs. TILT’s reported that they engaged com-
munity members and made new connections to local commu-
nity, but membership recruitment was a significant challenge,
and they experienced considerable upheaval in child welfare
agencies. Further, 36% of the senior leaders reported that they
were not using a trauma screen at baseline, and this rate was
only improved to 30% 6 months later.
All told, while it seems certain that these educational stra-
tegies increase awareness and reported commitment to the
basic idea of system level changes, it is not possible to docu-
ment whether changes in practice have actually increased (e.g.,
giving resource families information about child trauma his-
tory, increased cross system communication, routine screening
in child welfare and mental health, more access to EBTs) or
what the outcomes are. As well, the efforts required involved
Child Maltreatment 21(2)
substantial external funding, and it is unclear how many of the
activities will be sustained once that funding expires. Bartlett
et al. (this issue) remark that members of the TILTS were
unsure about whether it would be possible to sustain them.
As Lang et al. (this issue) observed, ‘‘two years of multiprogam
implementation was not sufficient’’ (p. 17).
One might identify certain practice changes as being expli-
citly trauma informed or trauma-specific and most likely to
make an impact such as screening for trauma exposure, asses-
sing trauma impact, and increasing access to trauma-specific
treatment. Multiple papers mention aspects of these three core
ingredients of TIC at the individual level. It is perhaps the sine
qua non of being trauma informed that children who have been
exposed or affected by trauma must be identified before they
can receive effective trauma-specific treatments. Simply know-
ing that many children or adolescents are exposed to various
traumatic events is not likely to represent a meaningful
response to specific children. Further, in the absence of a spe-
cific therapeutic response or facilitated referral to a trauma-
specific regimen, screening itself could be iatrogenic.
One of the barriers to routine screening has been a concern
that asking children about their trauma experiences is ‘‘trau-
matizing’’ or upsetting to children. There is little evidence to
support this concern. Researchers conducting epidemiological
surveys of children using lay interviewers following computer-
assisted scripts have not only been able to learn about trauma
from the responding children, they found that few children
report distress (e.g., Finkelhor, Vanderminden, Turner, Hamby,
& Shattuck, 2014). Notwithstanding these results, profession-
als argue that this finding does not apply to clinical samples. A
recent implementation study of children seeking mental health
care found that the children also did not report being distressed
by trauma screening (Jenson personal communication, 2016).
So, screening for trauma does not appear to cause distress.
Given that screening is the only way to identify children
affected by trauma and in need of trauma-specific services and
that screening is not distressing to the children, routine screen-
ing in mental health settings and child welfare, especially foster
care, should be implemented. The three statewide initiatives
identify routine screening as a goal, either in foster care (Kerns
et al., this issue) or in child welfare and mental health (Bartlett
et al., this issue; Lang et al., 2016). In Kerns et al., trauma
exposure screening was not done, but trauma impact was added
to the current screening approach for foster children. But infor-
mation is not reported about whether this increased referral for
trauma-specific care when children screened in. In Bartlett (this
issue), while according to the members of the multidisciplinary
teams, a majority (64%) stated they used trauma screening
(Bartlett et al., 2016), this still means that despite external
funding and a statewide initiative, screening is not yet routine.
Several of the papers reported that an aspect of the trauma-
informed initiative was to increase the availability of trauma-
focused cognitive–behavioral therapy (TF-CBT) as an inter-
vention for trauma impact. Given that TF-CBT is a well-
established intervention that has been shown to be effective,
increasing availability is an inherently trauma-informed
Berliner and Kolko
activity. Two papers report on positive outcomes for children
receiving TF-CBT, one of the statewide initiatives that incor-
porated several EBTs (Bartlett et al., this issue) and Cohen et al.
(this issue). Cohen reports results of a randomized controlled
trial of TF-CBT in residential care showing positive outcomes,
although there were high rates of nonparticipation by youth
meeting eligibility criteria and high rates of therapist drop out.
The extent to which this program was embedded in a broader
TIC, initiative was not formally examined.
Overall, the TIC movement does appear to have at least
modest benefits. One potential positive byproduct may be rais-
ing the general quality of care in child-serving systems by
encouraging professionals to be more empathic and under-
standing and more attuned to how services are delivered
whether the children have been affected by trauma or not. And
there is little downside to brief awareness training as long as it
does not consume many resources and is not considered a
substitute for changing practices to improve identification,
assessment, and linkage to effective services.
At the same time, much remains to be learned about how
TIC is defined and evaluated. If the goal is primarily increasing
awareness, then it is important to identify what are the most
important pieces of information that should be widely shared.
For example, in addition to informing professionals about the
prevalence and negative impact of trauma, it is just as impor-
tant to convey that most children, even foster children, are
resilient and do not have persisting general or trauma-related
problems (Bell, Romano, & Flynn, 2015; Miller-Graff &
Howell, 2015). The awareness training programs may need to
be tailored for different parts of the system of care sectors to
maximize its usefulness since paying for and attending train-
ings is expensive for organizations and may or may not actually
lead to specific benefits for clients.
If TIC is intended to produce changes in practice, then it is
important to shift the focus onto conceptualizing and operatio-
nalizing the intended outcomes and measuring them. We need
to document specific system-level and individual-level practice
changes and their actual impact on trauma-affected children
and their families. To address some of the gaps noted in the
papers in this special series, we envision developments in sev-
eral areas. In terms of the general principles aspect of TIC,
there is a need to develop and test tools to assess client percep-
tions of safety, empowerment, and voice in service settings to
identify the specific strategies that would increase positive
perceptions. Similarly, several papers highlight the importance
of better system coordination across the various service sys-
tems and phases of TIC. But how is this operationalized in
terms of both the general principle of better case coordination
and the trauma-informed aspect of increased identification and
linkage to trauma-specific services? Given that more services
and more time spent coordinating may not always be the most
beneficial use of scarce professional and organizational
resources, approaches that are more parsimonious and focused
may be promoted (Berliner et al., 2014).
To extend the established finding that participation in a
trauma-specific EBT improves outcomes, it is important to
171
identify and evaluate the policy and practice changes that will
insure that more affected children receive these services. Of
special importance is studies that identify individual and orga-
nizational contributors to heightened adoption and mainte-
nance of TIC practices such as routine screening, assessment,
and increased access to trauma-specific EBTs. Studies may
benefit from using novel measures specifically designed to
capture constructs related to TIC, such as the Trauma Systems
Readiness Tool (Hendricks, Conradi, & Wilson, 2011), which
may help to document the extent to which actual changes in
provider behavior translates into improved client outcomes that
are of clinical significance.
Information is needed about the financial costs of providing
training, ongoing support to staff, and sustainment of aware-
ness or practice changes that are initiated with external or
grant support. Innovative collaborative mental health and
child welfare training programs (Saunders & Hanson, 2014)
may be a more efficient and cost-effective approach because it
trains both child welfare and mental health together, so that
the goals or increased service coordination and improved
access to effective treatments are accomplished at the same
time. Such programs could also assess whether the rates of
children accessing EBTs in a community are increased. Some
changes may not in themselves have costs (e.g., implementing
routine trauma exposure/impact screening as part of standard
assessment in foster care or mental health), but the quality
assurance to insure that positive screens result in specific
activities may require additional organizational or profes-
sional effort. Identifying methods for incentivizing and rein-
forcing the practice changes will be necessary to sustain them
in some cases.
It is a desirable goal that all trauma exposed children
receive a warm and caring response from knowledgeable
professionals, but the most important needed change is cre-
ating systems that identify traumatized children and ensure
that they get effective care. One of the many notable
strengths of the studies in this series represents the broad
scope of their efforts to spread TIC awareness and skills
across workgroups in large organizations or diverse service
sectors. Consistent with the insights offered by these novel
applications, the most logical way to get to those outcomes is
to make routine screening for trauma exposure and impact a
priority in child welfare and mental health systems, and to
increase the availability of effective trauma treatment. These
practices must remain the central target of TIC efforts if the
movement is to be a meaningful one for children and families
affected by trauma.
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) received no financial support for the research, author-
ship, and/or publication of this article.
172
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