Skip to main content

Table 3 TIC Model, design, context and outcomes in TIC implementation articles

From: What are effective strategies for implementing trauma-informed care in youth inpatient psychiatric and residential treatment settings? A realist systematic review

Author (year), title TIC approach Design Context Outcome and implications
Azeem, Aujla, Rammerth, Binsfield, & Jones (2011)
Effectiveness of Six Core Strategies based on Trauma
Informed care in reducing seclusions and restraints at a
child and adolescent psychiatric hospital
6 core strategies:
(6CS-National Association of State Mental Health Program Directors-NASMHPD)
Six core strategies are: Leadership Toward Org Change, Use of Data to Inform Practice, Youth & Family Inclusion, Workforce Development, S/R Prevention Tools, Debriefing
Design retrospective chart review of seclusion and restraint data for youths admitted (n = 458) July 2004-March 2007 (implementation of 6CS in final 6 mos)
Sample examined S/R episodes for 458 youth (276 females/182 males)
Measures age, race, gender, admission dx, LOS, admission status, seclusion, restraint episodes
Limitations possible intervening variable: concurrent Dialectical Behavior staff training
26-bed adolescent unit (9-bed adol girl unit; 9-bed adol boy unit; 8-bed unit boys & girls, aged 6-12)
External factors: Centers for Medicare and Medicaid Svcs, Joint Commission issued guidelines regarding use of seclusion and restraint
Marked reduction in use of seclusion and restraint—from 93 episodes (73 seclusions/20 restraints pre-6CS) to 31 episodes (6 seclusions/25 restraints) following implementation of Six Core Strategies
Results achieved quickly and maintained over a period of time
Leadership commitment
Workforce transformation
Outcome orientation
Brown, Baker, & Wilcox (2012)
Risking Connection Trauma Training: A Pathway Toward Trauma-informed Care in Child Congregate Settings
Risking Connection (RC) trauma training:
“The RC training teaches a trauma framework which asserts that childhood trauma…derail the trajectory of development in three critical areas—attachment, brain and nervous system, and self-capacities or self-regulation skills.”
Design: Study examined change in knowledge, beliefs, and self-reported behaviors pre- and post-Risking Connection (RC) training
Sample: 261 child congregate care trainees over 17 months in 2008-2009
Measures: Risking Connection Curriculum Assessment, Trauma-informed Belief Measure, Staff Behavior in Milieu Measure
Limitations: No observational data
Five youth congregate care agencies (residential, foster, etc.) serving children and youth with serious emotional and psychiatric problems
External factors: NASMHPD’s & SAMHSA’s National Child Traumatic Stress Network (NCTSN) promotion of TIC in residential care
Three post-training measures indicated increase in (a) knowledge, (b) increase in beliefs favorable for TIC, and c) increase in self-report of TIC behavior
Staff trained as trainers showed maintenance of positive changes in knowledge, beliefs, and behaviors
Model selection
Workforce transformation
Caldwell, et al. (2014)
Successful Seclusion and Restraint Prevention Efforts in Child & Adolescent Programs
6 Core Strategies:
(6CS-National Association of State Mental Health Program Directors-NASMHPD)
Six Core Strategies are: Leadership Toward Org Change, Use of Data to Inform Practice, Youth & Family Inclusion, Workforce Development, S/R Prevention Tools, Debriefing
Design: Three site study of 6CS implementation.
Qualitative description of 6CS implementation features + outcomes.
Sample: Inpatient psychiatric facility with 52 youth beds; secure residential facility with 84 secure beds +48 therapeutic group home beds
Measures: Mechanical & physical restraints, seclusions, focus groups with youth
Limitations: Article profiles 3 different facilities’ implementation experiences. Descriptive; no methods reported
Site #1: Children’s Center with 52 youth psychiatric beds
Site #2: Secure residential facility for youth with serious emotional disturbance
Site #3: State of CT largest intensive residential program 100 male youth beds
External factors: Part of larger national Building Bridges initiative, which sought to integrate the principles of trauma-informed care in residential and community settings
In Site #1: Between 2005 and 2013, mechanical restraints were 100% eliminated; restraint was reduced by 87%; seclusion reduced by 67%
In Site #2: Restraints reduced from 49 in January 2012 to 1 in 2014
In Site #3: Restraint reduced by 75% between 2011 and 2013
Leadership commitment
Workforce transformation
Community inclusion
Deveau & Leich (2014)
The impact of restraint reduction meetings on the use of restrictive physical interventions in English residential service for children and young people
Post Restraint Reduction Meetings (RRM):
RRM are routine staff meetings to analyze/evaluate Restrictive Physical Intervention use; after initial training, they ideally occur within 72 h of each restraint episode
Design: Longitudinal pre-post intervention design examined impact of RRM on frequency of restraint
Sample: 10 residential/Children’s Home settings
Measures: Type, restrictiveness, length of time, & frequency of Restrictive Physical Interventions (RPI)
Limitations: Intervention fidelity not monitored; confounding variables not assessed
UK children’s homes & residential full-time homes for looked after children and children with behavioral & emotional disturbance (BESD)
External factors: Seclusion and restraint reduction measures in U.S.
Reduced mean frequency of Restrictive Physical Interventions pre- to post-intervention by 31.6%
Greatest reduction in most restrictive supine floor restraints
Workforce transformation
Goetz & Trujillo (2012)
A change in culture: Violence prevention in an acute behavioral health setting
Patient-Focused Intervention (PFI) Model:
Nine component model which includes TIC, aggression management, code event review, leadership involvement, quality feedback, recovery orientation, patient assessment, education, collaboration
Design: Pre-posttest, nonequivalent groups
Sample: Adults & adolescents admitted during 5-year period from 2005–2010
Measures: S/R data, Code Gray episode data, staff injuries; staff safety survey
Limitations: Gross reduction in Code Grey episodes reported but shown only in minutes of restraint usage
80 bed facility including two adol programs—19-bed adol female tx center; 15-bed acute psychiatric facility for youth 12–18 years old
External factors: 2003 manual on reducing violence, & coercive measures by American Psychiatric Assn (APA), American Psychiatric Nurses Assn (APNA), National Assn of Psychiatric Health Systems (NAPHS), & American Hospital Assn (AHA)
Staff injuries decreased by 48% in first year of implementation
Seclusion and restraint rates were reduced by 50%; 75% reduction in hours of S/R in first 2 years
One full year after implementation, staff survey data showed improvement in 5 of 10 areas, including staff perception of aggression mgmt. program
Leadership commitment
Outcome orientation
Shared maintenance
Greene, Ablon, & Martin (2006)
Use of collaborative problem solving to reduce seclusion and restraint in child and adolescent inpatient units
Collaborative Problem Solving (CPS)
Cognitive behavioral approach focused on adult-child decision making rather than teaching or motivating children to comply with adult directives
Design: Pretest-post- test; nonequivalent groups
Sample: 100 children, mean age 9.14 years, were admitted during study period; 80% significant trauma histories; 95% admitted for severe out of control behavior
Measures: Restraint episodes, staff and patient injuries
Limitations: Could not control for intervening variables; generalizability may be affected by selecting unit with high pre-training # of S/R episodes
U.S. 13 bed, locked in-patient child psychiatry unit in Massachusetts children serving ages 3–14 years with average stay of 14 days
External factors:
Evidence of fatalities and other adverse outcomes following S/R use
Reduced S/R from 281 episodes recorded 9 mo pre-training to 1 incident recorded 15 mo post-training
Reduced staff and patient injuries from an average of 10.8 per month to 3.3. per month
Model selection
Workforce transformation
Outcome orientation
Shared maintenance
Greenwald, Siradas, Schmitt, Reslan, Fierle, & Sande (2012)
Implementing trauma-informed treatment for youth in a residential facility: First-year outcomes
Fairy Tale Model: (a) Designed for children, teens, & adults; (b) strong family and community component; (c) incorporates milieu treatment; (d) Included staff education and case mgmt.; (e) scripted interventions including each phase accompanied by telling of Fairy Tale; (f) model encouraged adaptation to agency’s existing culture Sample: Youth ages 10-21 in facility between 2008-2009 (n = 53)
PTSD sx, presenting problems, time to discharge, type of discharge
H1: ↓ PTSD sx
H2: ↓Primary presenting probs
H3: ↓ Time in residential care
H4: Rate of +discharges
Limitations: Missing data on PTSD symptoms; delivery of individual therapy was uneven; no treatment fidelity measures; no comparison group due to AB design
Residential treatment facility serving children and youth aged 10–21
External factors: Western NY agency’s desire to address trauma component of clients’ problems. Positive Peer Culture, an evidence informed peer support model, was in place prior to implementation of trauma-informed treatment
Study found a 34% increase in problem reduction; 39% reduction in treatment time, double the rate of positive discharges
Model selection
Workforce transformation
Outcome orientation
Hodgdon, Kinniburgh, Gabowitz, Blaustein, & Spinazzola (2013)
Development and implementation of trauma-informed programming in youth residential treatment centers using the ARC framework
Attachment, Regulation, and Competency model:
Framework for youth with complex trauma. Nine core building blocks: (1) Caregiver affect mgmt.; (2) attunement; (3) consistent response; (4) routines & rituals; (5) affect identification; (6) modulation; (7) affect expression; (8) executive functions; & (9) self-development
Included elements of DBT
Sample: Young women aged 12–22 in two residential settings (n = 126)
Measures: CBCL; UCLA PTSD Reaction Index; physical restraints
Limitations: Statistically significant reductions in PTSD symptoms but modest clinical improvement, possibly due to uneven delivery of ARC model across programs
Two Massachusetts residential programs for young women ages 12–22, including an Intensive Residential Treatment Program and a residential school
External factors
Implementation of ARC model for this study was based on Fixsen et al. (2005) implementation stages. Funded by SAMSHA as part of National Child Traumatic Stress Initiative
Significant decrease in overall PTSD symptoms, and decrease in aggression, anxiety, attention problems, rule breaking, depression, thought problems, and somatic complaints based on CBCL scores
There was a 50% reduction of use of restraint in the first 6 months and the trend continued downward
ARC did not create any statistical difference in rates of PTSD numbing and avoidance
Leadership commitment
Workforce transformation
Outcome orientation
Holstead, Lamond, Dalton, Horne, & Crick (2010)
Restraint reduction in children’s residential treatment facilities: Implementation at Damar Services
Resource Management Team focused on reducing restraint use. Training in verbal de-escalation. Each staff member experienced a restraint as part of training, and staff heard from patients who had experienced restraint. In 2008, agency declared itself restraint free Sample: 215 youth with behavioral and developmental problems
Measures: # of restraint, length of restraint, staff injury, client injury
Limitations: Insufficient methodological information
Private non-profit residential setting for adults and children (N = 215) in Indianapolis, IN. Serves children with behavioral and developmental problems and many failed placements. Children and youth served have had as many as 30 failed prior placements Reduced restraints from 5000 in 2004 (56 per child) to 786 in 2008 (3.66 restraints per child). Minutes in restraint decreased from 21 min avg to 12 min avg
Staff injury rate decreased from .0199 to .0159 per person between 2004 and 2008. Client injury rate decreased from 307 to 145, or 3.49 injuries from restraint to .68 injuries per person
Leadership commitment
Workforce transformation
Hummer, Dollard, Robst, & Armstrong (2010) Creating Trauma-informed Care Environments Curriculum Sample: Youth with emotional and behavioral issues
Measures: 75 interviews, 33 clinical record reviews, 12 treatment team observations, and reviews of policy and procedure manuals
Limitations: Insufficient methodological information
Eight Medicaid-funded residential settings in Florida including a statewide inpatient psychiatric program, therapeutic foster care, and therapeutic group care.
External factors:
High rate of dependent children and youth in out of home mental health treatment programs and recognition of need for TIC in Florida
The sites studied were found to have varying levels of TIC in their programming. The most successful demonstrated organizational readiness; competent trauma-informed organizational, clinical, and milieu practices; & youth and family engagement in TIC
Leadership commitment
Model selection
Workforce transformation
Community inclusion
Martin, Krieg, Esposito, Stubbe, & Cardona (2008)
Reduction of restraint and seclusion through collaborative problem solving: A 5-year prospective inpatient study
Collaborative Problem Solving (CPS)
Sees child aggressive bx stemming from lagging cognitive skills in the areas: executive functioning, language processing, emotion regulation, cognitive flexibility, and social skills
Prospective study
Sample: 755 children hospitalized between 2003-2007
Measures: Seclusion, restraint, duration, staff injuries
Limitations: Unable to pinpoint variables responsible for S/R reduction; no empirical measures of aggression; no info on psychotropic meds; no systematic data on child injuries; client injury data limited; no objective measures of adherence to CPS; no assessment of staff, children or family perceptions
Fifteen-bed psychiatric inpatient unit for school age children
External factors: Federal legislation to reduce restrictive interventions; local investigations into deaths related to restraint and seclusion; condemnation of S/R by all major child serving professional organizations
37.6 fold reduction in restraint and a 3.2 fold reduction in seclusion. Mean duration reduced from mean 27 to mean 21 min per episode
Black and Hispanic children were 4x and 50% more likely than White children, respectively, to be restrained or secluded. IQ may have been a confounder
Restraint reduction was a more achievable initial target for improvement. Changes maintained despite acuity
Community inclusion
Model selection
Rivard, Bloom, McCorkle, Abramovitz (2005)
Implementing a trauma recovery framework for youths in residential treatment
Sanctuary Model:
Treatment environment is core modality for modeling healthy relationships among community members. Uses SELF framework (Safety, Emotional mgmt., Loss, Future)
Aimed at reducing complex trauma sx among youth in residential settings
Comparison group design, measurement intake, discharge, 6 months
Sample: Youth sample (N = 158)
Measures: youth demographics, COPES; CBCL, TSC-Children; Rosenberg Self Esteem Scale, Nowicki-Strickland Locus of Control Scale; Inventory of Parent and Peer Attachment; Youth Coping Index; Social Problem Solving Questionnaire
Limitations use of 3- month youth self-report measures which may not be sensitive to change
Sixteen residential treatment units for adolescents: 4 self-selected; 4 were randomly assigned; 8 units usual services comparison group
External factors:
Large nonprofit mental health and social service agency seeking to better meet trauma needs of children and families it serves—including children with serious emotional disturbance
Sanctuary units outperformed comparison units on COPES scale (see Mechanisms for Improvement, left)
Few changes observed in youth outcomes, but Sanctuary unit youths showed ↓ verbal aggression and ↑sense of control over their lives compared to service as usual youths
Workforce transformation
Outcome orientation
Russell, Maher, Dorrell, Pitcher, & Henderson (2009)
A comparison between Devereux’s safe and positive approaches training curricula in the reduction of injury and restraint
Safe and Positive Approaches (SPA): Comprehensive, multi-component crisis intervention and intervention training program designed to equip staff with knowledge and ability to safely and effectively prevent, de-escalate, and manage crisis situations Sample: Six programs over 6 years; n = 6361
Data analyzed by quarter rather than unique child
Measures: All restraint rate, rate of prone restraints, youth restraint related injuries; staff restraint related injuries
Limitations: Variability in definitions regarding restraints and types of restraints and thus data inconsistency
Six residential programs providing treatment to children & youth w/at-risk behaviors, emotional and behavioral disorders, involvement in the criminal justice system, and intellectual and developmental disabilities
External factors
Regulatory policies at center, state, and federal levels
Restraint rates, prone restraint rates, youth injury rates, staff injury rates lower for SPA users than for comparison group
Model selection
Workforce transformation