Children and Youth Services Review 91 (2018) 30–38

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Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth

Implementation of Trauma Systems Therapy-Foster Care in child welfare T

⁎
Jessica Dym Bartlett , Berenice Rushovich
Child Trends, Inc., 7315 Wisconsin Ave, Ste 1200W, Bethesda, MD 20814, United States

A B S T R A C T

Trauma exposure is pervasive among children living in foster care, and yet most resource parents (foster parents
and kinship caregivers), child welfare staff, and others in the child welfare system are not adequately prepared to
recognize and respond effectively when children exhibit trauma symptoms. Trauma-systems Therapy-Foster
Care (TST-FC) is a systemwide model of trauma-informed care focused on meeting the emotional needs of
children in foster care who have experienced traumatic events. This study evaluated the implementation of TST-
FC in two state child welfare agencies that included training for staff (n = 123) and resource parents (n = 111).
Study findings show training participants had positive perceptions of TST-FC and found it useful. TST-FC also
was associated with significant increases in trauma-informed parenting and tolerance of children's misbehavior
by resource parents, as well as more trauma-informed policies and practices in the child welfare agencies.
Training participants reported that TST-FC provided useful tools and a common language about trauma that
enhanced their capacity to collaborate with one another and manage children's difficult behavior. An ex-
ploratory study of resource home retention and children's placement stability revealed fewer foster home clo-
sures and placement disruptions when resource parents were trained in TST-FC compared to homes not trained
in the model. The results of this study suggest that TST-FC is a promising model for increasing the capacity of
child welfare agencies to provide trauma-informed care to children and families in the foster care system.

1. Introduction
Child abuse and neglect is a serious and pervasive public health
problem, with approximately 3.4 million children in the United States
reported to child protective services (CPS) in 2015 alone (U.S.
Department of Health and Human Services, 2017). Child victims often
suffer severe and long-lasting adverse effects of maltreatment, including
impairments in brain functioning (Bruce, Fisher, Pears, & Levine, 2009;
Gunnar & Vazquez, 2001; Shonkoff et al., 2012), alterations to gene
expression (Mehta et al., 2013; Yang et al., 2013), problems with
physical growth and development (Johnson & Gunnar, 2011; Roeber,
Tober, Bolt, & Pollak, 2012), difficulty forming attachments (Cyr, Euser,
Bakermans-Kranenburg, & van Ijzendoorn, 2010), chronic health pro-
blems (Brown et al., 2010; Gooding, Milliren, Austin, Sheridan, &
McLaughlin, 2016; Widom, Czaja, Bentley, & Johnson, 2012; Widom,
Horan, & Brzustowicz, 2015), and mental health conditions, such as
posttraumatic stress disorder (PTSD) (Kearney, Wechsler, Kaur, &
Lemos-Miller, 2010; Kolko, 2010; McLaughlin et al., 2013). However,
child welfare staff and resource parents (foster parents and kinship
caregivers) often receive little professional preparation to help them
understand and address the impact of trauma when caring for these
children.
For children in foster care, the negative effects of maltreatment are
often exacerbated by family disruption and placement in multiple re-
source parent homes, leading to additional traumatic experiences of
separation and loss that further jeopardize children's mental health and
well-being (Goldsmith, Oppenheim, & Wanlass, 2004; Kisiel,
Fehrenbach, Small, & Lyons, 2009). For example, children who ex-
perience unstable placements in addition to abuse and neglect are twice
as likely to develop behavior problems compared to children who
achieve stability in foster care soon after placement (Rubin, O'Reilly,
Luan, & Localio, 2007). They also have high rates of PTSD. Kolko
(2010) found that 19% of maltreated children placed in foster care had
symptoms of PTSD compared to 11% of children who remained at
home. Another study by Pecora et al. (2005) determined that 30% of
foster care alumni met the clinical criteria for PTSD compared to < 8%
of the general population.
Posttraumatic stress and associated behavior problems among
children in foster care often lead to placement instability in the first
placement, as foster and kinship caregivers struggle to care for these
children (Chamberlain et al., 2003). Research suggests that approxi-
mately 20% of placement changes in foster care are related to children's
behavior problems (Kolko, 2010), and the longer traumatic stress re-
actions remain unaddressed, the more likely children are to exhibit

⁎
Corresponding author at: Child Trends, Inc., 56 Robbins Street, Acton, MA 01720, United States.
E-mail addresses: jbartlett@childtrends.org (J.D. Bartlett), brushovich@childtrends.org (B. Rushovich).

https://doi.org/10.1016/j.childyouth.2018.05.021
Received 8 February 2018; Received in revised form 17 May 2018; Accepted 17 May 2018
Available online 19 May 2018
0190-7409/ © 2018 Elsevier Ltd. All rights reserved.
J.D. Bartlett, B. Rushovich
psychological distress and continue to experience placement disrup-
tions (Cook et al., 2005; Rubin et al., 2007). Thus, it is essential that
resource parents (foster parents and kinship caregivers), child welfare
staff, and others in the child welfare system who are responsible for the
well-being of maltreated children are knowledgeable about child
trauma and prepared to offer trauma-informed care (TIC; Child Welfare
Information Gateway, 2015).
2. Trauma-informed child welfare systems
Given that children involved in the child welfare system are at
higher risk for exposure to traumatic events than are children in any
other service system (Ko et al., 2008), it is not surprising that there is
increasing consensus in the field that, to meet the needs of abused and
neglected children, child welfare systems must develop and maintain a
cadre of professionals and resource parents who have the skills and
knowledge to work together to identify and respond to child trauma.
This requires the adults in children's lives to help children learn to self-
regulate their emotions and behaviors, to provide stable placements in
which children can recover from traumatic events, and to find perma-
nent homes for children as soon as possible (Chadwick Trauma-
Informed Systems Project, 2013; Child Welfare Information Gateway,
2015; Substance Abuse and Mental Health Services Administration
[SAMHSA], 2014). According to the National Child Traumatic Stress
Network (n.d.):
A trauma-informed child and family service system is one in which
all parties involved recognize and respond to the impact of trau-
matic stress on those who have contact with the system including
children, caregivers, and service providers. Programs and agencies
within such a system infuse and sustain trauma awareness, knowl-
edge, and skills into their organizational cultures, practices, and
policies. They act in collaboration with all those who are involved
with the child, using the best available science, to maximize physical
and psychological safety, facilitate the recovery of the child and
family, and support their ability to thrive.
Unfortunately, to date the training and professional development ef-
forts needed to support a trauma-informed system have not yet been
widely disseminated or evaluated (Annie E. Casey Foundation, 2016).
2.1. Trauma training in child welfare
Providing trauma training for resource parents, child welfare staff,
and other system stakeholders is a key strategy for developing and
implementing a trauma-informed child welfare system (Chadwick
Trauma-Informed Systems Project, 2013). Children's difficulties with
self-regulation and forming healthy relationships, coupled with ex-
tensive psychological needs, can be challenging for even the most ex-
perienced resource parents and professionals. A shift in beliefs about
the causes of problem behaviors in children who experience maltreat-
ment is an important first step. When adults view children or them-
selves as culpable for these negative behaviors, children's stress reac-
tions may worsen, increasing the risk for placement disruption (Barth
et al., 2007; Rubin et al., 2007). On the other hand, when adults un-
derstand the effects of trauma on children, learn to manage difficult
behaviors, and gain skills for responding effectively, the quality of care
can improve and out-of-home placements are more likely to remain
intact (Agosti, Conradi, Halladay Goldman, & Langan, 2013; Hartnett,
Falconnier, Leathers, & Testa, 1999; Henry, Sloane, & Black-Pond,
2007). Keeping resource parents engaged and supported throughout
training also has been shown to contribute to placement stability and
the retention of resource homes. Given the critical shortage of resource
homes and high rates of resource parent turnover in the U.S. (Casey
Family Programs, 2014)— attrition rates have been estimated to range
from 30% to 50%, with most resource homes closing within a year of a
first placement (Gibbs & Wildfire, 2007)—promoting resource parents'
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Children and Youth Services Review 91 (2018) 30–38
capacity to care for children who have been exposed to trauma is also
essential to supporting a viable foster care system.
Several promising training initiatives for resource parents and child
welfare staff have emerged in recent years, derived from evidence-
based and evidence-informed trauma treatment models (Agosti et al.,
2013; Bartlett et al., 2016; Bartlett et al., 2018; Lang, Campbell,
Shanley, Crusto, & Connell, 2016; Murphy, Moore, Redd, & Malm,
2017; Redd, Malm, Moore, Murphy, & Beltz, 2017; Sullivan, Murray, &
Ake III, 2016). Still, additional research is needed to understand ef-
fective implementation (Fraser et al., 2014) and to identify the parti-
cular attributes of trauma training models that support successful child
welfare outcomes and are primary drivers of positive change (Fixsen,
Naoom, Blase, Friedman, & Wallace, 2005). The current study evaluates
the implementation of Trauma Systems Therapy-Foster Care (TST-FC),
a promising trauma-informed training initiative based on Trauma Sys-
tems Therapy (Saxe, Ellis, & Brown, 2016) and piloted in child welfare
agencies in two states.
2.2. Trauma Systems Therapy-Foster Care (TST-FC)
Trauma Systems Therapy (TST; Saxe et al., 2016) was developed by
Glenn Saxe, M.D. and colleagues as a clinical model to improve emo-
tional, social, and behavioral functioning among children and youth,
ages 6 to 18, who have experienced trauma. TST uses a research-based,
integrative treatment approach that attends to both the child's in-
dividual emotional needs and his or her social environment, including
parents and other caregivers, social service workers, and clinicians. The
model has roots in Bronfenbrenner's ecological systems theory
(Bronfenbrenner, 1979; Bronfenbrenner & Morris, 2006), acknowl-
edging the interplay between individual development and the social
ecology. TST is both a clinical and an organizational model that em-
phasizes breaking down barriers between services, understanding the
child's trauma symptoms in his or her developmental context, and
building on family strengths. TST has been tested in a number of child
and youth service settings, including residential care (Brown,
McCauley, Navalta, & Saxe, 2013) and a private child welfare agency
(Murphy et al., 2017; Redd et al., 2017). In the current study, we focus
on Trauma Systems Therapy-Foster Care (TST-FC), an organizational
model developed with the aim of creating a trauma-informed system in
child welfare agency settings. Typically, TST trainers and/or developers
offer training and technical assistance to organizations for a period of
one to two years to embed the model in the organizational system.
TST was first adapted for child welfare as a systemwide training
with an emphasis on training for resource parents—both foster parents
and kinship caregivers (Trauma Systems Therapy-Foster Care; TST-FC).
TST-FC was developed by Kelly McCauley with support from Drs. Glenn
Saxe and Adam Brown and incorporates the same principles of TST, as
well as many of its tools and measures. TST-FC can be implemented in a
child welfare setting with or without the TST clinical model. It was first
implemented in child welfare in a private agency in Kansas, KVC Health
Systems (KVC) in combination with the original clinical TST model.
Findings from an evaluation of the model implemented in KVC revealed
it could be successfully implemented across all levels of the system,
although the process was complex and somewhat challenging, with
marked progress in fidelity to the model over time (Redd et al., 2017). A
second study on KVC focusing on child outcomes found increases in
child exposure to the combined model was associated with significant
improvements in functioning and behavioral regulation, but not emo-
tional regulation. However, higher levels of model fidelity were asso-
ciated with improvements in children's emotional regulation skills, and
increased fidelity over time was related to greater placement stability
(Murphy et al., 2017).
Following implementation in a private child welfare agency, the
developers made adaptations to make the model responsive to the
particular nature of public child welfare settings. For example, public
child welfare staff do not typically provide mental health counseling,
J.D. Bartlett, B. Rushovich
therapy, or psychiatric services within the agency, and more often en-
gage outside partners to provide these services. To fully implement all
components of TST and TST-FC with its comprehensive, team-based
approach, public child welfare agencies must both train their own staff
in the clinical approach and resource parent training and work colla-
boratively with external partners. This complicates the implementation,
as these relationships may need to be established or strengthened.
However, again, it is important to note that implementation of the TST
clinical model is not a required element of TST-FC. When TST-FC is
implemented alone, staff are trained on the material provided in the
resource parent training without being trained in the clinical model.
The TST-FC curriculum for resource parents is made up of four modules
(2.5 hours each for Modules 1 and 2; one hour each for Modules 3 and
4). The modules are presented sequentially, but how the modules are
presented over time has flexibility (e.g., once per week for four weeks
versus two modules per week for two weeks) and can be based on the
training needs of foster parents and staff. Considerations for foster
parents include levels of experience, schedules, and training hour re-
quirements. Considerations for training staff include staff availability,
schedules, and skill level.
TST-FC's clinical model is team-based and services are provided in
the home of the resource parents, as well as in an agency setting, and
the model requires resource parents and service providers to participate
actively as team members in the treatment process. Prior to this study,
TST has not been tested in a public child welfare system—the most
common setting for child protective services in the United States.
2.3. The current study
This study is an evaluation of TST-FC in two child welfare agencies.
The two agencies began to implement the clinical TST intervention as
well as TST-FC, however due to the limited duration of the evaluation
period, and the fact that the agencies had not yet fully implemented the
clinical model, we were not able to complete this component of the
evaluation. Thus, the current study focuses on findings on TST-FC
alone. We investigated two central research questions: (1) How well
was TST-FC implemented in each child welfare agency, and how was
the training perceived by staff and resource parents? and (2) Among
staff and resource parents who participate in TST-FC, does TST-FC in-
crease their knowledge of the impact of trauma on child behavior and
functioning, improve their skills and approaches to working with and
caring for children who have experienced trauma, and support the use
of TST-FC tools and approaches? In addition, we conducted an ex-
ploratory investigation of whether TST-FC was associated with im-
provements in placement stability and resource home retention.
3. Method
3.1. Sample and procedures
The evaluation of TST-FC implementation was conducted in public
child welfare agencies in two states. The first agency (Agency A) is in a
mid-Atlantic state, and is partially state-supervised and partially child
welfare agency administered. The second agency (Agency B) is located
in a mid-western state and is county-administered. The two states are
comparable in size and in the racial/ethnic make-up of its citizens: The
county in which Agency A is located is 81% Non-Hispanic White, 10%
Non-Hispanic black or African American, 4% Hispanic and 5% other;
Agency B is 86% Non-Hispanic White, 7% Non-Hispanic black or
African American, 2% Hispanic and 5% other. Agency B's county has a
lower median household income than Agency A ($41,877 vs. $56,228)
and a higher percentage of families with incomes below the poverty
level (12.5% vs. 9.7%, respectively).
The study period was approximately one year, from July 2015
through July 2016, beginning with a six-month implementation plan-
ning process, followed by training for child welfare staff, child welfare
32
Children and Youth Services Review 91 (2018) 30–38
trainers, and resource parents. The initial six months was pre-
dominantly spent planning implementation of the clinical model (as
mentioned above, the clinical model was not fully implemented during
the evaluation period and thus this aspect of implementation will not be
discussed further), selecting staff to train as trainers, and planning
training logistics. TST-FC was implemented using a train-the-trainer
model, with developers first preparing child welfare trainers to provide
the TST-FC training to licensed resource parents and child welfare staff.
Staff included managers, supervisors, direct service workers, leader-
ship, and mental health providers. The Annie E. Casey Foundation,
which funded the development of TST-FC, provided training materials
and technical assistance to the sites (e.g., sharing of information and
expertise on implementation, items for resource parents). The curri-
culum developers and trainers from the original KVC pilot in private
child welfare led all trainings for staff, observed the first resource
parent training in each of the two counties, and provided feedback and
guidance to the child welfare trainers.
The evaluation of TST-FC employed a range of data collection ac-
tivities, including paper-and-pencil surveys and on-line surveys, focus
groups, observations of training, monitoring of training attendance, and
meeting notes. Evaluators administered surveys before training (pre-
training) and after training (post-training) at both the child welfare staff
trainings and the resource parent trainings. Surveys were administered
again one month later with resource parents and three months later
with staff. Evaluators held focus groups separately for several groups:
agency leaders, staff, mental health providers, resource parents, trai-
ners, and TST-FC developers in Spring 2016. Although the TST clinical
component was introduced to study sites, it was not fully integrated
during the time of the evaluation and therefore is not included in the
current study. All study activities were approved by the evaluation
team organization's Institutional Review Board.
3.2. Sample
The current study included data collection from three groups: child
welfare staff, mental health providers, and resource parents. Trainers
held a TST-FC staff and mental health provider trainings. Trainers also
held a two-day train-the-trainer for staff providing the resource parent
training. Only staff and mental health providers at the general training
participated in the evaluation by completing surveys.
3.2.1. Child welfare staff
A total of 118 staff participated in the evaluation (35 from Agency A
and 82 from Agency B). See Table 1 for additional demographic in-
formation on child welfare staff. Most staff were case managers
(n = 66, 63.46%) or supervisors (n = 24; 23.08%). On average, case-
workers worked in their agency for eight years, M (SD) = 7.97 (7.63)
and worked with children for an average of 10 years, M (SD) = 10.20
(7.12), and supervisors worked in their agency for 12 years, M
(SD) = 12.09 (5.70) and worked with children for an average of
14 years, M (SD) = 14.41 (5.66). There were no significant differences
in staff characteristics between the two child welfare agencies.
Staff in both agencies indicated the amount of training they had
received prior to TST-FC (1 = None; 4 = a lot) in three areas: child
trauma, parent trauma, and secondary trauma. Responses for both
agencies fell in the “very little” (2) to “some” (3) range for all three
areas. Agency A staff received significantly more training in secondary
trauma: Agencies A M (SD) = 2.97 (0.71); Agency B M (SD) = 2.45
(0.73); t (121) = −3.34, p = .001. There were no other significant
differences between the two agencies on other characteristics of this
group.
3.2.2. Resource parents
A total of 111 licensed resource parents (82 in Agency A and 29 in
Agency B) participated in the evaluation. See Table 1 for additional
information on resource parent demographic characteristics. Resource
J.D. Bartlett, B. Rushovich Children and Youth Services Review 91 (2018) 30–38

Table 1
Characteristics of study participants, by role.
Characteristic Child welfare staff (n = 118) Mental health providers (n = 21) Resource parents (n = 111)

Agency A Agency B Total Agency A Agency B Total Agency A Agency B Total

% (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n)

Female 90.32 (28) 85.92 (61) 87.25 (89) 83.87 (5) 76.92 (10) 78.94 (15) 59.76 (49) 68.97 (20) 62.16 (69)
Race/ethnicity
Non-Hispanic white 93.55 (29) 86.11 (62) 88.35 (91) 50.00 (3) 76.92 (10) 68.42 (13) 87.81 (72) 82.76 (24) 86.49 (96)
Non-Hispanic black 3.22 (1) 11.11 (8) 8.74 (9) 50.00 (3) 7.69 (1) 21.04 (4) 6.10 (5) 6.90 (2) 6.31 (7)
Other 3.22 (1) 2.78 (2) 2.94 (3) N/A 15.00 (2) 10.53 (2) 6.10 (5) 6.90 (2) 5.41 (6)
Age group
≤30 years 16.13 (5) 16.44(12) 16.34 (17) 50.00 (3) 30.77 (4) 36.80 (7) N/A 6.90 (2) 1.80 (2)
31–49 years 83.87 (17) 67.13 (49) 63.47 (66) 16.67 (1) 38.46 (5) 31.58 (6) 60.98 (50) 37.93 (11) 54.95 (61)
50 years + 29.03 (9) 16.44 (12) 20.19 (21) 33.33 (2) 30.77 (4) 31.58 (6) 39.02 (32) 55.17 (16) 43.24 (48)

parents in the two agencies had an average of approximately five years
of experience as resource parents, M(SD) = 5.25(4.96) Range = 0–21.
They reported having adequate financial resources and were able to pay
their bills, buy food, and utilize transportation; on a four-point scale
(1 = Never; 4 = Always) mean scores were in the 4-point range, M
(SD) = 3.92(0.46), Range = 2–4. Similar to child welfare staff, resource
parents in both agencies were asked to indicate the amount of training
they had received prior to TST-FC on child trauma, parent trauma, and
secondary trauma on a scale of 1–4 (1 = None; 4 = A lot). Mean scores
were comparable for child trauma training across the agencies (Agency
A, M = 2.37, and Agency B, M = 2.29), indicating that resource parents
had some prior training. There were no significant differences in the
characteristics of resource parents between the two sites.
4. Measures
4.1. Child welfare staff surveys
The pre-training survey for staff collected information on partici-
pant demographics, prior training in child, parent, and secondary
trauma, the extent to which they felt that they and their agencies were
practicing TIC and agencies had trauma-informed policies, and staff
confidence in providing TIC. The evaluation team developed all survey
items aside from those included in the Trauma Informed Systems
Change Instrument (TISCI; Richardson, Coryn, Henry, Black-Pond, &
Unrau, 2012). The TISCI has 18 questions answered on a five-point
Likert scale (1 = Not at all true for my agency/me to 5 = Completely true
for my agency/me) with weighted scores ranging from 20 to 100 that
make up the following three subscales: (1) Agency Policy; (2) Agency
Practice; and (3) Individual Practice. Staff also responded to questions
about their confidence providing TIC, on a six-point Likert scale
(1 = Strong Disagree to 6 = Strong Agree). The post-training survey,
developed by project evaluators, asked staff to indicate their percep-
tions of the training and its potential benefits based on a six-point Likert
scale (1 = Strongly Disagree to 6 = Strongly Agree). The follow-up
survey, administered three months after the training ended, included a
second administration of the TISCI and questions on staff confidence
providing TIC to assess change over time. The TISCI has good internal
consistency (Chronbach's alpha = 0.74–0.87) and test-retest reliability
(Cohen's D = 0.36–0.37) (Richardson et al., 2012).
4.2. Resource parent surveys
Resource parent surveys included items developed by evaluators, as
well as a measure developed by the National Child Traumatic Stress
Network, the Resource Parent Knowledge and Beliefs Survey-Version 4
(RPKBS; Sullivan, Murray, Kane, & Ake, 2014). The RPKBS is a self-
report measure that captures resource parents' beliefs and attitudes
related to parenting a child who has experienced trauma. Parents rate
their agreement with statements on a five-point Likert scale (strongly
disagree to strongly agree). There are three separate scales on the
RPKBS: (1) Trauma-Informed Parenting (TIP); (2) Tolerance of Mis-
behavior (TOM); and (3) Parenting Efficacy (EFF). We included the
RPKBS in the follow-up survey to assess change over time. The RPKBS is
currently undergoing psychometric testing.
4.3. Focus groups and interviews
To further understand the process of implementation of TST-FC and
the perceptions of participants in TST-FC, we conducted focus groups
and interviews in late spring 2016. A total of 66 people participated
between the two agencies. Evaluators developed focus group protocols
and conducted interviews and focus groups with key stakeholders in
person, during site visits, and by telephone. Telephone interviews were
conducted with TST-FC developers and technical assistance staff, and
all others participated in in-person focus groups with evaluators.
Questions focused on the participants' prior experience with TIC
models, perceptions of the extent to which the agency had adopted TST-
FC principles and practices, opinions and benefits of the training, and
facilitators and barriers to implementing TST-FC in a child welfare
setting.
4.4. Child welfare administrative data
To examine placement stability for children, and resource home
retention we collected child welfare administrative data prior to im-
plementation (2014–2015), as well as during and after implementation
(January 2016–July 2017). Data included the number of licensed re-
source homes, children in resource homes, resource home closures, and
placement disruptions, as well as the reasons for closures and disrup-
tions.
4.5. Data analysis plan
We employed both qualitative and quantitative data analysis in the
study, depending on the method most appropriate for answering the
research question. We conducted all quantitative analyses in SPSS
(Version 24), including t-tests investigating differences in responses
prior to and following TST-FC training. We analyzed notes from focus
groups, interviews, and team meetings using NVivo (Version 10), a
qualitative analysis software program. Qualitative data analysis in
NVivo included the identification and refinement of relevant themes
through a constant comparative model, and using template analysis
(King, 2004). Evaluators developed a scheme or ‘template,’ of key
themes based on a priori knowledge of the subject as reflected in the
focus group guides. Evaluators identified and refined themes in ac-
cordance with their relevance to specific research questions. The re-
sponse rate in both agencies for the pre- and post-training surveys was

33
J.D. Bartlett, B. Rushovich
over 90% for staff, and over 80% for resource parents. The response
rate for the follow-up surveys was lower: 36% for staff and 42% for
resource parents. Resource parents and staff had the option of being
contacted for the follow-up survey by telephone or email. Evaluators
made a minimum of three attempts to reach respondents via their
preferred method. There were no significant demographic differences
between staff or resource parents between those who completed only
the pre-training surveys and those who completed both the pre- and
post-training surveys. For paired samples t-tests, we excluded records
with a missing timepoint. To assess resource home retention, we used
aggregated child welfare administrative data collected from both sites.
We combined the number of homes open on the first day of the period
with the number of homes licensed or certified during that period to
calculate the total number of homes open during a given period (169
total homes pre-implementation, and 167 home post-implementation).
We then calculated the number of resource homes that closed for ne-
gative reasons (i.e., closed by resource parents for reasons other than
adoption or guardianship, and homes closed by the agency; 20 homes
pre-implementation and 26 homes post-implementation). The percen-
tage of homes closed for negative reasons were divided by the total
number of homes available during that period. To increase sample size
for analysis, we combined data from the two child welfare agencies.
5. Results
5.1. Perceptions of TST-FC training
Both child welfare staff and resource parents reported that TST-FC
was an effective training, increasing their knowledge about child
trauma, offering useful strategies for working with children who have
experienced trauma, and providing a common language for talking
about trauma that was beneficial to their work with one another. The
train-the-trainer approach was successful in preparing staff to train
resource parents; especially with practice, trainers in both agencies
reported their competence as trainers improved. However, learning and
making time for a new curriculum was challenging for child welfare
staff given existing demands on their time.
5.2. Child welfare staff training
The majority of participants in both agencies agreed that the child
welfare staff training was useful, M (SD) = 4.81 (1.06), balanced, M
(SD) = 4.78 (1.02), and clearly presented, M (SD) = 5.12 (0.87). They
agreed the training improved their knowledge of strategies to address
child trauma, M (SD) = 5.08 (0.72), and felt more equipped to care for
children exposed to trauma, M (SD) = 4.85 (0.91). There were no sig-
nificant differences in perceptions of the training between the two
agencies as assessed using quantitative data from training surveys.
Agency A selected six staff, all with prior experience as trainers and
an average of 15 years working at the agency (Range = 1–24 years) to
co-train TST-FC. Each person prepared a single training module and
became proficient in presenting that module. While Agency B trained
several staff, they selected a trainer from outside the agency with
Table 2
Resource parents' opinions of TST-FC training, by agency.
Agency A
(n = 69)
M SD Range
Sessions interesting 4.88 1.08 1–6
Sessions balanced 4.96 1.08 1–6
Already knew material 3.62 1.38 1–6
Presenters clear 5.14 0.99 1–6
Activities helpful 5.01 1.02 1–6
Children and Youth Services Review 91 (2018) 30–38
25 years of training experience to conduct TST-FC trainings. During
focus groups, an Agency B staff member reported learning to “speak the
same language” as mental health professionals, echoing the reports of
resource parents who had similarly noticed that they had gained a
shared language for talking about trauma. This staff member believed
this would facilitate communication among providers caring for the
same child, and that this staff member would “be able (to) address
problems with kids together instead of separately.”
Agency A felt prepared to begin implementing TST-FC after training
and believed they would improve with practice. Some staff reported
learning useful new ways to explain trauma, as one staff member
commented, “I loved the cat hair analogy (a method of explaining a
trauma trigger) the best out of anything. I have been able to transfer the
analogy to a supervision setting.” Staff also reported the training had
given them a greater understanding and insight into the trauma chil-
dren and parents had experienced. As one staff member said, “maybe
(understanding) one of the things that has happened with this child is
because of the trauma they've experienced, … (is) bringing (trauma) to
the forefront of discussions in supervision.”
Trainers reported that TST-FC was an excellent curriculum, with
many new useful tools and concepts, and, because of its novelty, was a
challenging curriculum to learn and teach. In part, this is because the
curriculum is focused on skill development among resource parents
rather than a didactic training to build knowledge alone, and trainers
themselves must acquire this skill set before training others. Several
trainers felt that TST-FC is content heavy and takes time to practice
before acquiring the skills and knowledge to present it effectively. As
one trainer stated, “I have been a trainer for (many) years, and I put
more time into preparing for this curriculum than any other.” The KVC
curriculum developer and trainer attended the first session of each
training, which trainers reported was beneficial.
5.3. Resource parent training
Agency A made TST-FC training a requirement for maintaining li-
censure and trained the majority of their licensed resource parents
(n = 69), whereas Agency B did not require attendance and thus had
lower training participation rates (n = 27). In retrospect, Agency B staff
and leadership believed this was an error, as one staff member said, “It
would be beneficial for families… so they are not walking in blind.”
There were significant differences in the two agencies' perceptions of
how interesting they found the sessions, t (75) = 2.50, p = .015, how
balanced the sessions were, t (75) = 3.29, p = .019, and whether they
perceived the presenters to be clear, t (75) = 2.42, p = .018. Agency B
reported a more favorable opinion in all of these areas; the Agency B
trainer was also more experienced. See Table 2 for detailed findings on
resource parents' perceptions of training by county. Resource parents
identified certain activities as the most useful, including role plays,
learning coping skills, and information that helped them to understand
and react to a range of challenging situations with children who ex-
perience trauma. One participant commented that “the training was
very informative and worth taking.”
Resource parents' responses in both agencies ranged from
Agency B Agencies combined
(n = 27) (n = 96)
M SD Range M SD Range
5.26 1.06 2–6 4.99 1.08 1–6
5.44 0.64 4–6 5.09 1.00 1–6
4.04 1.22 1–6 3.74 1.35 1–6
5.52 0.64 4–6 5.25 0.92 1–6
5.19 1.18 2–6 5.06 1.06 1–6
34
J.D. Bartlett, B. Rushovich Children and Youth Services Review 91 (2018) 30–38

“somewhat agree” to “agree a lot” (on a four-point scale) that TST-FC
benefits all children, M (SD) = 3.66 (0.48), Range = 3–4, and that they
were more equipped to care for children impacted by trauma, M
(SD) = 3.57 (0.58), Range = 2–4. They also believed the training
helped them have more productive conversations with the child's social
worker, M (SD) = 3.57 (0.68), Range = 1–4. There were no significant
differences between agencies in measures of their perceptions of the
training.
Most resource parents reported enjoying TST-FC and benefiting
from the information, tools, and approaches. Both staff and trainers
described the quality of the training content as higher-level and thus
markedly different from other trauma-informed trainings. A staff
member who attended the resource parent training commented that
trainers, “were engaged and interactive. I felt as though they were lis-
tening and understanding the information.” On the other hand, several
resource parents in both agencies reported dissatisfaction with the
structure of the training. One parent reported finding the training to be
“a very, very long day without organized, predictable breaks.”
Nevertheless, most parents reported the training was successful in
helping them care for children coping with trauma. Staff and trainers in
both agencies reported parents responded well to the training. One
trainer commented: “I think the resource parents were really en-
thusiastic about it. People liked it and were getting something out of it.”
5.4. Increase in trauma-informed care
The results of the evaluation revealed positive changes in training
participants' knowledge, skills, approaches, and use of TST-FC tools
with children exposed to trauma, both at the individual and agency
level.
5.5. Trauma-informed policy and practice
Analysis of changes on the Trauma-Informed Systems Change
Instrument (TISCI; Table 3) revealed that the two child welfare agen-
cies, both separately and combined, demonstrated considerable im-
provements on all three subscales: Agency Policy, Agency Practice, and
Individual Practice. Specifically, from pre-training to follow-up, im-
plementation of TST-FC was associated with significant improvements
in Agency Policy, t (30) = −3.51, p = .001, Agency Practice, t
(30) = −3.52, p = .001, and Individual Practice, t (31)0 = −4.56,
p = .000. Agency A scored significantly higher on Individual Practice at
follow-up than Agency B, M (SD) = 82.67 (15.70) vs. M (SD) = 68.72
(20.38); t (39) = −2.28, p = .028. There were no significant differ-
ences in Agency Policy or Agency Practice between the two agencies at
Table 3
Trauma-informed practices and policies.
Pre-training Follow-up 95% CIs
follow-up. Staff and resource parents reported developing a shared
language that helped them understand trauma and its impact on chil-
dren, and talk about ways to address problems related to trauma. This
was evident to one staff member in Agency B who noticed a resource
parent “using the language.” Similarly, child welfare staff found
common ground with mental health providers when talking about
trauma using similar terminology.
5.6. Staff confidence
Staff confidence significantly improved (p < .05) from pre- to post-
training in 10 out of 14 areas. Agency A staff confidence improved in
eight areas: teaching caregivers self-care, t (16) = −2.13, p = .049;
supporting caregivers in identifying triggers, t (16) = −2.67, p = .017;
understanding how trauma impacts children's brains, t (16) = −2.31,
p = .034; understanding that almost all children in foster care have
experienced trauma; t (16) = −2.43, p = .027; identifying trauma re-
minders in the lives of children, t (16) = −4.69, p = .000; under-
standing that children's past experiences impact how to respond to their
misbehavior, t (16) = −3.05, p = .008; viewing self-care as an im-
portant part of my work, t (16) = −2.40, p = .029; and understanding
there is always a reason for misbehavior, t (16) = −2.28, p = .037.
Agency B staff confidence improved in one area: recognizing self-
care as an important part of their work, t (16) = −2.13, p = .049.
There were significant differences at follow-up between the two agen-
cies on six questions regarding confidence in TIC, with Agency A
scoring higher than Agency B across all areas: teaching caregivers self-
care, t (39) = −2.16, p = .037; assessing if families need additional
support, t (39) = −2.28, p = .028; understanding how trauma impacts
children's brains, t (39) = −2.77, p = .009; recognizing that almost all
children in foster care have experienced trauma; t (38) = −2.15,
p = .038; the ability to tell others about child trauma symptoms, t
(38) = −2.44, p = .019; and identifying trauma reminders in the lives
of children, t (38) = −2.98, p = .005.
5.7. Resource parent knowledge and beliefs about trauma-informed care
Resource parents' knowledge and beliefs about parenting a child
who has experienced trauma improved directly following the training
(see Fig. 1 for changes in each of the RKBS scales over time). On all
three subscales, we found a statistically significant improvement.
Average Trauma-Informed Parenting (TIP) scores increased from pre-
training, M (SD) = 3.78 (0.48), to post-training, M (SD) = 4.29 (0.46);
t (58) = −10.67; p = .000; mean scores for Tolerance of Misbehavior
(TOM) also increased from pre-training, M (SD) = 3.46 (0.63) to post-
training (M (SD) = 3.82 (0.73); t (73) = −5.04; p = .000); and, mean
Parenting Efficacy (EFF) scores increased from pre-training, M
(SD) = 3.93 (0.56), to post-training, M (SD) = 4.21 (0.52); t

M SD M SD n Min. Max.

Agency A
Agency policy 43.75 18.57 70.63⁎⁎ 18.25 12 −45.63 −8.12
Agency practice 53.13 18.07 69.87⁎ 13.19 12 −28.72 −4.75
Individual practice 56.67 20.00 84.44⁎⁎⁎ 12.81 12 −41.51 −14.04

Agency B
Agency policy 53.42 20.70 62.11 16.54 19 −17.93 0.57
Agency practice 48.95 17.38 60.80⁎ 19.22 19 −23.26 −0.45
Individual practice 58.25 23.29 69.12⁎ 20.51 19 −19.92 −1.84

Combined
Agency policy 49.68 20.16 65.40⁎⁎⁎ 17.44 31 −24.87 −6.58
Agency practice 50.57 17.47 64.31⁎⁎⁎ 17.48 31 −21.71 −5.77
Individual practice 57.63 21.74 75.05⁎⁎⁎ 19.24 31 −25.22 −9.62

⁎ Fig. 1. Changes in Resource Parents' Knowledge and Beliefs about Child

p < .05.
⁎⁎
p < .01. Trauma, by Time Point*. *Changes on all three scales from pre-training to post-
⁎⁎⁎
p < .001. training were significant, p = .000.

35
J.D. Bartlett, B. Rushovich
(70) = −6.05; p = .000. Results were comparable when we examined
each agency separately.
Resource parent's knowledge and beliefs about TIC also significantly
improved from pre-training to follow-up (one month after the training):
Trauma Informed Parenting, M (SD) = 3.78 (0.48) versus M
(SD) = 4.11 (0.44); t (18) = −4.50; p = .000; Tolerance of
Misbehavior, M (SD) = 3.46 (0.63) versus M (SD) = 3.71 (0.65); t
(23) = −2.19; p = .039; and Parenting Efficacy M (SD) = 3.93 (0.56)
versus M (SD) = 4.09 (0.56); t (22) = −1.78; p = .089. Resource par-
ents in both Agency A and Agency B maintained these gains made on
the Trauma-Informed Parenting scale from pre-training to follow-up,
and resource parents in Agency B also maintained gains in the
Parenting Efficacy scale. When we examined differences between the
end of the training and three months later for both agencies combined,
the only significant change was for Trauma Informed Parenting, M
(SD) = 4.29 (0.46) versus M (SD) = 4.13 (0.42); t (17) = 1.80;
p = .089, a small but significant decline after the completion of the
training. The two agencies had similar results when examined sepa-
rately. The only significant difference between the two agencies on all
scores was on the Parenting Efficacy scale (Agency A: M (SD) = 4.00
(0.53) versus Agency B: M (SD) = 4.50 (0.35); t (21) = 22.131;
p = .045).
In focus groups, staff in both agencies reported resource parents
were using the skills they learned. As one staff person asserted, “It
seemed like they immediately caught on to the tools and the language
and were ready to jump in.” Other staff members heard resource par-
ents wonder why they had not been doing this all along. One resource
parent commented, “I was made more aware of what (my child) could
have been thinking” when they acted erratically. Another resource
parent commented, “Training made me more sympathetic to the kids'
situation. We allowed (them to do) a few more things than we would
otherwise.”
5.8. Placement stability and resource home retention
To explore whether TST-FC was associated with reductions in pla-
cement disruptions, we compared the differences between homes
closing for negative reasons under two conditions: (a) the percentage of
trained versus untrained homes after implementation ended; and (b)
the percentage of all homes pre-implementation compared to all homes
post-implementation. In the first comparison, the difference was sta-
tistically significant (n = 4, 7% versus n = 20; 20%; p = .032), in-
dicating better foster home retention in TST-FC trained resource homes
compared to untrained homes. In the second comparison, the difference
was not significant. (n = 20; 12% versus n = 4, 7%; p = .324). We
conducted similar comparisons to assess placement stability and found
that that the percentage of children exiting TST-FC trained homes for
negative reasons was significantly lower than exiting untrained homes
(n = 10, 14%, versus n = 88, 33%, p = .002). The difference between
pre-implementation and post-implementation was not significant but
showed a statistical trend (n = 94, 24% versus n = 10, 14%, p = .086).
5.9. Sustainability of TST-FC
At the end of the study period, both agencies expressed the desire to
continue TST-FC and were committed to using the model in the future.
By the end of the study period, Agency A was continuing to require all
resource parents participate in TST-FC training and planned to offer it
twice per year; Agency B also planned to continue training resource
parents but had yet moved forward with these plans.
Staff from both agencies noted the importance of obtaining ongoing
funding to continue the implementation of TST-FC training. Agency A
staff continued to actively discuss how children and parents may have
been impacted by trauma, even for non-TST-FC cases, and expressed the
need for more trauma-trained therapists in the area. Both counties
viewed mandatory TST-FC training for all resource parents as essential
36
Children and Youth Services Review 91 (2018) 30–38
to sustaining the practice. Several staff in both agencies reported that
the technical assistance from both the developers and the Annie E.
Casey Foundation consultants was important to successful im-
plementation. This included the structure and important logistical
support from the consultants, and the regular and extra phone calls
with the developers. The developers emphasized that implementation is
a lengthy process that can take a year or more.
6. Discussion
The results of this evaluation suggest that TST-FC can be success-
fully implemented in child welfare with meaningful benefits for re-
source parents, child welfare agencies, and the children they serve.
Thus, it adds to a small but growing literature on trauma-informed care
training initiatives in child welfare (Agosti et al., 2013; Bartlett et al.,
2018; Fraser et al., 2014; Lang et al., 2016; Murphy et al., 2017; Redd
et al., 2017; Sullivan et al., 2016). This work is critical, as the field is
just beginning to identify achievable strategies to enhance the child
welfare system's responsiveness to child trauma (Kerns et al., 2016).
6.1. Changes in trauma knowledge, beliefs, and practices
There is a dearth of evidence on specific changes in beliefs,
knowledge, and skills that are associated with trauma-informed curri-
culum training (Cohen et al., 2017). In the current study, we found that
resource parents showed marked improvements in self-reported
knowledge, confidence, and capacity to provide TIC to children placed
in their homes, including better tolerance of children's misbehavior and
a sense of self-efficacy in parenting. They also reported gaining valuable
practical tools and strategies for recognizing and responding to trauma-
related behaviors in children. There was a small but significant drop in
their use of trauma-informed parenting techniques from post-training to
follow-up. Interestingly, out of the three scales measured using the
Resource Parent Knowledge and Beliefs Survey (Trauma-Informed
Parenting; Tolerance of Misbehavior; Parenting Efficacy), resource
parents scored highest on Trauma-Informed Parenting, despite the
slight decline after the training ended. It is possible that resource par-
ents held themselves to a higher standard of caregiving after gaining
more familiarity with effective parenting strategies and, as a result,
were more conservative about rating themselves after completing TST-
FC training. An alternative explanation might be that they did not re-
tain all information they learned, which is consistent with the finding
that their scores on two subscales also decreased, though the differences
were not significant. In either case, these findings support the ob-
servation made by several child welfare staff that a “booster training”
and additional support for implementing TST-FC concepts and strate-
gies may be needed to maximize TST-FC resource parent training out-
comes.
Child welfare staff also reported significant improvements in TIC in
relation to their own individual practices, as well as agency practices
and policies. However, compared to Agency B, Agency A staff scored
higher on individual practices; they also reported more confidence in
providing TIC. Given the lack of demographic differences found be-
tween staff at the two agencies, it may be that these differences stem
from agency level factors. For example, Agency A demonstrated more
systemic integration of TST-FC, requiring that all resource parents
participate in training. It is also possible that the characteristics of the
two agencies varied in ways we did not measure but influenced their
practice (e.g., quality of supervision, size of caseload) (Child Welfare
Information Gateway, 2016; Social Work Policy Institute, 2011).
6.2. Child outcomes
The current study offers preliminary evidence that TST-FC can lead
to better child welfare outcomes for children, including increased pla-
cement stability and foster home retention. Fewer TST-FC trained foster
J.D. Bartlett, B. Rushovich
homes closed and fewer children had to leave TST-FC trained resource
homes (for negative reasons) compared to non-trained resource homes.
This may reflect a greater understanding of trauma and its effects by
resource parents, as well as an improved capacity to manage children's
difficult behaviors and prevent placement disruptions. This is a pro-
mising finding, and is in-line with the results of prior studies on TST in
private child welfare agencies (Murphy et al., 2017; Redd et al., 2017).
However, these results should be interpreted with caution due to the
small sample size and lack of a control group. Further investigation will
be important to establish more conclusive evidence, especially given
limited empirical research on the impact of TIC on outcomes for chil-
dren involved with the child welfare system (Hanson & Lang, 2016).
6.3. Implementation strengths and challenges
Study participants highlighted the value of developing a common
language about child trauma among child welfare staff and leaders and
resource parents. Staff from both counties indicated that this was a key
change in their ability to understand and talk about trauma, and one
that enhanced communication among the adults charged with chil-
dren's care. Other evaluations of TIC models have noted similar find-
ings. For example, an evaluation of a statewide TIC initiative in child
welfare that brought together child welfare workers, clinicians, other
service providers, and consumers found that “This work often began
with finding a common language between CW [child welfare] workers
and clinicians who were providing EBTs [evidence-based treatments]”
(Bartlett et al., 2016, p. 105).
There are numerous challenges in the process of building a trauma-
informed child welfare system in general, and related to the process of
implementing TST-FC in two county public child welfare agencies in
particular. The final report of a five-year evaluation of TST in a private
child welfare setting concluded that, “Incorporating trauma-informed
care throughout KVC's system of care was no simple task; it was an
intensive and iterative process carried out over multiple years”
(Murphy et al., 2017). Thus, it is not surprising that both counties were
still working toward full implementation of TST-FC after only one year.
There was no clear consensus about how the TST-FC training
structure and format might be improved, but certain criticisms and
suggestions for improvement seem worthy of note, as they were raised
by a number of study participants. For example, some individuals who
became TST-FC trainers through this process did not feel adequately
prepared to train resource parents. Some also reported not having en-
ough time to learn how to teach the curriculum. Feeling over-burdened
is a common problem among child welfare staff and requires a con-
certed effort by leadership and policymakers to address. They expressed
concern about being ready to become TST-FC trainers in the absence of
additional supports. Most participants reported that additional gui-
dance and support for the staff training is needed. This is consistent
with reports from both agencies that technical assistance was important
to successful implementation.
6.4. Sustainability
Both child welfare agencies planned to continue using TST-FC and
to make the training mandatory for all resource parents. To continue
the gains each agency has made and to make additional progress to-
ward becoming a trauma-informed child welfare system, “buy-in” at all
levels will be necessary, including attention to organizational infra-
structure, policies and procedures, human resources, workforce devel-
opment, community engagement, and continued data collection to
monitor progress (SAMHSA, 2014).
6.5. Limitations
There are several limitations of the present study that are important
to note. First, this evaluation constitutes a preliminary, short-term,
37
Children and Youth Services Review 91 (2018) 30–38
descriptive analysis of the implementation of TST-FC in two county
child welfare agencies. We cannot claim a causal link between TST-FC
and more trauma-informed child welfare systems. We were not able to
control for existing characteristics of the two sites (e.g., population
served; qualifications of the staff; demographic characteristics of staff,
foster parents/kinship caregivers, or children), and we did not have a
control group that would allow us to establish true impact of the in-
tervention. In addition, the response rate among resource parents one
month after the training was quite low, and, despite the fact that there
were no significant demographic differences between those who took
the follow-up survey and those who did not, it is possible that this in-
troduced a response bias (e.g., those who were more responsive to the
training and more likely to apply the knowledge they gained were more
likely to respond). We did not offer an incentive for completing the
study surveys to either staff or resource parents. It is possible an in-
centive may have increased participation rates. We were not able to
assess changes in parenting skills, only changes in resource parents'
knowledge and attitude. Observing actual changes in resource parents'
caregiving that are attributable to TST-FC is an important next step
toward evaluating its effectiveness. We believe that these limitations
highlight specific areas of inquiry for further investigation and that our
findings provide key insights regarding the role of TST-FC in creating a
culture of TIC in a child welfare context.
6.6. Implications and conclusions
The results of this evaluation offer early evidence that the im-
plementation of TST-FC is a feasible approach to improving a public
child welfare agency's capacity to provide TIC to children and their
families. The model of TIC may be a successful mechanism for
strengthening our foster care system by increasing the skills and
knowledge of the people who care for our most severely maltreated
children. Clearly, larger scale, long-term rigorous research is still
needed to establish links between TST-FC's model of TIC with child
welfare service providers, parents, resource parents, and other adults in
children's lives, as well as with child outcomes over time. In addition, to
inform effective TIC policies and practices, research on other central
components of TST-FC and comparable models (e.g., screening and
referral practices; key elements of successful child welfare-behavioral
health collaboration) is warranted. The field also would benefit from
investigation into how various aspects of implementation (e.g., dosage;
training format and structure; supervision; use with different popula-
tions, the addition of booster trainings) moderate or mediate outcomes
for children and their caregivers. While there has been increased at-
tention to TIC at the local, state, tribal, and national level in recent
years, there is still much work to be done to ensure that the full spec-
trum of adults who interact with abused and neglected children are
truly prepared to recognize and respond to child trauma.
Declarations of interest
Both authors have no conflicts of interests to declare.
Acknowledgements
Funding for this project was provided by The Annie E. Casey
Foundation (214.0268). We would like to thank Doreen Chapman and
consultants Laura Neal, Maureen Heffernan, and Denise Goodman. We
are also grateful for our collaboration with Dr. Glenn Saxe, Dr. Adam
Brown, and Kelly McCauley.
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