Measuring Trauma-Informed Care Across Sectors Part I: What & Why

Measuring Trauma-Informed Care Across Sectors

Federal, state, and local governing bodies are increasingly mandating trauma-informed care (TIC), requiring organizations, schools, and service systems to demonstrate they are advancing TIC in their settings. Yet, organizations and schools have little guidance about how to do so. For example, the Family First Services Prevention Act requires Qualified Residential Treatment Programs (QRTPs) to demonstrate effective use of a TIC framework but leaves it to states and QRTPs to determine how to evaluate their efforts. Schools face similar pressures to show positive outcomes for their trauma sensitive school initiatives.

 What Is Trauma-Informed Care?

TIC is an approach to education and care where a system (i.e., a human service agency, hospital, school district, juvenile probation system, housing bureau, child welfare system, etc.) realizes the profound impact of trauma in those they serve, recognizes the signs and symptoms of trauma, responds by integrating knowledge about trauma into policies and practices, and resists re-traumatization. TIC assumes these practices at all levels of the system (SAMHSA, 2014).

While TIC practice is trending strongly in many sectors, measuring the effectiveness of TIC is lagging in that there is little empirical evidence that TIC actually works. Therefore, promoting planful, valid TIC measurement is essential to advancing and sustaining TIC practice.

Measuring Trauma-Informed Care versus Trauma-Specific Treatments

This series is about measuring TIC. But, implementing and measuring TIC is often confused with implementing and measuring trauma-specific treatment interventions such as Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Seeking Safety, or Cognitive-Behavioral Intervention for Trauma in Schools (CBITS).  

Implementation of trauma-specific treatments is an important component of TIC implementation in a system, but only one component. Trauma-specific treatments are treatment protocols or models designed for individuals or groups of people with histories of trauma whereas, again, TIC refers to how a whole system approaches support for people impacted by trauma. For example, an organization’s clinicians may be trained in TF-CBT, but this does not make them a trauma-informed organization. Clinicians may be doing great trauma therapy but, without broader training, direct care workers, case managers, or support staff may be treating clients in a punitive and re-traumatizing way.

This is an important distinction because it is far more complex and difficult to show progress in measuring TIC than trauma-specific treatment. With trauma-specific treatments, one generally measures person-level outcomes like depression, anxiety, or PTSD symptoms and it is easier to show that treatment impacts these outcomes. When changing systems, there are many more possible outcomes to measure and factors that can impact the change process.

For this reason, there are currently many recognized evidence-based, trauma-specific treatments and few, if any, evidence-based models of TIC. This makes working to measure TIC that much more important.

Why Do Organizations Want to Measure TIC?

• To assess their readiness for a TIC change process.

• To know if their TIC change efforts are showing progress.

• To know if a particular intervention such as training, or a new screening protocol had a positive impact.

• To determine if organizations are truly trauma-informed compared with those using more traditional or universal approaches.

• To assess whether TIC change in the organization has been sustained.

• To demonstrate success to stakeholders such as boards of directors, referral sources, or governing bodies enacting TIC mandates.

• To build the evidence base for the TIC field.

What Tools are Available to Measure TIC?

In the last several years, more tools have been developed to measure TIC. Many were designed specifically for a certain intervention or context (i.e., to measure a particular TIC training for a school), but increasingly there are tools that are applicable for different kinds of interventions across a variety of settings. A critically important development is the creation of psychometrically valid tools to measure TIC. These tools are the result of rigorous research and increase the chance that the tool actually measures what it proposes to measure. Currently, there are only a handful of these tools.  

The Attitudes Related to Trauma-Informed Care (ARTIC) Scale. The ARTIC Scale is a psychometrically validated instrument that is the most widely used. It measures professional and para-professional attitudes favorable or less favorable toward TIC. In August 2021, the California Evidence-Based Clearinghouse for Child Welfare officially added the ARTIC Scale to their list of evidence-based measurement tools for child welfare. The ARTIC Scale received an assessment rating of “A – Psychometrics Well-Demonstrated,” the highest rating offered by the CEBC. It is the only measure of trauma-informed care (TIC) listed on the CEBC. 

What is Most Important for Organizations to Consider When Planning to Measure TIC?  

• The big picture of measuring TIC is complex, but there are ways to keep it doable.

• Unless you are a professional evaluator or researcher, you will probably want to limit the questions you are trying to answer to: how trauma-informed is the system? and/or does being trauma-informed impact the quality of services?

• The more intense and long-term your intervention, the more likely you are to show change to the quality of services and people being better off.

• Use psychometrically valid measurement tools. They increase the chance that you are measuring what you think you are measuring. Certain measurement tools such as the ARTIC Scale are available via online platforms and enable you to compare your scores to other scores in your sector using benchmarks.

• Choose specific outcomes that are meaningful in your setting.

• In addition to measurement tools, you can also use data metrics to chart your progress. These include things such as school suspensions, restraints, appointment no-shows, school attendance, staff turnover, number of staff trained, number of clients screened, and many others.

• As you are selecting outcome metrics to track when possible use ones that you already track routinely in your system.

• When selecting metrics, be certain that the metric is a concern or problem in your system. Don’t choose restraints if your restraint rate is already very low. You are less likely to see change.