Trauma Systems Therapy (TST)

Scientific Rating:
NR
Not able to be Rated
See scale of 1-5
Child Welfare System Relevance Level:
High
See descriptions of 3 levels

About This Program

The information in this program outline is provided by the program representative and edited by the CEBC staff. Trauma Systems Therapy (TST) has been reviewed by the CEBC in the areas of: Trauma Treatment - Client-Level Interventions (Child & Adolescent) and Trauma Treatment - System-Level Programs (Child & Adolescent), but lacks the necessary research evidence to be given a Scientific Rating.

Target Population: The combination of a traumatized child/adolescent who, when exposed to trauma reminders, has difficulty regulating their emotions and behavior and their caregiver/system of care who is not able to adequately protect the youth or help them to manage these survival in the moment states

For children/adolescents ages: 4 – 21

For parents/caregivers of children ages: 4 – 21

Brief Description

Trauma Systems Therapy (TST) is a comprehensive, phase-based treatment program for children and adolescents who have experienced traumatic events and/or who live in environments with ongoing stress and/or traumatic reminders. TST is designed to address the complicated needs of a trauma system, which is defined as the combination of a traumatized child/adolescent who, when exposed to trauma reminders, has difficulty regulating his/her emotions and behavior and his/her caregiver/system of care who is not able to adequately protect the youth or help him/her to manage this dysregulation. The most common setting in which TST is implemented is for youth involved with the child welfare system who may be in birth homes, foster care, residential treatment centers, community-based prevention programs, juvenile justice settings, school-based programs, and programs for unaccompanied alien minors.

TST aims to stabilize the child’s environment while simultaneously enhancing his/her ability to regulate emotions and behaviors. TST begins by assessing each child and his/her environment. Based on this assessment, the child is placed into one of three treatment phases. A TST priority problem is established, and a TST treatment team is assembled to address this priority problem from multiple perspectives. Different interventions and therapies are indicated within each phase, designed to both help the youth to better regulate survival states, and to help caregivers and providers to become better able to meet the child’s needs.

Program Goals:

The goals of Trauma Systems Therapy (TST) are:

  • Improve the functioning of the trauma system by:
    • Focusing assessment and treatment planning on both sides of the system, in other words, seeking to stabilize the social environment/system of care, as well as to improve the youth’s ability to regulate their emotions and behavior
    • Seeking to improve the functioning of agencies that provide service to traumatized youth in the child welfare system

Essential Components

The essential components of Trauma Systems Therapy (TST) include:

  • The focus is on a trauma system, rather than solely on a child.
  • TST is an organizational model as well as a clinical model.
  • TST utilizes an organizational planning process to ensure agency goals are outlined prior to implementation and that the program is set up to succeed, so as to maximize success and ensure administrative commitment and support.
  • TST utilizes a specific assessment and treatment planning process to assess functioning of both youth behavior and the social environment to measure the interaction between both sides of the trauma system.
  • Specific treatment interventions are targeted to each treatment phase. Detailed intervention guides are available targeted to each of the three phases of treatment.
  • Specific engagement process is designed to maximize involvement of both youth and caregiver.
  • There is an emphasis on involvement of the caregiver as being essential to success.
  • Case-based fidelity process is to be done by supervisor to ensure adherence to fidelity for a specific case.
  • Service provision is anchored around 10 TST Treatment Principles.
  • There is a process to follow for the creation of a TST Priority Problem which specifically links emotional and behavioral functioning with trauma triggers in the environment and leads to specific solutions.
  • A web-based assessment system is offered to agencies implementing the model to help monitor both youth progress and organizational outcomes.
  • An emphasis on innovation while maintaining minimum fidelity standards allows the model to be adapted to a variety of settings, populations, and needs.
  • There is a monthly TST Innovation Community Call in which the community of sites currently implementing the model shares ideas and tools. These include county child welfare and mental health providers and private agencies that provide foster care, residential treatment, community based prevention, mobile mental health, and outpatient clinics that are actively implementing TST and are engaged in the process of generating innovations in mental health and child welfare practice. The TST Innovation Community is a large and diverse community of provider organizations coordinated by the program’s developers for the dissemination of TST in a great variety of settings and populations.
  • TST was designed for individual and family treatment, but has been adapted by members of the intervention's innovation community for use in a group setting in residential treatment, with approximately 5-8 group members.
  • TST is a phase-based model, with a specific assessment process to determine current treatment phase that is repeated at regular intervals:
    • For youth in the Safety-Focused Phase, services are typically provided in the home and community a minimum of twice per week, and focus on stabilizing the home and community to make sure it is adequately helpful and protective in order to meet the youth’s physical and emotional needs. A focus on safety planning and supporting caregivers is also emphasized in this phase.
    • For youth in the Regulation-Focused Phase, services are typically provided in the office by a mental health clinician, and focus on psychoeducation and emotion regulation skill building. It is common in this phase for other members of the team to share and reinforce the skills learned in therapy with caregivers and other service system providers such as school staff, foster care caseworkers, direct care staff, etc.
    • For youth in the Beyond Trauma Phase, the emphasis is on psychotherapy to help the youth gain an understanding of trauma and how it is impacting them. Cognitive awareness and coping is emphasized, as is the development of a trauma narrative, and a focus on meaning making and orienting to the future. Caregivers are included in treatment in addition to individual therapy sessions.
    • Psychopharmacology may be indicated for all 3 phases, and a psychiatrist or clinical nurse practitioner is always included as an integral member of the TST treatment team.

Child/Adolescent Services

Trauma Systems Therapy (TST) directly provides services to children/adolescents and addresses the following:

  • Experienced traumatic event, emotional and behavioral dysregulation (survival states) when confronted with reminders of the traumatic events

Parent/Caregiver Services

Trauma Systems Therapy (TST) directly provides services to parents/caregivers and addresses the following:

  • Caregivers (birth families, foster families, and direct care providers in hospital and residential settings) of youth with emotional and behavioral dysregulation who experienced a traumatic event and lack of skills to help them manage trauma triggers or learn coping skills
Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: This program involves the family or other support systems in the individual's treatment: TST requires the engagement of the child’s caregivers and the larger service system in order for the approach to be successful. TST utilizes a unique approach to engaging caregivers, called Ready Set Go, which is designed to involve both youth and their caregivers by helping them to determine their goals and priorities, what gets in the way of achieving these, and how TST can help. Treatment cannot begin in TST until this engagement has been achieved (TST principle 5: “don’t go before you are ready”). TST is a team-based approach which also attempts to engage all relevant providers including extended family, school, community supports, and service systems.

Delivery Settings

This program is typically conducted in a(n):

  • Adoptive Home
  • Birth Family Home
  • Community Agency
  • Foster/Kinship Care
  • Hospital
  • Outpatient Clinic
  • Residential Care Facility
  • School
  • Juvenile detention/justice facility

Homework

Trauma Systems Therapy (TST) includes a homework component:

Youth/families in phase 1 are involved in tasks to help create/maintain environmental stability. Skill-based psychotherapy components for phases 2 and 3 include work to be done outside of treatment sessions including emotion regulation skill building, cognitive processing, and meaning making.

Languages

Trauma Systems Therapy (TST) has materials available in languages other than English:

Korean, Spanish

For information on which materials are available in these languages, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

TST is designed to be sustainable, and for agencies to be able to implement the program utilizing existing resources. The minimum required resources involve training and technical assistance as well as the ability to perform office-based and home-based work and to create a multidisciplinary team including mental health therapists, psychopharmacology, advocacy, and home-based service provision. When all services are not provided by a given agency, the TST team helps consult with the organization for build the partnerships necessary to provide all elements of the model.

Minimum Provider Qualifications

A multidisciplinary team is required including clinical, educational, and case management staff members that are able to collaborate on assessment, treatment planning and implementation. The minimum educational requirement varies by discipline. Clinicians should have at least a Master's degree and case workers often have a Bachelor's degree.

Education and Training Resources

There is a manual that describes how to implement this program, and there is training available for this program.

Training Contact:
Training is obtained:

Training is provided via contract to an agency onsite. Training is typically done in the context of a one-year consulting relationship which involves organizational planning, 3 days of onsite training, weekly consultation/technical assistance, and a train-the-trainer and certification process.

Number of days/hours:

Training typically consists of 3 full days of onsite training, and a year of weekly conference calls to provide technical assistance.

Relevant Published, Peer-Reviewed Research

This program has been reviewed and it was determined that this program lacks the type of published, peer-reviewed research that meets the CEBC criteria for a scientific rating of 1 – 5. Therefore, the program has been given the classification of "NR - Not able to be Rated." It was reviewed because it was identified by the topic expert as a program being used in the field, or it is being marketed and/or used in California with children receiving services from child welfare or related systems and their parents/caregivers. Some programs that are not rated may have published, peer-reviewed research that does not meet the above stated criteria or may have eligible studies that have not yet been published in the peer-reviewed literature. For more information on the "NR - Not able to be Rated" classification, please see the Scientific Rating Scale.

Child Welfare Outcomes: Not Specified

Show relevant research...

Saxe, G., Ellis, H., Fogler, J., Hansen, S., & Sorkin, B. (2005). Comprehensive care for traumatized children. Psychiatric Annals, 35, 443-448.

Type of Study: One group pretest-posttest study
Number of Participants: 110

Population:

  • Age — 5-20 years, Mean=11.21 years
  • Race/Ethnicity — Not specified
  • Gender — 55% Male
  • Status — Participants were traumatized children.

Location/Institution: Boston Medical Center Child Psychiatry Outpatient Clinic (BMC), and Ulster County, New York, Departments of Mental Health and Social Services (UC)

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This paper examines Trauma Systems Therapy (TST) on children. Measures utilized include the Child and Adolescent Needs and Strengths – Trauma Exposure and Adaptation Version (CANS-TEA). Results show significant improvement in children receiving TST on several dimensions of psychiatric symptoms, and the treatment effected measurable changes in children’s social environments and stability. Limitations include the lack of a comparison or control group, non-randomization of subjects, and sole reliance on clinician reported measures.

Length of postintervention follow-up: None.

Saxe, G., Ellis, B. H., Fogler, J., & Navalta, C. P. (2012). Innovations in practice: Preliminary evidence for effective family engagement in treatment for child traumatic stress- Trauma Systems Therapy approach to preventing dropout. Child and Adolescent Mental Health, 17(1), 58–61.

Type of Study: Randomized controlled trial
Number of Participants: 20

Population:

  • Age — 7–18 years, Mean=13.7 years
  • Race/Ethnicity — 68% Black, 18% Hispanic, 10% White, and 4% Mixed race
  • Gender — 11 Females and 9 Males
  • Status — Participants were children with exposure to a traumatic event as well as a score above or equal to 24 on the UCLA PTSD Reaction Index.

Location/Institution: Child psychiatry clinic of a large, urban hospital

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study aimed to determine whether Trauma Systems Therapy (TST) engages and retains traumatized children and their families in treatment. Youth were randomized to receive either TST or treatment as usual (TAU). Measures utilized include the UCLA PTSD Reaction Index (PTSD-RI), the Child Behavior Checklist (CBCL), and the Child Assessment of Needs and Strengths-Trauma Exposure and Adaptation Version (CANS-TEA). Results at 3-month assessment showed 90% of TST participants were still in treatment, whereas only 10% of TAU participants remained in treatment. Within-group analyses of TST participants demonstrated significant reductions in posttraumatic stress and aggression as well as a slight improvement in home safety, although it was not possible to compare the TST and TAU samples at the 3-month assessment as 90% of the TAU sample had dropped out. Limitations include small sample size, gender differences between the groups at baseline, and retention problems.

Length of postintervention follow-up: None.

Ellis, B. H., Fogler, J., Hansen, S., Forbes, P., Navalta, C. P., & Saxe, G. (2012). Trauma Systems Therapy: 15-Month outcomes and the importance of effecting environmental change. Psychological Trauma: Theory, Research, Practice, and Policy, 4(6), 624-630.

Type of Study: One group pretest-posttest study
Number of Participants: 124

Population:

  • Age — 3-20 years
  • Race/Ethnicity — 58.9% Caucasian, 11.3% Biracial or Multiracial, 10.5% White Hispanic, 6.5% African American, 4.8% Black Hispanic, and 7.3% Other including Native American
  • Gender — 45% Female
  • Status — Participants were traumatized children.

Location/Institution: Ulster County, New York

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study examined children receiving Trauma Systems Therapy (TST). Analyses compared hospitalization rates before and after implementation of the model and comparative cost savings were estimated. Measures utilized the Child and Adolescent Needs and Strengths-Trauma Exposure and Adaptation Version (CANS-TEA). Results showed emotion regulation, social-environmental stability, and child functioning/strengths improved significantly with treatment. Improvement in child functioning/strengths and in social environmental stability significantly contributed to overall improvement in emotion regulation. Children who became stable enough to transition to office-based services during early treatment tended to stay in treatment and continued to improve. The number of children needing crisis-stabilization services at 15 months was reduced more than half for those who completed treatment. Limitations include the lack of a comparison group, lack of structured diagnostic instruments, and possible biases on the clinician report measures.

Length of postintervention follow-up: None.

References

Brown, A., Laitner, C., & Saxe, G. N. (2017). Trauma Systems Therapy for Children and Adolescents. In M. A. Landolt, M. Cloitre, & U. Schnyder (Eds.), Evidence-based treatments for trauma related disorders in children and adolescents (pp. 363-384). New York: Springer Press.

Murphy, K., Moore, K. A., Redd, Z., & Malm, K. (2017). Trauma-informed child welfare systems and children's well-being: A longitudinal evaluation of KVC's Bridging the Way Home initiative. Children and Youth Services Review, 75, 23-34.

Saxe, G. N., Ellis, B. H., & Brown, A. D. (2016). Trauma Systems Therapy for Children and Teens (2nd ed.). New York: Guilford Press.

Contact Information

Name: Adam Brown, PsyD
Agency/Affiliation: NYU Child Study Center
Website: www.med.nyu.edu/child-adolescent-psychiatry/research/institutes-and-programs/trauma-and-resilience-research-program/trauma-systems-therapy
Email:
Phone: (646) 754-5103
Fax: (646) 754-5210

Date Research Evidence Last Reviewed by CEBC: March 2017

Date Program Content Last Reviewed by Program Staff: May 2017

Date Program Originally Loaded onto CEBC: December 2012