What we’ve learned from the first randomised controlled trials of Trauma-Informed Practice 

YEF recently published four evaluations on Trauma-Informed Practice (TIP) – the first robustly-designed randomised controlled trials on TIP and children’s outcomes that we are aware of. Together they mark an important step in filling the evidence gap on whether TIP can reduce children and young people’s involvement in crime and violence.  

What do we mean by trauma and Trauma-Informed Practice? 

Trauma occurs when an event or set of circumstances causes physical or emotional harm which leads to lasting adverse effects on wellbeing. There is substantial evidence that childhood trauma is associated with poorer outcomes across health, education, employment, and involvement with the criminal justice system.  

TIP aims to ensure organisations and staff understand the impacts of trauma, recognise its signs, and adapt how services engage with clients to prevent retraumatisation (where experiences associated with past trauma, such as physical restraint, can make someone feel they are reliving the original trauma).

TIP originally emerged within healthcare settings for survivors receiving trauma-specific therapies around domestic abuse. It was recognised that these treatments could be undermined if the physical settings and interactions patients had with the wider service risked retraumatisation, or failed to identify when people might benefit from evidence-based interventions for trauma (such as therapy).  

The rapid spread of TIP 

As evidence of the negative impacts of trauma have grown, so too has awareness of its relevance across different services. This has created a moral imperative to ensure services seeking to support young people do not inadvertently worsen these impacts. Many people and services have understandably become passionate advocates for TIP being the vehicle for this, and in recent years there has been substantial investment in TIP across many sectors.  

However, the lack of clear definitions of what TIP involves in practice has meant the TIP label has been applied to very variable activities – from one-off, short trainings to whole service reorganisations. At the same time, it has also shifted away from its original roles of supporting the effective access to, and delivery of, trauma-specific therapies. Indeed, TIP is increasingly being seen as an intervention in its own right, with optimism that it can directly impact young people’s outcomes.  

What we’ve evaluated 

This rapid spread of TIP has far outpaced the evidence base. To address this the Home Office and YEF co-funded four evaluations of TIP interventions’ impact on young people’s outcomes: 

• More Good Days at School and Trauma-Informed Schools UK are whole school approaches, involving whole staff training and substantial training and support to senior leadership and pastoral staff.
• Fostering Connections provides training and support to foster care social workers, working with foster carers and young people.  
• Relationship Building Together (RBT) trains practitioners across youth justice, edge of care, youth development and early help services in Bridgend Council, with a tiered response to young people depending on existing levels of trauma experience. Where there is substantial trauma, multi-agency meetings map developmental and trauma histories, with a trauma lead or clinical psychologist developing an intervention plan out of this (an approach known as Enhanced Case Management).

What did we learn? 

The two school-based projects and the foster care project found no or very small positive impacts on children’s behavioural difficulties and mixed results across a range of secondary outcomes. Due to challenges in final data collection (partly reflective of the overstretched staff and services these were operating in) the confidence we can place in these findings is very low, but they remain the most robust evidence that exist on this topic. 

The RBT trial found a moderate reduction in self-reported offending (the primary outcome). This is promising, but there are reasons for caution: there was a lot of uncertainty in this finding so we can’t be really confident in how large or reliable the effect was. Other outcomes were also mixed; we would have expected some outcomes to lead to others (such as young people’s behavioural difficulties leading to reduced offending), but because the secondary outcomes are so varied in direction (positive or negative) and size, the findings don’t provide a clear understanding how any change might have happened.  

Across all four programmes practitioners generally valued the training and reported learning useful skills. However, there was also feedback, particularly in Fostering Connections and RBT, that the approach largely reinforced existing good practice rather than bringing in anything new. Significant implementation challenges were also common. Embedding new practices and systems within overstretched services proved difficult, particularly where inconsistent senior leadership support, staff turnover and workload pressures affected training uptake and implementation.  

What does this tell us about TIP as an intervention for violence prevention? 

These results support YEF’s existing position in our Education Practice Guidance and Youth Sector Practice Guidance: caution is warranted when considering investing in TIP for the primary purpose of preventing young people’s involvement in violence.  

The more direct, focused approach to informing interventions for specific young people in RBT suggests there may be some, heavily caveated and cautious, indications of promise here. But the more universal approaches amongst schools and social workers in the other three programmes show little indication that they are sufficient to change young people’s outcomes in the short to medium term.  

So where the primary aim for commissioners, with limited budgets, is the prevention of young people’s involvement in crime and violence, there are stronger evidence-based approaches, such as mentoring or psychological therapies, that directly tackle challenges with behaviours. 

What can we learn about TIP as an approach to service improvement? 

This does not diminish the potential value of TIP in improving services and young people’s engagement with them, nor in supporting better referrals to evidence-based trauma-specific interventions. Recognising the impact of trauma and avoiding retraumatisation remain important principles, and TIP often forms part of the positive move to more responsive services and developing trusting, supportive and respectful relationships with young people (see for example HMIP’s relational practice guidance).  

However, these evaluations also underline how difficult and resource-intensive meaningful system change can be. Without addressing wider pressures – including high staff turnover, consistency of leadership support, workload demands and limited organisational capacity – services are unlikely to embed TIP consistently or sustainably. 

Key takeaways 

• We know the impact that trauma has on young people’s longer term life outcomes, and ensuring practitioners understand this and that services can respond appropriately to it is important. 
• Where commissioners have a primary aim of reducing young people’s involvement in crime and violence, these trials suggest TIP is not sufficient to change young people’s outcomes (particularly in overstretched services), and tight resources are likely better spent on stronger evidence-based interventions. 
• Where commissioners are considering TIP as part of overall system improvements for young people’s experiences of services and access to specialist services (rather than expecting direct changes to young people’s outcomes), careful consideration should be given to the capacity of pressurised services and staff to do this effectively, and the sustained costs and leadership involved in doing so.  

YEF is currently undertaking a new systematic review of all the evidence on TIP, including these evaluations, and we will be updating our Toolkit on TIP later this year.