Trauma Systems Therapy (TST)
About This Program
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
Program Overview
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
Logic Model
The program representative did not provide information about a Logic Model for Trauma Systems Therapy (TST).
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.
Program Delivery
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: "do" 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.
Recommended Intensity:
For a given case, there is a weekly team meeting, with multiple members of the team engaged in assessment and treatment planning. Interventions will vary depending on the phase of treatment the trauma system is assessed as being in at a given time. For youth assessed as being in the most intense phase, safety-focused treatment (a dysregulated youth in a threatening environment), interventions will take place in the home/community, and will likely be frequent (at least twice a week for at least 60 minutes) and intensive. In the highest phase, beyond trauma (an emotionally regulated youth in a stable environment), the intervention will likely be individual psychotherapy to focus on trauma processing, correcting cognitive distortions and meaning making, for 45-60 minutes per week.
Recommended Duration:
As an organizational model, the intervention is carried out on a universal basis continuously. For a given youth/trauma system, it will depend on the phase of treatment. Ideally, a youth will continue to receive services until they reach phase 3. As services within the child welfare system are often time-limited, phase-based needs may be recommended as follow-up care. Full implementation of the model for a given youth typically and ideally lasts approximately 7-9 months.
Delivery Settings
This program is typically conducted in a(n):
- Adoptive Home
- Birth Family Home
- Foster / Kinship Care
- Hospital
- Outpatient Clinic
- Community-based Agency / Organization / Provider
- Group or Residential Care
- Justice Setting (Juvenile Detention, Jail, Prison, Courtroom, etc.)
- School Setting (Including: Day Care, Day Treatment Programs, etc.)
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.
Manuals and Training
Prerequisite/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.
Manual Information
There is a manual that describes how to deliver this program.
Training Information
There is training available for this program.
Training Contact:
- Adam Brown, PsyD
adam.brown2@nyumc.org
phone: (646) 754-5103
Training Type/Location:
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
Saxe, G., Ellis, H., Fogler, J., Hansen, S., & Sorkin, B. (2005). Comprehensive care for traumatized children: An open trial examines treatment using Trauma Systems Therapy. 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 basic study design, measures, results, and notable limitations)
This paper examines the effectiveness of Trauma Systems Therapy (TST) on traumatized 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 controlled 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. doi:10.1111/j.1475-3588.2011.00626.x
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 basic study design, measures, results, and 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 controlled 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. doi:10.1037/a0025192
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 basic study design, measures, results, and 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 controlled postintervention follow-up: None.
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. doi:10.1016/j.childyouth.2017.02.008
Type of Study:
Pretest-posttest
Number of Participants:
1,499
Population:
- Age — 6-18 years (Mean=11.98 years)
- Race/Ethnicity — 59% Caucasian/White, 23% African American/Black, 8% Hispanic/Latino, and 11% Other Race/Ethnicity
- Gender — 54% Female
- Status — Participants were children involved the child welfare system.
Location/Institution: KVC Kansas (KVC), Kansas City Metropolitan and East Kansas regions
Summary:
(To include basic study design, measures, results, and notable limitations)
This study evaluated the effectiveness of a system-wide reform effort to implement trauma-informed care, Trauma Systems Therapy (TST), across a large, private child welfare system. The longitudinal associations among implementation of TST and four measures of children's well-being (functioning, emotional regulation, and behavioral regulation) and placement stability were examined. Measures utilized the UCLA-Post Traumatic
Stress Disorder [PTSD]-Reaction Index, the Moment-by-Moment assessment tool, Emotion Regulation Guide (ER Guide), the Child Ecology Check-In (CECI), the Child and Adolescent Functioning Assessment Scale (CAFAS) and the Priority Problem Worksheet.
Results indicate that, as children's care teams implement TST, children demonstrate greater improvements in functioning, emotional regulation, and behavioral regulation and they experience increased placement stability. Moreover, results demonstrate that positive effects of implementation of TST are produced by both those who work closely with the child (caregivers, case managers, and therapists) and those who work more distally with the child (case manager supervisors and family service coordinators), suggesting that no one staff member or caregiver is central to providing trauma-informed care; rather it may be the confluence of the TST skills of the child's entire care team that produces better outcomes.
Length of controlled postintervention follow-up: None.
Redd, Z., Malm, K., Moore, K., Murphy, K., & Beltz, M. (2017). KVC's Bridging the Way Home: An innovative approach to the application of Trauma Systems Therapy in child welfare. Children and Youth Services Review, 76, 170-180. doi:10.1016/j.childyouth.2017.02.013
Type of Study:
One-group pretest-posttest study
Number of Participants:
30 case managers, 25 therapists, and 40 foster families
Population:
- Age — Children: 6-18 years
- Race/Ethnicity — Not specified
- Gender — Not specified
- Status — Participants were case managers, therapists, and foster families involved the child welfare system.
Location/Institution: KVC Kansas (KVC), Kansas City Metropolitan and East Kansas regions
Summary:
(To include basic study design, measures, results, and notable limitations)
This study focuses on how effectively Trauma Systems Therapy (TST) was integrated into the full continuum of care at KVC, an organization that provides out-of-home care to children served by the Kansas Department for Children and Families in the Kansas City Metropolitan and East Kansas regions. This article describes the results and implications of the implementation evaluation. Measures utilized the UCLA-Post Traumatic
Stress Disorder [PTSD]-Reaction Index, the Moment-by-Moment assessment tool, Emotion Regulation Guide (ER Guide), the Child Ecology Check-In (CECI), the Child and Adolescent Functioning Assessment Scale (CAFAS) and the Priority Problem Worksheet.
Participants found the process of implementing and expanding TST demanding, iterative and complex, yet ultimately TST was implemented across levels. The majority of staff and foster parents completed training in TST and fidelity measures showed progress in TST use over time. KVC's implementation of TST provided both the knowledge and the tools necessary for foster parents to better care for the children in their homes. KVC's efforts show it is possible to infuse trauma-informed care into a large child welfare organization across all levels of care.
Length of controlled postintervention follow-up: None.
Additional 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
- 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: adam.brown2@nyumc.org
- 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: August 2020
Date Program Originally Loaded onto CEBC: December 2012
