Discussion 3:

Trauma-Informed Juvenile Justice Systems: A Systematic Review of Definitions and Core Components

Christopher Edward Branson New York University School of Medicine

Carly Lyn Baetz Icahn School of Medicine at Mount Sinai

Sarah McCue Horwitz and Kimberly Eaton Hoagwood New York University School of Medicine

Objective: The U.S. Department of Justice has called for the creation of trauma-informed juvenile justice systems in order to combat the negative impact of trauma on youth offenders and frontline staff. Definitions of trauma-informed care have been proposed for various service systems, yet there is not currently a widely accepted definition for juvenile justice. The current systematic review examined published definitions of a trauma-informed juvenile justice system in an effort to identify the most commonly named core elements and specific interventions or policies. Method: A systematic literature search was conducted in 10 databases to identify publications that defined trauma-informed care or recommended specific practices or policies for the juvenile justice system. Results: We reviewed 950 unique records, of which 10 met criteria for inclusion. The 10 publications included 71 different recommended interventions or policies that reflected 10 core domains of trauma-informed practice. We found 8 specific practice or policy recommendations with relative consensus, including staff training on trauma and trauma-specific treatment, while most recommendations were included in 2 or less defini- tions. Conclusion: The extant literature offers relative consensus around the core domains of a trauma- informed juvenile justice system, but much less agreement on the specific practices and policies. A logical next step is a review of the empirical research to determine which practices or policies produce positive impacts on outcomes for youth, staff, and the broader agency environment, which will help refine the core definitional elements that comprise a unified theory of trauma-informed practice for juvenile justice.

Keywords: juvenile justice, adolescents, trauma-informed, trauma responsive, traumatic stress

Childhood exposure to violence and other traumatic events is increasingly recognized as a major public health challenge because of its association with a host of deleterious long-term outcomes (National Prevention Council, 2011). Although the majority of Americans will experience at least one traumatic event before the age of 18 (McLaughlin et al., 2012), trauma disproportionately

affects youth involved with the juvenile justice system (Miller, Green, Fettes, & Aarons, 2011). An estimated 70% to 90% of youth offenders have experienced one or more types of trauma, including high rates of physical or sexual abuse, witnessing do- mestic violence, and exposure to violence in school or the com- munity (Abram et al., 2004; Ford, Hartman, Hawke, & Chapman, 2008). Accumulating evidence suggests that childhood trauma exposure is likely a key risk factor for subsequent juvenile justice involvement (Kerig & Becker, 2010). Juvenile offenders are a particularly vulnerable population, but those with histories of trauma exposure and/or symptoms of posttraumatic stress disorder (PTSD) have higher rates of recidivism, co-occurring disorders, school dropout, and suicide attempts (Cauffman, Monahan, & Thomas, 2015; Haynie, Petts, Maimon, & Piquero, 2009; Wasser- man & McReynolds, 2011; Wolff, Baglivio, & Piquero, 2015). Multiple investigators have argued persuasively that youth may cope with traumatic stress in ways that increase their risk of arrest, including using drugs to avoid distressing memories, running away from an abusive home, and carrying a weapon or joining a gang to prevent revictimization (DeHart & Moran, 2015; Ford, Chapman, Mack, & Pearson, 2006; Kerig & Becker, 2010).

Involvement in the justice system itself places youth at risk for exposure to additional trauma as well as harsh practices that may exacerbate their psychological distress and contribute to worse legal outcomes. Potential sources of trauma in the justice system

This article was published Online First February 6, 2017. Christopher Edward Branson, Department of Child & Adolescent Psy-

chiatry, New York University School of Medicine; Carly Lyn Baetz, Department of Psychiatry, Icahn School of Medicine at Mount Sinai; Sarah McCue Horwitz and Kimberly Eaton Hoagwood, Department of Child & Adolescent Psychiatry, New York University School of Medicine.

Carly Lyn Baetz is now at the Department of Child & Adolescent Psychiatry, New York University School of Medicine.

Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under Award K23MH104697. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. We thank Raquel Rose for her contributions to the systematic review.

Correspondence concerning this article should be addressed to Christopher Edward Branson, New York University Child Study Center, 1 Park Avenue – 7th Floor, New York, NY 10016. E-mail: christopher.branson@nyumc .org

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Psychological Trauma: Theory, Research, Practice, and Policy © 2017 American Psychological Association 2017, Vol. 9, No. 6, 635– 646 1942-9681/17/$12.00 http://dx.doi.org/10.1037/tra0000255

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include discriminatory law enforcement practices like “Stop and Frisk,” abusive behavior by correctional staff, and the high rates of physical and sexual victimization in juvenile justice facilities, all of which are associated with an increased risk of PTSD symptoms (Dierkhising, Lane, & Natsuaki, 2014; Geller, Fagan, Tyler, & Link, 2014). Youth with prior trauma exposure may be “triggered” and suffer psychological distress in response to several invasive or coercive practices commonly used in the justice system, including strip-searches or pat-downs, placement in secure facilities with limited access to loved ones, and use of punitive seclusion or physical restraint in detention or correctional settings. A small retrospective study of young adults (ages 18-20) that had been discharged from a juvenile justice facility in the past year found that exposure to abuse and/or harsh punishments (i.e., seclusion) while incarcerated was positively associated with post-release criminal behavior and PTSD symptoms (Dierkhising et al., 2014). Thus, the justice system may impede the efforts of trauma survi- vors to rehabilitate and desist from crime.

The negative impact of trauma within juvenile justice goes beyond youth offenders. It is increasingly recognized that front- line justice system professionals are frequently exposed to traumatic stressors in the line of duty, including witnessing or experiencing violence and hearing details of trauma experi- enced by crime victims or youth offenders (Chamberlain & Miller, 2008; Kunst, 2011; Rainville, 2015). A growing litera- ture reveals high rates of moderate to severe traumatic stress symptoms in samples of correctional staff, probation officers, law enforcement, and attorneys (Denhof & Spinaris, 2013; Levin et al., 2011; Skogstad et al., 2013). Traumatic stress is associated with impaired job performance among justice system professionals (Denhof & Spinaris, 2013). Taken together, these findings suggest that trauma contributes to worse outcomes for all involved with the juvenile justice system.

Trauma-Informed Care

Increased public awareness of trauma’s pernicious effects and its prevalence among society’s most vulnerable populations has led to calls from a number of key stakeholders for the creation of trauma-informed public service systems (National Association of State Mental Health Program Directors, 2005; Substance Abuse and Mental Health Services Administration, 2014). Trauma- informed care (TIC) is an approach to organizing services that integrates an understanding of the impact and consequences of trauma into all interventions and aspects of organizational func- tioning (American Association of Children’s Residential Centers, 2014). Implementing TIC goes beyond offering mental health interventions designed to treat symptoms of PTSD, and requires organizations and service systems to examine how their practices, policies, and environments foster a sense of safety among con- sumers with histories of trauma exposure (Kusmaul, Wilson, & Nochajski, 2015). According to Elliott, Bjelajac, Fallot, Markoff, and Reed (2005), in a trauma-informed organization,

all staff . . . from the receptionist to the direct care workers to the board of directors, must understand how violence impacts the lives of people being served, so that every interaction is consistent with the recovery process and reduces the possibility of re- traumatization. (p. 462)

For many agencies and service systems, TIC represents a signifi- cant shift in thinking and practice.

The concept of trauma-informed service systems was first in- troduced into the literature over 15 years ago by Harris and Fallot (2001). Since then, several researchers and stakeholder groups have attempted to define a TIC approach. These definitions include broad principles or domains of TIC (e.g., staff education/compe- tence around trauma, physically and psychologically safe environ- ment of care, client-centered service planning) and/or recommen- dations for specific trauma-informed practices or policies (e.g., eliminating or restricting harsh or coercive practices, mandatory trauma training for all staff, universal screening of clients for trauma exposure and related impairment; Hopper, Bassuk, & Ol- ivet, 2010; Raja, Hasnain, Hoersch, Gove-Yin, & Rajagopalan, 2015; Wall, Higgins, & Hunter, 2016). Although there is general agreement in the literature that TIC refers to the integration of trauma awareness and understanding throughout an organization or service system, there is currently no consensus-based definition on the particular practices or policies that comprise this approach for any service system (Hopper et al., 2010). Multiple authors have identified the lack of consensus on the definition of TIC as a primary barrier to creating trauma-informed systems (Hanson & Lang, 2016; Hopper et al., 2010; Wall et al., 2016).

The Current Study

Although the basic definition of TIC cuts across service sys- tems, the particular practices or policies that are implemented should be tailored to fit the unique mission and challenges of each system. There is currently no TIC definition for juvenile justice that has been widely accepted, even though several federal agen- cies and stakeholder organizations have established initiatives to promote the adoption of TIC in the justice system (Federal Part- ners Committee on Women and Trauma, 2013; National Council of Juvenile and Family Court Judges, n.d.). This lack of consensus has contributed to confusion among juvenile justice system leaders and frontline providers as to what exactly is meant by TIC (Donisch, Bray, & Gewirtz, 2016). Identifying the specific com- ponents (practices, policies) of a trauma-informed juvenile justice system is a prerequisite for developing and evaluating TIC service models. The primary aim of the current study is to systematically review the extant literature on definitions or descriptions of TIC for the juvenile justice system in order to identify the most com- monly named core domains and recommended practices or poli- cies. Additionally, we will identify areas of consensus or disagree- ment and directions for future research.

Method

Study Protocol and Inclusion Criteria

The first author developed the study protocol based on the established guidelines for systematic literature reviews (Shamseer et al., 2015). A copy of the full protocol is available upon request. Our review focused on identifying English-language records pub- lished since 2000 that proposed an original definition of TIC specific to the juvenile justice system (whole system or any of the following settings: law enforcement, juvenile courts, diversion programs, probation departments, detention or correctional fa-

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636 BRANSON, BAETZ, HORWITZ, AND HOAGWOOD

cilities). For the present review, we operationalized this as publications for which a primary focus was identifying core principles or domains of TIC (i.e., promoting a safe environ- ment of care) and/or recommending specific trauma-informed practices, policies, or procedures for the juvenile justice system (i.e., staff training on working with trauma-affected youth, trauma-specific mental health services).

We excluded publications that called for TIC in juvenile justice without defining it, simply cited an existing definition without adding new recommendations, or defined TIC for the adult criminal justice system or for multiple service systems without offering juvenile- justice-specific definition/recommendations. Because TIC is a system- wide approach, we excluded publications whose definition/recom- mendations were limited to trauma-informed clinical services (i.e., screening/assessment, treatment). Additionally, we limited our search to journal manuscripts, books, white papers, government/stakeholder agency reports or policy statements, articles in trade magazines/ newsletters (e.g., American Jails magazine), and web-based resources (i.e., stakeholder agency websites with TIC definitions). We excluded dissertations, conference abstracts/presentations, webinars or online presentations, blog posts, and popular-press articles.

Literature Search Strategy

We used a four-step process to identify eligible studies. First, literature searches were conducted in 10 databases (EBSCO Crim- inal Justice, ERIC, National Criminal Justice Reference Service, Ovid PsycINFO, ProQuest Criminal Justice, ProQuest Psychol- ogy, ProQuest Published International Literature on Traumatic Stress, ProQuest Social Science, ProQuest Social Services Ab- stracts, PubMed) using the search terms (“trauma informed” OR “trauma focused” OR “trauma responsive”) AND (“juvenile jus- tice” OR probation OR court� OR “law enforcement” OR “diver- sion program” OR “juvenile detention”). In May 2016, the first author conducted the literature searches and compiled a list of the complete reference and abstract for every record identified. Two reviewers (C. E. Branson and C. L. Baetz) independently reviewed all abstracts to determine if they met our inclusion criteria. For each abstract that was selected for further review by either re- viewer, we then retrieved the full-text document. Two reviewers independently reviewed the full-text articles to determine if they met inclusion criteria. In cases of disagreement, the two authors discussed the publication until a consensus was reached. The overall level of interrater agreement was adequate (� � .62).

In the second step, the first author reviewed the reference lists of all publications selected for inclusion to identify other potentially eligible records. Next, we conducted a “cited by” search in Google Scholar of all selected publications. For all new publications identified through these steps, we repeated the two-step process (independent review of abstracts, then full-text review). The final step consisted of a Google Internet search for web-based resources. We made the a priori decision to limit our review to the first 20 pages of hits (i.e., 200 websites). Web-based records that appeared to meet inclusion criteria were saved in PDF format and reviewed by the first and second authors.

Data Extraction and Coding

Two reviewers (C. E. Branson and C. L. Baetz) independently extracted and coded data from all articles selected for inclusion

using a data collection form and codebook designed for the current study (available upon request). The following variables were ex- tracted and coded: publication year, publication type (i.e., journal article, agency report), focus of TIC definition (i.e., entire juvenile justice system or particular setting such as probation departments), core elements of TIC (i.e., broad principles or categories of TIC for juvenile justice system), and specific trauma-informed practices/ policies/interventions that were recommended.

Data Analysis and Synthesis

We used content analysis to identify and code recurring themes regarding the core principles or domains of TIC for juvenile justice and the specific strategies or practices recom- mended for each domain. This approach was guided by the “coding consensus, co-occurrence, and comparison” methodol- ogy described by Willms et al. (1990), in which both a priori and emergent themes (i.e., core domains or specific practices) are coded to construct a conceptual framework (Palinkas, 2014). First, a primary coder (first author) extracted and coded data from all the records. A second coder (second author) repeated this for 50% of the records and examined the first coder’s work on the other half. Three a priori categories (clin- ical services, agency context, system-level) provided an initial framework for organizing the data. The coders extracted ver- batim anything that appeared to be a recommendation (e.g., agencies/systems should train staff on trauma) or explicitly identified core domains or principles of a trauma-informed juvenile justice system. After reading through all the data, the coders drafted preliminary domains (e.g., creating a safe envi- ronment). Next, the coders organized similar recommendations together in a word processing document and assigned them to a domain. Through discussion, the two coders came to a consen- sus on names of the broad domains and the wording and categorization of specific practice or policy recommendations.

Results

Literature Search Results

Our literature search identified a total of 950 unique records, of which 898 were excluded during the initial screening. Re- cords excluded at this stage included numerous studies on the prevalence/impact of trauma exposure (e.g., Wolff et al., 2015) and trauma-specific mental health services (e.g., Black, Wood- worth, Tremblay, & Carpenter, 2012) for youth offenders and other populations. Fifty-two full-text records were reviewed, of which 42 were excluded, leaving a total of 10 publications selected for inclusion (denoted by asterisks in the References). The 42 excluded full-text records included 15 publications that called for TIC in juvenile justice but did not provide a definition or detailed recommendations (e.g., Ko et al., 2008), six publi- cations that discussed trauma screening/treatment only (e.g., Igelman, Ryan, Gilbert, Bashant, & North, 2008), and five publications that cited someone else’s definition of TIC (e.g., Crosby, 2016).

There were five instances in which we found multiple pub- lications from the same author(s) that met our inclusion criteria. We extracted and coded the data from all of these publications.

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637TRAUMA-INFORMED JUVENILE JUSTICE SYSTEMS

In four cases, we excluded a second publication that included identical or less complete recommendations (Feierman & Fine, 2014; Ford, 2012; National Center for Mental Health and Ju- venile Justice, n.d.; Sickmund, 2016) than another eligible publication from the same author(s) (Feierman & Ford, 2016; National Center for Mental Health and Juvenile Justice & Technical Assistance Collaborative, 2015; National Council of Juvenile and Family Court Judges, 2015). In the remaining case, we excluded a series of policy briefs from the National Child Traumatic Stress Network (Burrell, 2013; Dierkhising, Ko, & Goldman, 2013; Kerig, 2013; Lacey, 2013; Rozzell, 2013; Stewart, 2013) in favor of a more recent publication (National Child Traumatic Stress Network, 2016), as the former explicitly stated that it was a preliminary attempt to start defining the core elements of TIC for juvenile justice. A complete list of the excluded records is available upon request. Figure 1 provides a detailed summary of our search.

Publication Characteristics

We reviewed 10 publications that defined TIC and/or recom- mended specific trauma-informed practices or policies for

the juvenile justice system (see Table 1). Four publications gave definitions or recommendations for the entire system, and three defined TIC for juvenile or family courts. The remaining three definitions/recommendations included one apiece for ju- venile detention/correctional facilities, diversion programs, and law enforcement. Publication dates ranged from 2012 to 2016, with half published in the past 2 years.

TIC Definitions and Recommendations

The 10 publications included a total of 71 different practice or policy recommendations representing 10 major principles or domains of trauma-informed practice for juvenile justice. We further organized these 10 domains into three categories based on their level of focus: clinical services, agency context, and system level (see Table 2). For each of these domains, we identified all of the specific trauma-informed practices or pol- icies that were recommended and how often they were recom- mended across the 10 definitions (see Table 3). The number of recommendations included in these definitions ranged from four to 37 (M � 19.20, SD � 11.24). On average, publications that defined TIC for the entire system included more recom-

Figure 1. Summary of the literature search. TIC � trauma-informed care; PTSD � posttraumatic stress disorder.

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638 BRANSON, BAETZ, HORWITZ, AND HOAGWOOD

mendations (M � 25.67, SD � 9.50) compared with definitions of TIC intended for particular justice settings like courts or law enforcement (M � 16.43, SD � 11.39).

Only eight of the 71 recommendations (11%) were included in the majority of definitions (i.e., n � 6). These recommendations were universal screening/assessment of youth for trauma-related impairment; providing evidence-based, trauma-specific treatment; practices/policies that address the needs of diverse groups of youth; access to social supports for youth and families; prioritizing youth and family preferences for services; staff training; policies/ procedures to promote a safe environment; and eliminating or reducing harsh/coercive practices. More than half of the recom- mendations (n � 39 or 55%) were included in only one or two definitions, with the remaining 24 recommendations (34%) in- cluded in three to five definitions.

Clinical Services Recommendations

Domain 1: Screening & assessment. All but one of the publications called for universal screening of youth offenders

for trauma-related impairment followed by a comprehensive mental health assessment for youth who screen positive. A smaller number of publications included recommendations about what to screen or assess for (e.g., trauma exposure and/or PTSD symptoms). Only three publications called for the use of assessment tools that have been validated with youth in the juvenile justice system.

Domain 2: Services & interventions. All but one of the publications called for justice systems to make evidence-based, trauma-specific mental health interventions widely available to youth and families involved with the system. Seven different recommendations were given regarding specific services, most commonly offering trauma-specific services to youth in both community-based juvenile justice agencies and detention/cor- rectional facilities (n � 4).

Domain 3: Cultural competence. Six publications recom- mended policies, procedures, and clinical services/program- ming that address the needs of diverse groups of youth and avoid or reduce disparities related to race/ethnicity, gender, sexual orientation, developmental level, and socioeconomic status. Three publications included recommendations for gen- der-responsive/specific programming to meet the needs of girls involved in the justice system. Three publications called for services to be tailored for lesbian, gay, bisexual, transgender, and queer youth.

Agency Context Recommendations

Domain 4: Youth & family engagement/involvement. Seven publications included recommendations around promoting youth and family engagement with the justice system. Six publications recommended that agencies/systems provide access to social sup- ports for youth and families. Other common recommendations within this area included prioritizing youth and family preferences

Table 1 Publications Included in Systematic Review

Publication Focus of TIC

definition Broad domains of TIC identified

American Bar Association (2014) Courts NA Attorney General’s National Task

Force on Children Exposed to Violence (2012) Whole system NA

Feierman and Ford (2016) Whole system NA Griffin, Germain, and Wilkerson

(2012) Juvenile justice

facilities NA

International Association of Chiefs of Police (2014) Law enforcement NA

National Center for Mental Health and Juvenile Justice & Technical Assistance Collaborative (2015)

Probation/Diversion programs

Leadership; Policy & procedures; Environment; Engagement & involvement; Cross sector collaboration; Intervention continuum; Funding strategies; Workforce development; Quality assurance & evaluation

National Child Traumatic Stress Network (2016)

Whole system Policies & procedures; screening; clinical assessment/intervention; programming & staff education; prevention & management of secondary traumatic stress; partnering with youth & families; cross-system collaboration; addressing disparities & diversity

National Council of Juvenile & Family Court Judges (2015) Courts/Judges NA

Pilnik and Kendall (2012) Courts/Attorneys NA Rapp (2016) Whole system Governing/leadership; culture/mission/goals; programming; staff/personnel; system

collaboration; policies; physical environment; monitoring/evaluationa

Note. TIC � trauma-informed care; NA � not applicable. a These domains were adapted from Substance Abuse and Mental Health Services Administration (2014).

Table 2 Core Domains of Trauma-Informed Care for Juvenile Justice

Area of focus Domains within this area

Clinical services 1. Screening & assessment 2. Services & interventions 3. Cultural competence

Agency context 4. Youth & family engagement/involvement 5. Workforce development & support 6. Promoting a safe agency environment 7. Agency policies, procedures, & leadership

System level 8. Cross-system collaboration 9. System-level policies & procedures

10. Quality assurance & evaluation

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639TRAUMA-INFORMED JUVENILE JUSTICE SYSTEMS

Table 3 Recommended Trauma-Informed Practices and Policies for the Juvenile Justice System

Domain/Recommendations Publications with this

recommendationa nb

Domain 1: Screening/assessment 1. Universal screening for trauma-related impairment (trauma exposure, PTSD) and comprehensive, trauma-

informed mental health assessments by a qualified clinician for youth who screen positive 1–4, 6–10 9 2. Use screening/assessment measures that are validated with diverse populations 1, 3, 8 3 3. Utilize screening/assessment measures that are validated with justice-involved youth 1, 6, 8 3 4. Use interviews over self-report measures to improve accurate identification of symptoms 7 1 5. Assessment should be used to monitor progress and evaluate client outcomes 7 1 6. Assessment must be completed without asking youth to repeat trauma stories in multiple interviews 10 1 Recommended areas to screen/assess

• Trauma exposure 2, 4, 7, 8, 10 5 • PTSD symptoms 4, 7, 8 3 • Relationship between PTSD symptoms and criminogenic risk-needs-responsivity factors 8 1 • Callous-unemotional traits 2 1 • Commercial sexual exploitation (CSEC) 1 1 • Family members’ information and history 10 1 • Co-occurring mental health/SUD problems 8 1 • Attachment failures 10 1

Domain 2: Services & interventions 7. Evidence-based trauma-specific treatment should be widely available/accessible to youth & families 1–4, 6–10 9 8. Offer treatment in community-based settings as well as juvenile detention/correctional facilities 3, 7, 8, 10 4 9. Provide a continuum of trauma-informed interventions (brief interventions to intensive treatment) 7, 8, 10 3 10. Services that teach youth self-regulation skills 3, 4, 8 3 11. Strengths-based framework 1, 4, 8 3 12. Develop trauma-informed safety plans (triggers, warning signs, coping strategies) with all youth affected

by trauma 7, 8 2 13. Integrate TIC principles into all services (mental health, substance use, medical) 3, 8 2

Domain 3: Cultural competence 14. Practices and policies should address the needs of diverse groups of youth and avoid/reduce disparities

related to race/ethnicity, gender, sexual orientation, developmental level, and SES 1–3, 8–10 6 15. Provide gender-specific/responsive interventions and programs 2, 3, 8 3 16. Tailor services for LGBTQ youth 2, 3, 8 3 17. Tailor services to the age/developmental level of youth 7, 8 2 18. Trauma-informed services for CSEC 1, 2 2 19. Create small, family style group living facilities for pregnant and parenting girls 2 1

Domain 4: Youth & family engagement/involvement 20. Prioritize youth and family preferences for services 3, 6–10 6 21. Provide youth and families with access to positive social support from people of similar backgrounds

(e.g., mentors, peer advocates) 2, 3, 6–8, 10 6 22. Provide education/service referrals to address parent/caregiver trauma and its impact on the family

system 1, 3, 7, 8 4 23. Involve youth & families in agency planning (advisory boards, routinely collecting feedback on

services) 6–8, 10 4 24. Provide tangible resources to reduce barriers to engagement and partnering (bus pass, child care, etc.) 8 1

Domain 5: Workforce development & support 25. Training for all staff to increase their understanding of trauma 1–10 10 26. Ongoing supervision to ensure that staff implement new approaches with fidelity 3, 7 2 27. Training for new hires and refresher trainings 8 1 Recommended topics for training

• Trauma-informed care principles/practices 1, 4, 7–10 6 • Impact of trauma on youth development & behavior 1, 5–8 5 • Skills for working with trauma-affected youth (i.e., identifying & responding to youth trauma reactions) 3, 5, 7, 8, 10 5 • Recognize the signs and triggers for traumatic stress reactions 6–9 4 • Family engagement/empowerment strategies 3, 5, 7, 10 4 • Ways that juvenile justice involvement can be triggering or re-traumatizing for youth 4, 5, 7 3 • Trauma-informed treatments/services available in the local community/justice system 5, 6, 9 3 • Trauma screening 6, 9 2 • Making appropriate referrals to services 3, 5 2 • Impact of trauma on youth delinquency 7, 8 2 • Adolescent development 5, 10 2 • Specialized Crisis Intervention Team training for law enforcement 5 1

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Table 3 (continued)

Domain/Recommendations Publications with this

recommendationa nb

• Family dynamics 10 1 • Culturally competent care with special populations 2 1 • Parenting skills 10 1

28. Address traumatic stress reactions among front-line staff (PTSD, secondary/vicarious trauma) 1, 6–8, 10 5 29. Education/training to increase staff awareness of the symptoms and causes of staff traumatic stress 1, 6–8, 10 5 30. Discuss staff traumatic stress/wellness in supervision and/or team meetings 1, 7, 8, 10 4 31. Employee assistance programs or referral to outside therapist for counseling to address traumatic stress 7, 8, 10 3 32. Teach staff strategies for preventing traumatic stress (self-care, emotion regulation skills) 8, 10 2 33. Develop procedure for debriefing with staff following work-related events that are potentially traumatic

(e.g., youth killed, youth or staff assaulted) 7, 8 2 34. Consult with outside expert on addressing staff traumatic stress within the organization 1 1 35. Create coworker support opportunities (e.g., peer support groups onsite in agency) 1 1 36. Employee recognition (i.e., reinforce staff success) 7 1 37. Create agency climate that says seeking help is a sign of strength, not weakness 7 1 38. Routinely collect feedback from staff/involve them in agency decision making 10 1 39. Increase staff salaries to increase staff retention (i.e., to provide stability/consistency for youth) 10 1

Domain 6: Promoting a safe agency environment 40. Policies/procedures promote a physically and psychologically safe environment for youth/families and

staff 3, 4, 6–8, 10 6 41. Restrict/eliminate harsh or coercive practices (e.g., seclusion, physical restraint, shackling, strip

searches) 1–3, 8–10 6 42. Promote respectful youth-staff interactions 3, 4, 6, 7 4 43. Minimize youth exposure to violence or threats from other youth or staff 3, 7, 8 3 44. Physical environment is calming, welcoming, and therapeutic 6, 7, 10 3 45. Transparent communication with youth/families about agency rules, their rights, and grievance process 2, 7, 10 3 46. Structure and predictability (consistent schedule, youth informed in advance of changes) 4 1 47. Ensure adequate security in the agency (lighting, cameras, security staff) 7 1 48. Use trauma-informed/positive behavior management strategies or systems 4 1 49. Create specialized crisis interventions teams 5 1 50. Facilities need private rooms for youth who do not feel safe or comfortable sharing a room at night 10 1 51. Eliminate uniforms 10 1

Domain 7: Agency policies, procedures, & leadership 52. Incorporate trauma-informed principles into all aspects of agency operations (mission statement, written

policies, protocols, procedures) 7, 8, 10 3 53. System/agency leadership must embrace a trauma-informed approach and build it into the organizational

value system and operational environment 6, 7 2 54. Create a task force to lead trauma-informed care initiative with staff from different departments and

roles 7 1

Domain 8: Cross-system collaboration 55. Collaborate with other systems/providers to coordinate care for youth with multi-system involvement 1, 5, 7, 8, 10 5 56. Work with community stakeholders to ensure that trauma-informed services are available in all child

service systems to address the impact of trauma before youth come into contact with justice system 3, 5, 7, 8 4 57. Establish information sharing agreements with other systems or providers that serve justice-involved

youth 7, 8 2

Domain 9: Systems-level policies & procedures 58. Policies/procedures to minimize justice involvement whenever possible (divert youth to community,

keep youth in least restrictive environment, and/or limit transfer to adult court) 2, 3, 5, 8, 9 5 59. Policies to require that a youths’ trauma history is used to connect them to services or limit juvenile

justice involvement and cannot be used against a youth in court (i.e., as aggravating factor, protection against self-incrimination during court-mandated assessments) 3, 7–9 4

60. Policy/legislation to promote the adoption of TIC by juvenile justice agencies/systems 3, 7, 9 3 61. Guarantee legal representation for all trauma-exposed youth accused of a crime 2, 8 2 62. Policies to prevent youth from entering status offense or juvenile justice system because of abuse or

neglect (e.g., ran away from abusive home, assaulted an abusive parent in self-defense) 3, 9 2 63. Appoint independent monitors to ensure that youth in facilities are safe and receiving appropriate

services 2, 3 2 64. Legislation to ensure that commercially sexually exploited children are treated as victims, not criminals 1, 2 2 65. School discipline policies to keep kids in school rather than driving them to justice system 2 1 66. Revise mission of juvenile justice to focus on rehabilitation/safety rather than a corrections mission 10 1

Domain 10: Quality assurance & evaluation 67. Conduct evaluations and focus on quality improvement 3, 7, 10 3

(table continues)

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during service planning (n � 6), involving youth/family members in systems evaluation or planning efforts (n � 4), and providing education and/or service referrals to address caregiver trauma and its impact on the family system (n � 4).

Domain 5: Workforce development & support. Staff train- ing on trauma was identified as a core element of TIC in all 10 publications, making it the only unanimous recommendation. A total of 15 different training topics were recommended across the 10 publications. The most frequently recommended topics for training were TIC principles or practices (n � 6), specific skills for working with trauma survivors (n � 5), and the impact of trauma on youth development/behavior (n � 5). Five publications recom- mended agency or system-wide efforts to address work-related traumatic stress reactions among frontline staff. Nine different strategies were identified, most commonly staff education on the signs and causes of work-related PTSD (n � 5) and discussion of work stressors in supervision or team meetings (n � 4).

Domain 6: Promoting a safe agency environment. Six of the publications identified policies and procedures to promote a sense of physical and psychological safety among youth, families, and staff as a core component of TIC. The most common recom- mendations for creating a safe environment were restricting/elim- inating the use of harsh or coercive practices that may trigger or retraumatize youth (n � 6) and promoting respectful youth-staff interactions (n � 4).

Domain 7: Agency policies, procedures, & leadership. Three publications recommended that juvenile justice agencies or systems institutionalize their commitment to TIC by embedding principles of TIC into their written policies and procedures. Ad- ditionally, two publications recommended that agency leadership embrace a trauma-informed approach and build into the organiza- tional value system.

System-Level Recommendations

Domain 8: Cross-system collaboration. Five publications called for cross-system collaboration in order to coordinate care with other service systems or providers that work with youth offenders. Four of these definitions recommended working with other community stakeholders to ensure that trauma-informed ser- vices/care is available throughout all local child service systems. Additionally, two publications recommended that juvenile justice establish information-sharing agreements with other service sys-

tems/providers to facilitate coordination of care for youth involved with multiple systems.

Domain 9: System-level policies & procedures. Five publi- cations recommended system-level policies to minimize youth contact with juvenile justice and/or keep them in the least restric- tive environment. Four publications recommended policies to en- sure that information about a youth’s trauma history is used to connect them with services and is never used against them in court. Three publications called for policies to promote the adoption of TIC within juvenile justice.

Domain 10: Quality assurance & evaluation. Three publi- cations called for ongoing data collection to evaluate the process and impact of implementing TIC. Recommended areas of focus for such efforts included youth outcomes (n � 2) and monitoring for racial/ethnic disparities in access to TIC and outcomes (n � 2). Notably, only one publication called for ongoing monitoring of staff fidelity to trauma-informed interventions/practices.

Discussion

The current study, to our knowledge, represents the first systematic review of the literature on existing definitions of the core components and practices or policies that comprise TIC for the juvenile justice system. Findings reveal that the bulk of the extant literature consists of studies examining trauma’s impact on youth offenders and theoretical articles outlining the ratio- nale for trauma-informed juvenile justice systems, with a far smaller number of publications (10 of the 950 records reviewed, or 1%) that actually define the core components of TIC. The 10 publications included definitions/recommendations for the whole system as well as for all major settings/professions within juvenile justice (law enforcement, courts, probation/ diversion, correctional/detention facilities). The overarching theme of our review is that the literature offers relative con- sensus around the core domains but less agreement on the key practices or policies that comprise a trauma-informed approach for juvenile justice. One clear theme is that further refinement of the definition is necessary.

The 10 publications included in the current review yielded a total of 71 different recommendations. Although this is a large number that includes a diverse range of practices and policies, we were able to identify 10 broad domains of TIC (e.g., promoting a safe agency environment, workforce development/support) that

Table 3 (continued)

Domain/Recommendations Publications with this

recommendationa nb

68. Assess effectiveness of trauma-informed services/youth outcomes 3, 7 2 69. Monitor for racial disparities/cultural disparities in access to and benefit from trauma-informed services 3, 7 2 70. Assess fidelity to evidence-based/trauma-informed practices 7 1 71. Assess whether juvenile justice services are being used for youth and families who could benefit from

voluntary or preventive services and may not need system involvement at all 3 1

Note. PTSD � posttraumatic stress disorder; TIC � trauma-informed care; SES � socioeconomic status; LGBTQ � lesbian, gay, bisexual, transgender, queer. a 1 � American Bar Association (2014); 2 � Attorney General’s National Task Force on Children Exposed to Violence (2012); 3 � Feierman and Ford (2016); 4 � Griffin, Germain, and Wilkerson (2012); 5 � International Association of Chiefs of Police (2014); 6 � National Council of Juvenile & Family Court Judges (2015); 7 � National Center for Mental Health and Juvenile Justice & Technical Assistance Collaborative (2015); 8 � National Child Traumatic Stress Network (2016); 9 � Pilnik and Kendall (2012); 10 � Rapp (2016). b Total number of publications that included this recommendation.

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642 BRANSON, BAETZ, HORWITZ, AND HOAGWOOD

encompass all of the recommendations. Furthermore, these do- mains are largely consistent with those found in definitions of TIC for other service systems (Hopper et al., 2010; Raja et al., 2015). This suggests a reasonable level of conceptual coherence around the core domains of a trauma-informed juvenile justice system. However, we found much less agreement around the specific interventions or policies that were identified as essential compo- nents of TIC for juvenile justice. Only eight of the 71 recom- mended practices or policies (11%) were included in the majority of publications, whereas most recommendations (n � 39 or 55%) were included in only one or two publications. This suggests that more work is needed to translate the broader domains of TIC into particular interventions or policies, which is also the case for efforts to define TIC in other child service systems (e.g., Wall et al., 2016).

Another key gap in the extant literature is the limited discussion of how to implement particular practices or policies and the potential barriers at the agency or systems level. For example, although there is unanimous agreement that all staff should un- dergo training on trauma, there was much less consensus around the specific areas that training should cover. Fifteen different content areas for training were proposed, ranging from understand- ing the impact of trauma on youth development to family engage- ment strategies. Surprisingly, just over half of the publications (six of 10) recommended training in specific skills for working effec- tively with traumatized youth. Teaching frontline staff to recognize when youth are experiencing a trauma reaction will have little impact on youth–staff interactions unless it is supplemented with training in specific skills for responding to such situations (e.g., trauma-informed de-escalation or engagement strategies). Addi- tionally, only one of the publications discussed the need for on- going supervision to assist staff in mastering and applying newly learned knowledge or skills to their work, an important omission given that training alone has been shown ineffective in helping staff achieve fidelity to evidence-based practices (Beidas & Ken- dall, 2010). The 10 publications that we reviewed represent the most detailed, published recommendations for TIC in juvenile justice, yet they rarely addressed such nuances. One exception is the National Center for Mental Health and Juvenile Justice and Technical Assistance Collaborative’s (2015) report on creating trauma-informed juvenile diversion programs, which identified implementation issues in several areas (e.g., interventions, fund- ing, quality assurance) and illustrated with real-world case exam- ples.

Notably, only five publications recommended agency-level ef- forts to prevent work-related traumatic stress among frontline staff, which is consistently identified as a core component of TIC in definitions for other service systems (Hopper et al., 2010). This is a troubling omission given that work-related traumatic stress symptoms are prevalent and associated with impaired job perfor- mance among frontline staff (e.g., attorneys, probation/correc- tional officers, law enforcement) in the justice system (Denhof & Spinaris, 2013; Levin et al., 2011; Skogstad et al., 2013). Addi- tionally, several groups of justice system professionals have ex- pressed their desire for greater organizational support around these matters (Donisch et al., 2016; Knowlton, 2015; Severson & Pettus- Davis, 2013).

Future Directions for Research

The final aim of the current review was to propose directions for future research in order to develop a consensus-based definition of TIC for juvenile justice. We identified just 10 publications from a small number of stakeholders, and it is unclear whether their views on the core components of TIC are representative of the larger field of juvenile justice professionals. Accordingly, we recom- mend surveys with nationally representative samples of frontline staff and system administrators to explore their perceptions of the core components of TIC. It would also be useful to assess how widely each of these practices has been adopted in juvenile justice systems across the country. Hanson and Lang (2016) recently published the findings of a similar survey of providers from multiple service systems, including juvenile justice, and noted the dearth of published research focused on defining or validating the core concepts of TIC.

A key question emanating from this review is which, if any, of these various recommendations will contribute to positive out- comes for the juvenile justice system. The answer requires a careful examination of published empirical studies to determine which practices or policies currently in use produce meaningful improvement in outcomes for youth, their families, staff, and the broader agency environment. Additionally, prospective studies are needed to evaluate the comparative effectiveness of different trauma-informed practices or policies. For example, Borckardt et al. (2011) examined the effectiveness of four TIC components (staff training, policy changes, modifications to physical environ- ment, client-centered treatment planning) for reducing the use of seclusion and physical restraint in inpatient psychiatric hospital settings by randomly assigning five inpatient units to implement these components in different order. Such research can help refine the core definitional elements that should comprise a unified theory of TIC for juvenile justice.

Limitations

The primary limitation of the current study was our approach to coding, categorizing, and describing the definitions/recommenda- tions for TIC. Although we followed established guidelines for systematic reviews (Shamseer et al., 2015), there are different approaches we could have taken to our narrative synthesis of the findings. For example, we did not analyze, in detail, the recom- mendations for particular TIC models, training curriculums, or interventions. Additionally, our decisions around assigning recom- mendations to one of the 10 broader domains, and even the number and names of these domains, were admittedly subjective. How- ever, this is a minor limitation, as we were more interested in identifying specific recommended practices or policies than broader domains or principles of a trauma-informed approach for juvenile justice.

Conclusions

The growth in recognition of the importance of TIC represents an unprecedented opportunity to improve our nation’s juvenile justice system and dramatically reduce the number of young lives damaged each year through harsh and ineffective responses to youth crime. However, to maximize this opportunity, it is neces-

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sary to first develop a consensus-based understanding of what constitutes a trauma-informed approach within juvenile justice. This process should be informed by all key stakeholders as well as empirical evidence on the impact of implementing particular prac- tices and policies within the justice system.

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Received August 22, 2016 Revision received December 1, 2016

Accepted December 28, 2016 �

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