The Administration for Children and Families, the Substance Abuse and Mental Health Services Administrations, the Administration for Community Living, the Offices of the Assistant Secretary for Health and the Assistant Secretary for Planning and Evaluation at HHS have worked together to develop this Guide to Trauma-Informed Human Services. The guide is intended to provide an introduction to the topic of trauma, a discussion of why understanding and addressing trauma is important for human services programs, and a “road map” to find relevant resources.
Experiencing deeply disturbing events or situations (i.e., trauma) can affect the way a person learns, plans, and interacts with others. This can have profound implications for how human services agencies interact with their clients. Many individuals experience few problems after enduring a traumatic event. Some will have short term symptoms lasting a few days or weeks, but will recover quickly. A few will suffer longer term changes in mood, behavior, and how they interact with others and the world around them.
This guide provides human services leaders at the local, State, Tribal, and Territorial levels with information and resources on recent advances in our understanding of trauma, toxic stress, and executive functioning. It especially highlights what these advances mean for program design and service delivery. The guide helps professionals learn about trauma-informed care and helps those currently engaged in trauma-informed work to improve their practice.
These resources provide an overview of key concepts related to trauma and a guide to resources from a range of HHS federal agencies and respected sources outside government. These materials are both a “front door” to the topic of trauma and a “road map” to relevant resources.
There are many concepts and terms associated with trauma-informed care. To start with a common framework, there are six key concepts that are particularly important for human services providers interested in expanding their understanding of trauma and its implications for service delivery.Next: Guiding Questions & Answers >
This resource answers guiding questions about trauma and a trauma-informed approach very broadly. Much of the general framing to these answers will serve as helpful background to leadership and staff at every level of an organization seeking foundational information on a trauma-informed approach. To supplement this general information, population-specific resource lists have also been developed that highlight resources for a range of human services populations from young children and their families to aging individuals, with a particular focus on special populations, such as members of underserved racial and ethnic groups, and victims of sexual abuse. Of course, individual clients may have needs relating to more than one area of specific focus, and could be members of multiple vulnerable or underserved groups (for example, a victim of domestic violence who is also an immigrant). Given the potential complexity of individual client situations and programmatic contexts, we expect that multiple resources may be relevant.
Please select a topic below to access related questions and answers.
According to the Substance Abuse and Mental Health Administration (SAMHSA), trauma refers to experiences that can cause intense physical and psychological stress reactions. It can refer to a single event, multiple events, or a set of circumstances that is experienced by an individual as physically and emotionally harmful or threatening and that may have lasting adverse effects on the individual’s physical, social, emotional, or spiritual well-being. Trauma may involve either natural events such as an earthquake or hurricane, or man-made events such as sexual abuse or witnessing violence.
Trauma technically refers to a particularly stressful experience or event. However, in practice many people use the term interchangeably to mean either a traumatic experience or event, the resulting injury or stress, or potential longer-term impacts and consequences of the experience.
Over two-thirds of U.S. adults have experienced some type of traumatic event at least once in their lives, and up to 90% of individuals served in behavioral health settings have experienced trauma. According to the National Child Traumatic Stress Network (NCTSN), 68% of children and adolescents have experienced a traumatic event by the time they are 16 years old. Trauma is associated with a range of negative physical and mental health outcomes. SAMHSA funded the development of a helpful infographic explaining some of the warning signs of trauma, in addition to information about how to seek treatment and talk to health care professionals. See the infographic.
Most people who experience trauma do not suffer long term effects. They are said to be resilient in that they process the trauma in a manner that minimizes ongoing impacts on their lives. A subset of people experiencing traumatic events will suffer short term effects such as nightmares or feeling emotionally numb, while even fewer will experience longer term impairments, including Post Traumatic Stress Disorder.
According to the NCTSN, complex trauma is a person’s exposure to multiple traumatic events that are invasive and interpersonal in nature. Complex trauma could involve direct harm, exploitation, or maltreatment, including neglect or abandonment by primary caregivers. Complex trauma often occurs at developmentally vulnerable times in a person’s life, such as early childhood or adolescence, but can occur throughout the lifespan. Please see more at the NCTSN about the effects and assessment of complex trauma.
Research on the biology of stress suggests that trauma can disrupt development in significant ways, depending on the phase of development. The range of severity of developmental outcomes depends on how frequently the individual was exposed to the traumatic stressor, and how severe the exposure was. The SAMHSA-funded NTSCN describes the impact of traumatic stress on different aspects of development in children and youth. Because individuals may experience trauma across several stages of development, they may also experience more than one of these biological, brain-based changes described below. It should again be noted that many children exposed to trauma do not experience long-term health effects.
Adverse Childhood Experiences (ACEs) are potentially traumatic events that can have negative, lasting effects on health and well-being. These experiences range from physical, emotional, or sexual abuse to parental divorce or the incarceration of a parent or guardian. A growing body of research has sought to quantify the prevalence of adverse childhood experiences and illuminate their connection with negative behavioral and health outcomes, such as obesity, alcohol use disorder, and depression, later in life. By definition, all of these experiences occur during the first 18 years of life, a time during which ongoing brain and body development confer particular vulnerability to stress. Although trauma experienced at any point in the life course can have enduring impacts, traumatic experiences in childhood, especially cumulative traumatic events and those in early childhood, can have lifelong consequences for physical and behavioral health, in part because of a potential disruption of the neurobiological system that develops early and guides the body’s response to stress. The US Centers for Disease Control and Prevention (CDC) originally partnered with Kaiser, a healthcare organization, to undertake the Adverse Childhood Experiences Study, one of the largest investigations adverse childhood experiences and health and well-being later in life. The CDC has many resources for understanding and preventing the wide-ranging health and social consequences of ACEs. In addition, the Philadelphia Urban ACEs Study expands upon the original ACEs work to recognize neighborhood safety and other issues especially relevant to low income urban communities.
Most individuals who have experienced adversity as children do well in spite of significant hardship. Stable and responsive relationships with caregivers buffer the impact of ACEs. This HHS Guide also includes a concept paper on resilience that summarizes recent research and approaches. Harvard University’s Center on the Developing Child has developed a working paper that explores how children develop resilience through supportive relationships.Next: Q&A: Post-traumatic Stress Disorder >
According to the National Institute of Mental Health (NIMH), PTSD develops in some people who have experienced a shocking, scary or dangerous event, such as a natural disaster, car accident, assault, or combat. After a trauma or life-threatening event, reactions such as trouble sleeping or upsetting memories of the event may occur. The US Department of Veterans Affairs (VA) maintains a National Center for PTSD with helpful information for the general public and professionals in addition to veterans and their families and loved ones. PTSD, by definition, involves symptoms that last more than a month. Symptoms that are of shorter duration may be classified instead as Acute Stress Disorder.
Sometimes these symptoms get worse or last longer than a few months, and could interfere with an individual’s life or work. Specialized behavioral health care providers such as psychiatrists and psychologists can diagnose PTSD. The American Psychological Association (APA) developed a fact sheet about new diagnostic criteria for PTSD, including information about PTSD for children younger than six years old (Preschool type). In addition to direct exposure to a traumatic event, PTSD can also occur when an individual learns that a close family member has, for example, died or experienced a violent assault.
According to the VA’s National Center, symptoms of PTSD can include:
People with PTSD can also have other health problems, including: chronic pain, depression or anxiety, and difficulties with relationships.
Most treatment involves counseling with specific types of talk therapy, with medication, or with a combination of the two. The combination of talk therapy and medication is generally considered best practice. For some people, treatment can mean a reduction or a complete loss of symptoms, while other people have fewer symptoms after treatment. Please see more details about the specific kinds of psychotherapies and classes of medications prescribed for PTSD at the website for the VA’s National Center. The Mayo Clinic also provides information on PTSD aimed at the general population.Next: Q&A: Trauma-informed Services >
The practice of trauma informed service is less about “what” you’re doing, and more about “how” you’re doing it. It requires being mindful of ways in which your interactions with clients might inadvertently make them feel unsafe, either physically or emotionally. According to SAMHSA’s concept of a trauma-informed approach, a program, organization, or system that is trauma-informed:
The SAMHSA-funded National Technical Assistance Center for Children’s Mental Health has put together a series of videos by practitioners and state administrators that describe what trauma-informed means as an organizational approach, particularly in agencies that serve children and families. Being trauma-informed is described by the director of an agency as:
Taking the principles about being sensitive to someone’s background and history and weaving those principles into everything you do organizationally. Not just a set-aside training program, but to really see it at the culture level, that it permeates everything you do [in an organization] from the policies and procedures to the practice and training; how you recruit, how you promote. Trauma-informed care sensitizes us.
A trauma-informed approach involves being aware of how clients who are affected by traumatic experiences may perceive and respond to your organization’s practices and services. Because implementing these approaches in some cases may involve considerable change in practice, for it to be successful leadership must commit to the change and actively engage in the process. Many organizations that have undertaken trauma-informed approaches have engaged in self-study that could involve self-assessment and/or small workgroups or task forces.
Trauma-informed practices articulated by the National Technical Assistance Center for Children’s Mental Health include:
Public human services agencies are charged with providing services and supports to individuals, children and families. However, for some clients who have experienced trauma, certain approaches, particularly aggressive or confrontational methods, may cause additional harm. A number of coercive practices that were once common but are no longer widely used have been of particular concern. These include seclusion and restraints or other harsh disciplinary practices in the behavioral health or school system, or intimidating practices used in the criminal justice system. Where they continue to exist, these and similar policies, practices, and procedures can severely undermine efforts to achieve desired outcomes for clients in service systems.
In the past, human service agencies were not as focused on how to understand the impact of traumatic experiences on client functioning and mitigate the re-traumatizing effect of our service systems. In recent years, a range of human service providing agencies in different sectors have focused on how to clients work through their reactions to traumatic events and reduce the chances of exacerbating existing problems through re-traumatization. The population-specific resource lists offer resources and suggestions that may be appropriate to the clients your organization or agency serves. A useful starting point is this article providing tips for service providers on ways to avoid re-traumatizing clients, prepared by a Canadian organization focusing on homelessness. Also the Department of Justice’s Office on Victims of Crime has developed a module which, while focused on trafficking issues, includes good tops on how to avoid re-traumatization.
The physical environment of your organization communicates your beliefs about the people you serve. It is important that your organization’s physical setting be perceived as safe and welcoming and interpersonal interactions with staff and other clients promote a sense of safety. Your physical space sets the tone for your interactions with clients. For clients who have experienced trauma, reactions to perceived insecurity may be heightened and could inadvertently sabotage the ability of staff to engage families.
In the past several years, there has been substantial research on interventions that address trauma in different populations. Interventions are considered evidence-based if there is empirical evidence of impacts when delivered to specific populations in particular settings, such as the clinic, home, community or school. Treatments are considered promising if research has yielded limited evidence of effectiveness. For victims of trauma to be able to access evidence-based treatments, qualified clinical staff must be adequately trained and supervised.
The California Evidence-Based Clearinghouse for Child Welfare (CEBC) identifies a number of interventions for addressing the consequences of trauma in children and adolescents and in adults. They define the topic area as, “interventions designed to help an individual process a trauma or multiple traumas they have experienced and learn how to cope with the feelings associated with the experience (e.g., fear, posttraumatic stress, anxiety, depression, etc.).”
With respect to interventions for children and adolescents, they find 4 models that either are well supported by research (their highest category) or supported by research (next highest category), as well as many additional promising approaches. Those backed by the most research include:
For adults, the clearinghouse identifies six interventions considered either supported or well-supported by research and another five that are promising based on early research. The specific programs in the well-supported and supported categories are:
The Georgetown National Technical Assistance Center for Children’s Mental Health with partners has developed a helpful series of video interviews with state administrators and clinicians that highlight experiences implementing and adapting evidence-based treatment modalities for children and families who have experienced trauma.
Additionally, a research-to-practice brief recently published by ACF’s Office of Planning, Research, and Evaluation (OPRE) discusses what is known about the impact
of trauma on infants and toddlers, and the intervention strategies that could potentially protect them from the adverse consequences of traumatic experiences.
The National Child Traumatic Stress Network has developed a Guide to Private Funding to Support Child Traumatic Stress and Other Trauma-Focused Initiatives. This resource provides practical guidance on how leaders can address state budgetary shortfalls and tight fiscal markets by getting started in pursuing private funding.Next: Q&A: Staff Capacity Building >
Becoming trauma-informed is a process for all members of the agency who interact with clients as well as those in other roles. There are a number of standardized screening instruments for individuals of different ages/developmental levels that staff can administer, and many of these screening tools are in the public domain. Although all staff in an organization may not be in a position to administer a screening tool to clients served, it is important for all staff in a trauma-informed organization or agency to understand the broad symptoms of trauma. The following symptom checklist appears in an infographic and fact sheet developed with SAMHSA resources, and applies largely to adults:
Please see population-specific resource lists for developmentally appropriate symptoms for particular age groups (early childhood, school age children, youth, and for aging individuals).
Becoming trauma-informed is a process that involves all staff and leadership in an agency. Clinical staff in organizations have specialized training needs in this area, yet all staff interacting with clients require the capacity to work with trauma survivors who may be experiencing mental health symptoms or other responses to their traumatic experiences. The National Center on Domestic Violence, Trauma, & Mental Health funded by the Administration for Children, Youth, and Families (ACYF) put together a helpful conversation guide that is designed to help build staff capacity to support survivors whose reactions to traumatic experiences affect interaction and communication. The guide is focused on committing to making discussions and interactions with survivors safe for each person to be, learn, and grow. The guide discusses specific communication skills that are helpful for respectfully engaging with survivors, including:
Secondary Traumatic Stress (STS) or Compassion Fatigue in human services settings may affect some staff who work with individuals who have experienced trauma. While staff react in a range of ways, both positive and negative, to working with traumatized clients, Secondary Traumatic Stress is a phenomenon to be aware of and it is important that staff practice self-care in order to deal appropriately with the stress of repeatedly confronting clients’ traumatic situations. STS mirrors the symptoms of Post-Traumatic Stress Disorder (PTSD), and different kinds of human services professionals are susceptible to this kind of stress. The symptoms may include:
Secondary Traumatic Stress is preventable and treatable and there are a variety of supports and resources for addressing this issue in human services settings, several of which were developed for the child welfare workforce.