Study Review

Trauma-informed models in out-of-home care

Frameworks used at an organisational level to enable trauma-informed practice.

Outcome Overall

This rating shows how effective the intervention is at achieving the evaluated outcome.

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Strength of

This rating shows how confident we can be about a finding, based on how the research was designed and carried out.

Children's behaviour Overall effectiveness: 1 (maximum 2) Strength of evidence : 0 (maximum 3)

Headline points

  • Very limited evidence that trauma-informed models improve outcomes for children in out-of-home care
  • Strength of the evidence is weak with a high risk of bias in six of the seven studies
  • All studies were conducted in the US. It is unclear whether these interventions would be successful outside of that context

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What is this?

There is widespread recognition that the experience of trauma can have adverse effects on children’s development, including both health and social outcomes. Therapeutic and trauma-informed models of care are, therefore, increasingly being adopted within out-of-home care settings. Three interventions were included in the review. All focus on the provision of frameworks (or guiding principles) that enable more trauma-informed practice to be embedded into organisations.

How is it meant to work?

The models provide a framework (or guiding principles) for an organisation to adopt. All interventions are designed to be applied at an organisational level. They include actions for everyone from the CEO to administrative staff. Although the three interventions differ in their exact approach, they broadly include the introduction of structures, processes, and practices that are designed to change the culture of the organisation to reduce the negative impacts of trauma.

What are the evaluated outcomes?

  • Children's behaviour

How effective is it?

The outcomes reported are inconsistent between the seven studies, they include general child behaviour, mental health symptoms, aggression and coping skills. Although a generalisation, they can broadly be described as ‘children’s behaviour’.

Children’s behaviour

Seven studies were reviewed. The studies report promising signs of improvements in children’s behaviour. However, the strength of the evidence is very weak. Therefore, the overall conclusion is that there is limited evidence that trauma-informed models improve children’s behaviour.

The reasons the evidence is classified as being ‘very weak’ are:

  • Five studies were considered to have a high risk of bias. The design of these studies were considered weak due to high drop-out rates, a lack of control or comparison group and that the intervention was not always implemented as intended.
  • Only one of the studies was considered to have a moderate risk of bias because it implemented the intervention in different residential units and different points in time. This created an opportunity for comparison groups.

Where has it been studied?

All three interventions were developed in the US. There is evidence that Local Authorities are adopting these practices, however, the review did not include any evaluations from the UK. In fact, all seven studies included in the review were conducted in the US and it is, therefore, unknown whether these interventions would be successful outside of the US context.

Who does it work for?

The models have been used with a wide age range, from 3-year-olds to adult populations. The review suggests that trauma informed models are not restricted to a certain age range, however, no formal analysis has been conducted.

As the studies report ethnicity differently, the suitability of the models for particular ethnic groups cannot be determined.

When, where and how does it work?

The models have been used in a variety of settings. They include, residential, non-residential, child protection teams, adoption teams, residential care homes and psychiatric hospitals. The relative effectiveness in different settings has not been tested.

It is suggested that for the models to work they must be implemented at an organisational level with change occurring through all levels of staff.

What are the costs and benefits?

No economic analysis was conducted as part of the review.

How is it implemented?


How is it implemented?

The three domains of intervention in the ARC model are:

  • Attachment: Strengthening the caregiving system surrounding children through enhancing supports, skills, and relational resources for adult caregivers.
  • Regulation: Cultivating awareness and skill in identifying, understanding, tolerating, and managing internal experience.
  • Competency: Building resilience in stress-impacted populations.

ARC is a framework that includes a set of principles that organisations integrate into their approach to working with children and families. Each organisation may choose to use ARC differently depending on the context they are working.

How is it delivered?

ARC isn’t an intervention in the traditional sense. It is a framework for organising approaches and a set of principles, of which some or all, can be integrated in practice.

Who can deliver it?

The ARC models has been applied in a wide variety of settings. The approach is not specific to a professional group.

What are the training and supervision requirements?

There is no formal certification process. However, ARC trainers and consultants can support an organisation to implement the ARC model.

What supports good implementation?

The available information suggests the approach is flexible to an organisation’s specific context and a definition of good implementation seems fairly varied.


How is it implemented?

The Children And Residential Experiences (CARE) model is built on six principles:

  • Developmentally focused
  • Family involved
  • Relationship based
  • Competence centered
  • Trauma informed
  • Ecologically oriented

Over a three-year period, CARE experts work closely with an organisation to implement and integrate the CARE practice model. Implementing CARE involves:

  • Identification of an implementation and integration work group
  • An assessment of culture/climate, current practice, and program
  • Training
  • Technical assistance

How is it delivered?

As with the other models, CARE is not an intervention in the traditional sense. It provides an approach that an organisation can take to change culture towards trauma informed practice.

Who can deliver it?

CARE is specifically designed for residential child care and organisations providing services to children and families. The training is delivered by CARE trainers from Cornell University.

What are the training and supervision requirements?

Training is delivered three to four times per year over a three-year period. Organisation are required to enter a three-year contract with the training provider (Cornell University).

What supports good implementation?

Available information suggests the implementation support provided by the CARE trainers is as important as the efficacy of the CARE model. Further, it requires commitment and change from all levels of staff.

The Sanctuary Model

How is it implemented?

The Sanctuary Model consists of four Pillars:

  • Shared knowledge (six domain of knowledge)
  • Shared values (seven commitments)
  • Shared language (an approach to practice – Safety, Loss, Emotions, Future i.e. SELF framework)
  • Shared practice (use of the sanctuary toolkit)

The pillars provide a framework for an organisation to follow to change culture. Within the pillars there are a set of practical tools.

How is it delivered?

The Sanctuary Model is not an intervention in the traditional sense. It a whole-system approach that changing culture towards the management of trauma. It requires organisations to not only engage in the practical activities (e.g. training to build and embed knowledge and approaches such as ‘Red Flag reviews’) but for all individuals in an organisation to adopt the Sanctuary Model perspective (or way of thinking) about trauma informed care.

Who can deliver it?

The materials for implementing the Sanctuary Model are available to purchase online.

What are the training and supervision requirements?

Once purchased, the materials seem to be self-service guides and manuals for implementing the Sanctuary Model. There is not a clear process for formal certification, however, the website does outline ‘characteristics of a certified sanctuary organisation’.

What supports good implementation?

The website states that “whether or not Sanctuary “works” is entirely dependent on the ways in which groups of people implement the methodology we have developed” suggesting that commitment and adherence to the model is critical.

Case study

In summary...

  • Very limited evidence that trauma-informed models improve outcomes for children in out-of-home care
  • Strength of the evidence is weak with a high risk of bias evident in six of the seven studies
  • All studies were conducted in the US. It is unclear whether these interventions would be successful outside of that context

Further resources

This summary is based on the original systematic review

Bailey, C., Klas, A., Cox, R., Bergmeier, H., Avery, J. and Skouteris, H. (2019). Systematic review of organisation‐wide, trauma‐informed care models in out‐of‐home care (OoHC) settings. Health & social care in the community 27(3), 10-22