Most children involved with the child welfare system, including a high percentage of those in foster care, have experienced trauma. The actions of child protection agencies, including investigation, removal, and placement, may exacerbate and cause additional trauma. Early, effective trauma treatment is essential to prevent lasting harm.

Traditional approaches to trauma include treatment of symptoms with psychotropic medication and clinical talk therapy. These therapeutic approaches may be appropriate for some, but they are not sufficient to meet the trauma and healing needs of all young people in the child welfare system.

There is longstanding concern about the overprescribing of psychotropic medication for youth involved with the child welfare system. While medication can decrease certain symptoms such as anxiety or depression, it does not provide healing opportunities or new coping skills for the youth to address past traumatic experiences.

There is a growing evidence base for clinical trauma treatments. The California Evidence-Based Clearinghouse for Child Welfare currently lists five child and adolescent trauma treatment programs as supported or well-supported by research evidence, and another 19 programs as promising. Unfortunately, many young people in foster care cannot access these evidence-based treatments due to cost, insurance restrictions, and/or scarcity of trained providers. In addition, some youth may resist or discontinue clinical services due to distrust, stigma, or lack of cultural relevance.

This brief presents key principles for child protection agencies to follow when expanding treatment services to address the trauma experiences and symptoms experienced by youth.¹ It also presents questions to help agencies further explore how they might apply these principles to support the healing and well-being of children and families in their care.

For information about other trauma-related aspects of child protection agency practice, see the companion briefs:

• How are child protection agencies implementing trauma-informed, healing-centered policies and practices?
• What resources are available to support trauma-informed, healing-centered approaches in child welfare?

Principle 1: All treatment must include and center family

Keeping children safe with their families not only is the overriding goal of the child welfare system, it also is clinically important. When forced family separation is part of the child’s trauma history, quick reunification with their family — if safely possible — may be the most effective treatment. Parents should be informed of their children’s diagnoses and engaged in their treatment prior to reunification so they are prepared and able to respond effectively to challenging behaviors or coping strategies that children may exhibit in response to trauma. Treatment and support should not end at reunification, as the effects of trauma can last a lifetime.

Support from the child’s birth, foster, and/or adoptive family is significant in all treatment approaches. Family engagement in clinical treatment has been shown to reduce severity of symptoms and improve outcomes for patients with many diagnosed mental health conditions, including depression.

Family engagement can begin at first contact. Child protection staff must be aware that children may consider their initial contact with them as unsafe or traumatic.

Family members of young people with mental health concerns often face significant challenges, including poverty, stress, and social isolation that may be exacerbated by the child’s condition. Therefore, it is important for the child’s recovery to maximize the family’s sense of safety while assessing and addressing not only the child’s immediate symptoms, but also the stressors and needs of the whole family. Addressing family members’ unmet needs, both psychological and practical, helps reduce caregiver burnout and has been shown to increase engagement and retention in mental health treatment programs.

Sharing information about children’s history and diagnoses is another important step — this information should be conveyed to everyone who will care for the child, including and most importantly kin and foster caregivers. Many evidence-based trauma interventions for young people recognize the importance of family engagement by explicitly requiring caregiver involvement. In other cases, family members will need parallel supports to help them better manage children’s trauma-related behaviors, reinforce therapeutic gains at home, and provide a secure and nurturing environment for healing.

Example: The Arc’s Treatment Foster Care Program

The Arc Northern Chesapeake Region Treatment Foster Care program in Maryland emphasizes the importance of building relationships among all adults connected to the child, including caseworkers, CASAs, birth parents, and extended family. Foster parents receive monthly trainings using the Birth and Foster Parent Partnership Relationship Building Guide. The agency hosts events, including annual diversity fairs and bowling parties, that provide additional opportunities for youth in foster care to see their birth parents and siblings, and for foster parents to interact with birth and extended family members in a relaxed environment that supports healing.

Questions to consider:

• How does our agency assess and acknowledge the ways in which child protective interventions, including family separation and multiple placements, contribute to children’s trauma symptoms?
• In recognition of the significant role that family plays in healing, how can our agency improve its practice to prioritize children re-establishing connections with family?
• How are our caseworkers and mental health partners assessing the trauma and treatment needs of children and all their family members?
• How are birth parents, kinship caregivers, and foster parents informed about children’s trauma history and mental health diagnoses, and how are we engaging them as partners in treatment?
• What efforts are we making to support families’ concrete and psychological well-being to ensure they have the resources to care for their children who have behavioral or mental health needs?

Principle 2: Acknowledge and address the role of historical, intergenerational, and racial trauma, along with the needs of LGBTQ+ youth

Generations of structural racism and violence, and the ongoing impacts of bias, racial injustice, and community trauma significantly affect young people’s mental well-being. Those impacts can be seen in the recent trends in young people’s mental health — and they are particularly alarming for young people of color and LGBTQ+ youth.

According to Youth-Centered Strategies for Hope, Healing, and Health, a joint report of the National Black Women’s Justice Institute and The Children’s Partnership, Black and Latino youth are more likely to experience mental health symptoms such as depression and have less access to services than white youth, a problem compounded further for youth from immigrant or undocumented families. A May 2022 article in The American Journal of Psychiatry reported that suicidal thoughts and behaviors, often caused by depression, are increasing much more rapidly among Black teens than white teens. The researchers tie structural racism and its consequences to an intergenerational transmission of depression among Blacks.

The Trevor Project reports that LGBTQ+ youth are more than four times as likely to attempt suicide than their peers, and those who experienced physical threats or harm reported nearly triple the rate of attempted suicide of those who did not. Where racial and gender/sexuality identities intersect, risk is even greater. For example, Indigenous youth who are LGBTQ+ were 2.5 times more likely to report a suicide attempt in the past year compared to their non-Indigenous LGBTQ+ peers.

These statistics can and must be countered with interventions that address the specific social inequities and cultural conditions that compound trauma for LGBTQ+ youth and youth of color. Positive identity development is a strong protective factor, and connections to family and community are essential. For some youth, working with a mental health professional or peer advocate who has a shared cultural identity or common life experiences may be most helpful. In the youth-centered strategies report, young people expressed that participating in concrete action to address social conditions and oppression, such as advocacy and organizing in their communities, supports their healing. They also said that learning about their culture, and strengthening connections to their communities and elders supports mental health (particularly for Indigenous youth).

Example: Medicine Fish Menominee Youth Leadership Initiative

Youth on the Menominee Indian Reservation in Wisconsin face many challenges, including opioid use, alcoholism, poverty, and high suicide rates. The Medicine Fish: Indigenous Resilience initiative seeks to counter these challenges and enhance quality of life for Indigenous youth by revitalizing their cultural connection to self and nature. Male children are selected to join the program at 10 to 12 years old and can participate through high school, focusing on development of lasting supportive relationships. The youth engage in both traditional and non-traditional activities, including fishing, making maple syrup, lacrosse, traditional Indigenous games, rice harvesting, and music immersion. Activities take place year-round, outdoors as much as possible, and aim to create a safe and supportive environment to enhance their resilience to stress. A growing body of research supports the role of nature in as a protective factor in promoting health and well-being.

Questions to consider:

• What trauma interventions in our agency’s service array specifically address the needs of LGBTQ+ youth and youth of color?
• What efforts are we making to engage more mental health professionals who have shared lived experiences or come from the same communities as the children and youth in care?
• How are our child welfare staff and related professionals trained about cultural bias and the impact of historical, intergenerational, and racial trauma on child and adolescent mental health?
• How is culture engaged as a protective factor and healing practice?
• What resources within a youth’s own community might be engaged to support positive identity development and healing?

Principle 3: Listen to youth and their families, and offer choices

Healing begins with asking youth what is important to them, what are their primary concerns, what are their strengths, and what is their vision for their own future. Youth should be presented with a range of potential trauma treatment options and therapeutic approaches and have age-appropriate opportunities to choose what will work best for them, in conversation with their families and other trusted adults. Trauma frequently involves a feeling of disempowerment, so offering choices helps restore that lost personal power.

Choice should extend to where and how the youth receive their services. Some may prefer to receive services in their own homes via mobile response or telehealth. For others, a lack of internet service, electronic devices, or technical knowledge may impede access to telehealth. Some youth, including LGBTQ+ youth who lack family support, may feel an office or a familiar community setting (such as school, place of worship, or community center) provides greater privacy and/or safety.

Example: The RightWay Foundation’s Operation Emancipation

The RightWay Foundation, headquartered in the South Central neighborhood of Los Angeles, provides a variety of trauma-informed, healing-centered mental health and employment services to alumni of foster care. The organization’s core program, Operation Emancipation, is an employment readiness workshop that integrates mental health support with employment services and financial education. Young adults receive a $400 stipend for attending 24 hours of training in one week. Once they complete the workshop, youth have access to other RightWay services, including one-on-one therapy, housing navigation, education referrals, job coaching, employment opportunities, and more.

RightWay uses trained therapists to provide its employment services so young people’s traumas can be addressed in real time, without requiring them to participate in formal therapy. RightWay also requires employer partners to complete five hours of trauma-informed, healing-centered training (Motivate, Mentor, & Manage, aka Triple M). Before implementing the trauma-informed, healing-centered approaches, young adults placed in jobs were staying between one day and three weeks. Today, the average time on a job is six months or longer. For more information, see PBS’ segment The RightWay Foundation’s Journey to Jobs.

 Questions to consider:

• How does our agency encourage and support youth choice in clinical and non-clinical treatments?
• How does our agency inform families about the availability of flexible supports?
• What concrete supports can our agency provide to help bridge potential barriers to treatment via mobile response or telehealth?

Principle 4: Expand community-based, non-clinical, and peer-driven support

Treatment options for youth should include alternative therapies and recreational activities whenever possible. Youth engaged with the child welfare system are more than just their traumas. Supporting healing sometimes may be as simple as looking at how young people not involved with the system thrive. Many activities beyond therapy can build young people’s confidence and resilience, while offering a much-needed experience of normalcy. These may include mentorship or participation in music, the arts, sports, gaming, and other online communities, cultural activities, employment readiness programs, clubs, or camps.

A recent policy brief from Youth Law Center argues that activities like these support healing and counteract the damage caused by trauma, and the evidence base is growing to demonstrate their effectiveness. One study found that physical activity is 1.5 times more effective in treating depression than counseling or medications. Other researchers have found evidence supporting the mental health benefits of engagement in the arts and music.

Peer mentorship also has been shown to support recovery and well-being in mental health settings. Youth peer mentorship can include one-to-one or group support, such as in-person or online support groups. A 2013 literature review conducted for Youth M.O.V.E. National notes that peer support often is credited with “changing the culture of mental health from illness and disability to health and ability,” and inspiring hope and the belief that recovery is possible. Newer research from the Adobe Foundation and the National Alliance on Mental Illness illustrates the importance of programs and strategies that incorporate creative activities into programming for youth, noting strong personal and mental health benefits, especially among those from marginalized communities.

Non-traditional therapies, extracurricular activities, and peer mentorship all share the advantages of not requiring a potentially stigmatizing diagnosis to access services and being unaffected by the current crisis-level shortage of licensed mental health providers.

Example: Music and Artistic Mentorship through Ascending Flow

New Narrative, a nonprofit in Oregon that supports alumni of young adults aging out of foster care through integrative mental health services, offers music and artistic mentorship through its Ascending Flow program. The program was co-founded by hip hop artist Talilo Marfil, who experienced homelessness as a youth. Like Marfil, all mentors come from marginalized communities and have lived experiences that help them relate to the alumni of foster care who they serve. The mentors provide advocacy for helping the youth connect to community resources, pursue their creative passions, and achieve their personal goals.

Questions to consider:

• What kinds of alternative or non-traditional therapies are available in our community, and how are we supporting youth participation in them?
• How does our agency incorporate extracurricular, social, and cultural activities — including art and music programs — into plans for well-being and trauma healing?
• How is physical activity encouraged and supported for youth who have experienced trauma?
• How can the definition of who can provide healing-centered supports be expanded to include faith and tribal leaders, peer mentors, and other peer supports?

1 Content of this brief was developed through ongoing consultation with members of the Knowledge Management Lived Experience Advisory Team. This team includes youth, parents, kinship caregivers, and foster parents with lived experience in the child welfare system, and who serve as strategic partners with Family Voices United, a collaboration between FosterClub, Generations United, the Children’s Trust Fund Alliance, and Casey Family Programs. Team members who contributed to this brief include Alisa Thornton, Marquetta King, Robert Brown, and Matt Pennon.