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The importance of trauma-informed care (TIC) is now recognized across most health and human service systems. Providers are calling for concrete examples of what TIC means in practice and how to create more trauma-informed organizations. However, much of the current understanding about implementation rests on principles and values rather than specific recommendations for action. This paper addresses this gap based on observations during the provision of technical assistance over the past decade in fields like mental health and addictions, juvenile justice, child welfare, healthcare, housing, and education. Focusing on the infrastructure for making change (the TIC workgroup), assessment and planning, and the early stages of implementation, the authors discuss barriers and challenges that are commonly encountered, strategies that have proven effective in addressing barriers, and specific action steps that can help sustain momentum for the longer term.

deaths from cardio vascular disease, 1 million newborn deaths, 900 000 deaths from tubercu losis, and half of all maternal deaths each year.Quality of care will become an even larger driver of population health as utilisation of health systems increases and as the burden of disease shifts to more complex conditions.The high mortality rates in LMICs for treatable causes, such as injuries and surgical con ditions, maternal and newborn complications, cardio vascular disease, and vaccine preventable diseases, illustrate the breadth and depth of the healthcare quality challenge.Poor-quality care can lead to other adverse outcomes, including un necessary health-related suffering, persistent symptoms, loss of function, and a lack of trust and confidence in health systems.Waste of resources and catastrophic expenditures are economic side effects of poor-quality health systems.As a result of this, only one-quarter of people in LMICs believe that their health systems work well. Health systems should measure and report what matters most to people, such as competent care, user experience, health outcomes, and confidence in the systemMeasurement is key to accountability and improvement, but available measures do not capture many of the processes and outcomes that matter most to people.At the same time, data systems generate many metrics that produce inadequate insight at a substantial cost in funds and health workers' time.For example, although inputs such as medicines and equipment are commonly counted in surveys, these are weakly related to the quality of care that people receive.Indicators such as proportion of births with skilled attendants do not reflect quality of childbirth care and might lead to false complacency about progress in maternal and newborn health.This Commission calls for fewer, but better, measures of health system quality to be generated and used at national and subnational levels.Countries should report health system performance to the public annually by use of a dashboard of key metrics (eg, health outcomes, people's confidence in the system, system competence, and user experience) along with measures of financial protection and equity.Robust vital registries and trust worthy routine health information systems are prerequi sites for good performance assessment.Countries need agile new surveys and real-time measures of health facilities and populations that reflect the health systems of today and not those of the past.To generate and interpret data, countries need to invest in national institutions and professionals with strong quantitative and analytical skills.Global develop ment partners can support the generation and testing of public goods for health system measurement (civil and vital registries, routine data systems, and routine health system surveys) and promote national and regional institutions and the training and mentoring of scientists. New research is crucial for the transformation of low-quality health systems to high-quality onesData on care quality in LMICs do not reflect the current disease burden.In many of these countries, we know little about quality of care for respiratory diseases, cancer, mental health, injuries, and surgery, as well as the care of adolescents and elderly people.There are vast blind spots in areas such as user experience, system competence, confidence in the system, and the wellbeing of people, including patient-reported outcomes.Measuring the quality of the health system as a whole and across the care continuum is essential, but not done.Filling in these gaps will require not only better routine health information systems for monitoring, but also new research, as proposed in the research agenda of this Commission.For example, research will be needed to rigorously evaluate the effects and costs of recommended improvement approaches on health, patient experience, and financial protection.Implementation science studies can help discern the contextual factors that promote or hinder reform.New data collection and research should be explicitly designed to build national and regional research capacity. Improving quality of care will require system-wide actionTo address the scale and range of quality deficits we documented in this Commission, reforming the foundations of the health system is required.Because health systems are complex adaptive systems that function at multiple interconnected levels, fixes at the micro-level (ie, health-care provider or clinic) alone are unlikely to alter the underlying performance of the whole system.However, we found that interventions aimed at changing provider behaviour dominate the improvement field, even though many of these interventions have a modest effect on provider performance and are difficult to scale and sustain over time.Achieving high-quality health systems requires expanding the space for improvement to structural reforms that act on the foundations of the system.This Commission endorses four universal actions to raise quality across the health system.First, health system leaders need to govern for quality by adopting a shared vision of quality care, a clear quality strategy, strong regulation, and continuous learning.Ministries of health cannot accomplish this alone and need to partner with the private sector, civil society, and sectors outside of health care, such as education, infrastructure, communication, and transport.Second, countries should redesign service delivery to maximise health outcomes rather than geographical access to services alone.Primary care could tackle a greater range of low-acuity conditions, whereas hospitals or specialised health centres should provide care for conditions, such as births, that need advanced clinical expertise or have the risk of unexpected complications.Third, countries should transform the health workforce by adopting competency-based clinical education, introducing training in ethics and respectful care, and better supportingThe Lancet Global Health Commission and respecting all workers to deliver the best care possible.Fourth, governments and civil society should ignite demand for quality in the population to empower people to hold systems accountable and actively seek high-quality care.Additional targeted actions in areas such as health financing, management, district-level learning, and others can complement these efforts.What works in one setting might not work elsewhere, and improvement efforts should be adapted for local context and monitored.Funders should align their support with system-wide strategies rather than contribute to the proliferation of micro-level efforts.In this Commission, we assert that providing health services without guaranteeing a minimum level of quality is ineffective, wasteful, and unethical.Moving to a highquality health system-one that improves health and generates confidence and economic benefits-is primarily a political, not technical, decision.National governments need to invest in high-quality health systems for their own people and make such systems accountable to people through legislation, education about rights, regulation, transparency, and greater public participation.Countries will know that they are on the way towards a high-quality, accountable health system when health workers and policymakers choose to receive health care in their own public institutions.

This paper 1) discusses two important contributions that are shaping work with vulnerable and under-resourced populations: Kaiser Permanente's (1998) Adverse Childhood Experiences Study (ACE) which includes the impact of adverse experiences in childhood on adult health and health behaviors and the more recent advent of what has come to be known as Trauma-Informed Care (TIC), programs which incorporate knowledge of the impact of early trauma into policies and programs. 2) Despite many positive benefits that have come from both contributions there are unintended consequences, described in the paper, that have an impact on research and program evaluation as well as social policies and programs. 3) Three key neuroscience concepts are recommended for inclusion in Trauma-Informed Care programs and practices in ways that can enrich program design and guide the development of practical, resilience-oriented interventions that can be evaluated for outcomes. 4) Finally, a resilience-oriented approach to TIC is recommended that moves from trauma information to neuroscience-based action with practical skills to build greater capacity for self-regulation and self-care in both service providers and clients. Examples from criminal justice are used.

The review in briefDespite growing support and increased rate of which traumainformed approaches are being promoted and implemented in schools, evidence to support this approach is lacking. | What is this review about?Exposure to different types of trauma have been associated with varying types and complexity of adverse outcomes, including adverse effects on cognitive functioning, attention, memory, academic performance, and school-related behaviors.Given the growing research on trauma and increased knowledge about the prevalence, consequences and costs associated with trauma, there have been increased efforts at the local, state and federal levels to make systems "trauma-informed" (Lang, Campbell, & Vanerploeg, 2015).While the intent of creating trauma-informed approaches in schools is a noble one, relatively little is known about the benefits, costs, and how trauma-informed approaches are being defined and evaluated (Berliner & Kolko, 2016).Adopting a trauma-informed approach in a complex system such as a school building or district is a time consuming and potentially costly endeavor and thus it is important to assess the effects of this approach to inform policy and practice.This aim of this review was to assess trauma-informed approaches in schools on trauma symptoms/mental health, academic performance, behavior, and socioemotional functioning.Trauma-informed approaches include programs, organizations, or systems that realize the impact of trauma, recognize the symptoms of trauma, respond by integrating knowledge about trauma policies and practices, and seeks to reduce retraumatization.At least two of the three key elements of a trauma-informed approach must have been present: Workforce development, trauma-focused services, and organizational environment and practices, which differ from trauma-specific interventions designed to treat or otherwise address the impact/symptoms of trauma and facilitate healing. What is the aim of this review?This Campbell systematic review sought to examine the effects trauma-informed schools on trauma symptoms/ mental health, academic performance, behavior, and socioemotional functioning.Although we conducted a comprehensive search to find studies testing traumainformed approaches in schools, no studies met the inclusion criteria. | What are the main findings of this review?No studies met criteria for this review, indicating that there is a lack of evidence of trauma-informed approaches in schools.-------

OBJECTIVE: The purpose of this review is to conceptualize child abuse and neglect within a developmental psychopathology perspective. Toward this end, issues of definition and epidemiology, etiology, and sequelae are addressed. METHOD: Research and theory on child abuse and neglect with relevance to a developmental perspective is reviewed. RESULTS: Considerable progress has been made in our understanding of the etiology and consequences of child abuse and neglect. Less progress has been made in utilizing this knowledge to inform treatment efforts. CONCLUSIONS: Incorporation of a developmental psychopathology perspective into efforts to understand and ameliorate the adverse effects of child abuse and neglect holds considerable promise for advancing research and intervention in the area of child maltreatment. The importance of providing comprehensive and coordinated services that incorporate knowledge of how maltreated youngsters negotiate stage-salient issues of development is stressed. The provision of child-focused treatment, parent-based models of intervention, and ecologically driven approaches to prevention all can benefit from an understanding of the adverse effects that maltreatment exerts on the process of development.