Dr John Lyons | Transforming Trauma Care: Building Person-Centred Systems for Children and Youth

Particularly in the absence of effective interventions and supports, traumatic experiences in childhood can have profound and lasting impacts on mental and physical health. Dr John Lyons from the University of Kentucky is part of a dedicated community of researchers working to improve trauma-informed care for children and young people. His innovative approach, called Transformational Collaborative Outcomes Management, is helping to create more effective, person-centred systems that can better support those affected by trauma and improve long-term outcomes.

The Hidden Impact of Childhood Trauma

Childhood should be a time of joy, growth and discovery. However, for too many children, this formative period is marred by adverse experiences that can have far-reaching, traumatising consequences. Adverse events such as physical or sexual abuse, neglect, family violence or loss of a caregiver can significantly alter a child’s developmental trajectory, affecting their mental and physical health well into adulthood.

The effects of childhood trauma are often not immediately apparent. Some children may initially seem resilient, only to develop symptoms later in life. Others may express their distress through behavioural problems or physical ailments that are not overtly linked to their traumatic experiences. This complexity makes it challenging for health and social care systems to identify those in need and provide appropriate support.

Recognising this critical issue, researchers and clinicians have been working to develop more effective approaches to trauma-informed care. One of the leaders in this field is Dr John Lyons, who has devoted his career to improving how we understand and respond to children and families in need.

A New Paradigm

Dr John Lyons, based at the Center for Innovation in Population Health at the University of Kentucky, has pioneered an approach called Transformational Collaborative Outcomes Management (TCOM). This framework aims to shift the focus of human service systems from simply delivering services to actively facilitating personal change and transformation.

At the heart of TCOM is the idea that care should be truly person-centred. Rather than applying a one-size-fits-all approach, Dr Lyons argues that systems need to be flexible and responsive to each individual’s unique needs, strengths and circumstances. This is particularly crucial when dealing with trauma, as each person’s experience and response to traumatic events can be very different.

The TCOM approach is built on three core values. Firstly, human service systems should primarily focus on facilitating personal change. Secondly, these systems are inherently complex and can only be managed through meaningful integration and collaboration. Lastly, all partners in the system are responsible for collecting and using accurate, relevant and respectful information about the people they serve.

Dr Lyons emphasises that this information-gathering process should not be a cold, bureaucratic exercise. Instead, it should be a collaborative effort that respects the individual’s voice and choice, is culturally responsive, and aims to create consensus on the best path forward.

Measuring What Matters

To implement these principles, Dr Lyons and his team developed the Child and Adolescent Needs and Strengths (CANS) assessment. Unlike traditional psychological tests, CANS is a collaborative tool that helps organise and communicate an individual’s story.

The CANS assessment covers a range of areas, including the child’s strengths, needs, risk behaviours and caregiver resources. Importantly, it also includes sections specifically focused on traumatic experiences and traumatic stress symptoms. This allows for a comprehensive understanding of the child’s situation, helping to identify not just problems but also potential sources of resilience and support. The CANS is accomplished in a manner that does not force a child to repeatedly answer questions from strangers about their adverse experiences, which is a critical component of a trauma-informed system.

What sets CANS apart is its flexibility. Dr Lyons explains that the tool can be customised to fit different contexts and populations while maintaining reliability and comparability across systems. This’ mass customisation’ approach balances standardisation and individualisation, ensuring that assessments are consistent and relevant to each child’s unique circumstances.

The CANS approach has been widely adopted, with Dr Lyons reporting that it is now used in 33 countries worldwide. In the United States alone, it touches approximately 95% of children and youth in public behavioural health or child welfare systems, amounting to about 10 million assessments each year.

From Assessment to Action

While having a good assessment tool is crucial, Dr Lyons stresses that it’s just the first step. The real challenge lies in using this information to create truly trauma-informed systems of care. To this end, Dr Lyons and his team have outlined several key processes that should be in place.

These processes include early detection of traumatic experiences, regular monitoring of traumatic stress symptoms, and an approach that respects individuals’ stories and doesn’t force them to repeatedly answer the same questions. The team also emphasises the importance of integrated training and supervision to create a continuously learning workforce, a differential response that tailors interventions to each individual’s specific circumstances, and the use of aggregate data to inform system performance and highlight opportunities for improvement.

Dr Lyons argues that these processes need to be embedded into the very structure of care systems, rather than simply relying on individual staff training. This is particularly important given the high turnover rates in many public sector systems.

Insights from Large-scale Studies

To demonstrate the potential of this approach, Dr Lyons and his colleagues have conducted large-scale analyses in both child welfare and behavioural health settings. These studies have revealed intriguing patterns that have significant implications for how we approach trauma-informed care.

In a study of children in the child welfare system, the team found that the relationship between traumatic experiences and observable traumatic stress symptoms was not straightforward. Many children, particularly younger ones, did not show signs of traumatic stress even after multiple adverse experiences. This indicates resilience for some children, but for others, it indicates that symptoms are being missed or may develop later. The later circumstances appear particularly pronounced among children with challenges in early development.

Interestingly, the pattern was different in the behavioural health system. Here, older youth were less likely to be identified as having traumatic stress symptoms, even with a history of traumatic experiences. These ‘missed’ cases had high levels of adverse experiences, but their behavioural health presentation was characterised by oppositional and delinquent behaviour. This suggests that different systems may have different blind spots throughout a child’s development to adulthood when it comes to recognising the effects of trauma.

These findings highlight the importance of a nuanced, system-specific approach to trauma-informed care. They also underscore the need for ongoing assessment and monitoring, as the effects of trauma may not always be immediately apparent.

Further Research and Development

While the TCOM approach shows great promise, Dr Lyons acknowledges that significant challenges remain. One major issue is the risk of over-pathologising normal responses to difficult experiences. Not every child who experiences trauma will develop long-term problems, and it’s important not to label children unnecessarily. However, there is also a risk of missing genuine traumatic stress symptoms, particularly when they manifest as behavioural problems rather than more obvious signs of distress. Dr Lyons and his team are now refining their assessment tools and processes to strike the right balance.

Looking to the future, Dr Lyons sees several key areas for further research and development. These include expanding the work to more culturally diverse settings to understand how culture influences resilience and the expression of traumatic stress, developing and testing interventions that can help children reach resilience without ever having to endure traumatic stress symptoms, and improving access to evidence-based trauma interventions for those who need them.