Integrating trauma-informed services in out-of-school time programs to mitigate the impact of community gun violence on youth mental health

Abstract

Community gun violence disproportionately impacts youth in low-income urban neighborhoods. Integrating trauma-informed mental health care in community-based out-of-school time (OST) programs is an innovative method of service delivery for these youth. This article provides justification for integrating evidence-based, trauma-informed services in OST programs within communities characterized by high rates of violent crime to minimize the impact of violence exposure on youth mental health. We describe the initial feasibility of a model program, the Violence Intervention and Prevention (VIP) Initiative, implemented in a small city in southeastern Pennsylvania. Within the first six months of the VIP Initiative, 95 community residents (90% under age 18; 51% Hispanic) received intervention services, primarily through single-session and short-term weekly group intervention in OST programs, and 80% of OST youth development staff participated in at least one trauma-informed professional development training. Recommendations to enhance and expand the delivery of trauma-informed services in the novel setting of OST programs are provided.

Keywords:

• community violence
• trauma-informed care
• out-of-school time
• academic-community partnership
• evidence-based practice

Nationally, 59% of youth ages 14–17 have witnessed an assault in their community over their lifetime, while another 17% have been indirectly exposed to community violence, and the risk of multiple exposure increases significantly among youth living in urban areas where violent crime is concentrated in low-resource neighborhoods (Finkelhor et al., 2013; Kang, 2016). For youth repeatedly exposed to community gun violence, access to acceptable, evidence-based trauma-informed services in established neighborhood after-school and summer programs holds promise for mitigating traumatic stress responses. Integrating trauma-informed services in out-of-school time (OST) programs aligns with recent calls from behavioral health advocates to expand the “dominant model of treatment delivery” (Alegría et al., 2022; Kazdin, 2019, p. 457; SAMHSA, 2014) characterized by individual psychotherapy administered by licensed professionals in specialty mental health clinics. There is a growing consensus that this dominant model of mental health care does not meet the needs of the majority of youth, as evidenced by the Office of the Surgeon General’s (2021) urgent call for systemic change in youth mental health care. Indeed, the dominant model is woefully inadequate, particularly for youth living in communities of concentrated poverty, where specialty mental health providers are scarce and barriers to accessing mental health services are well documented (Castro-Ramirez et al, 2021; Cummings et al., 2017; Santiago et al., 2013).

Minimal attention has been paid to the potential value of integrating trauma-informed care in the context of community-based OST programs, despite evidence that among youth in low-income, urban communities with high rates of violent crime, community interventions targeting youth and their environment produce stronger effects than interventions targeting youth alone or even interventions based in schools within low-income neighborhoods (Farahmand et al., 2012, p. 212). While some state and national groups have advocated for trauma-informed service delivery in OST programs (e.g., National Afterschool Association, 2020), to date there are only a handful of articles published in academic journals describing trauma-informed care integrated in established OST programs. In fact, a review of research published from 2004 to 2019 examining the implementation of trauma-informed practices within the youth service sector revealed that none of the 54 identified articles addressed service delivery in OST programs (Lowenthal, 2020). The purpose of this article is to fill the gap in the existing literature on trauma-informed service delivery in OST programs. This article will accomplish three goals: justify the need for integrating such services within communities with high rates of gun violence; describe the initial feasibility of evidence-based services delivered as part of a new university-community partnership known as the Violence Intervention and Prevention (VIP) Initiative which aims to minimize the impact of community gun violence on youth mental health; and identify recommendations to enhance and expand the delivery of trauma-informed services in the novel setting of OST programs.

Integration of trauma-informed services in OST programs in high-crime neighborhoods

Access to evidence-based, trauma-informed behavioral health care is crucial to address the mental health needs of youth in neighborhoods with high concentrated poverty because exposure to gun violence is a pervasive feature of these communities that increases risk for post-traumatic stress, anxiety, and depression (Bancalari et al., 2022; Kravitz-Wirtz et al., 2022). Community gun violence is distinct from other forms of violence because of its lethal nature, the potential for bystanders to be injured, the high likelihood of indirect exposure (e.g., through hearing gunshots), and the toll that it takes on youth’s sense of safety (Bancalari et al., 2022). Yet, the very same economically marginalized youth who are at greatest risk for exposure to community gun violence are the least likely to receive needed mental health care. Delivering interventions in community OST programs that are a haven and source of support for youth in high-risk communities is an innovative method for increasing access to care for this population (Frazier et al., 2007). Integrating behavioral health services free of charge in OST programs also addresses some of the most frequently cited perceived barriers to service utilization for youth and individuals with limited income, including lack of knowledge about where to seek professional help and concerns about cost and transportation (Santiago et al., 2013). In addition, offering engaging mental health promotion programs for youth as a preventive intervention in OST programs gives young people a positive experience with mental health practitioners in a familiar setting while also increasing their mental health literacy, two factors that facilitate help-seeking (Aguirre Velasco et al., 2020). Finally, multipurpose OST programs, including after-school programs sponsored by city parks departments and nonprofit organizations such as the Boys and Girls Clubs of America, are specifically designed to promote youth development, well-being, and life skills (Frazier et al., 2007); therefore, integrating social-emotional learning activities that promote mental health in multipurpose OST programs aligns with their overall mission.

There are very few examples of stand-alone evidence-based psychological interventions delivered during OST or published accounts of evidence-based mental health interventions integrated into established community-based OST programs. One example of the former is the Summer Treatment Program, an evidence-based intervention delivered daily by counselors, teachers, and aides during a six- to nine-week summer camp for youth 5–16 years of age diagnosed with ADHD, which has demonstrated positive impacts on academic and social skills (Fabiano et al., 2014). In contrast, the Emotion Detectives Prevention Program (EDPP; Ehrenreich-May & Bilek, 2011) was designed to be integrated into a recreational sports camp as a universal preventive intervention targeting anxiety and depression for children ages 7–10. The EDPP showed promise for decreasing child anxiety following fifteen 45-minute twice weekly sessions, and it was a precursor to the evidence-based Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children (UP-C; Ehrenreich-May et al., 2017) which is widely used in clinical settings. In addition to summer camps, Frazier et al. (2015) and Goodman et al. (2021) have implemented mental health interventions in public parks for youth living in low-income communities with high rates of violent crime. These examples illustrate that linking mental health programming in the OST setting shows promise for problems such as poor social skills and anxiety, yet there is a lack of research on trauma-specific programs during OST.

A review of published research to date revealed only three examples of trauma-specific interventions integrated within OST programs, each focusing primarily on the prevention of traumatic stress symptoms and building resiliency among community members. Burns et al. (2019) devised the Safe, Secure, and Loved program to focus on underserved Latine families involved in a nonprofit multi-service agency that provided social service and educational programming, along with the opportunity to volunteer as part of a community workforce. Utilizing a mindfulness-based, trauma-informed framework, the group intervention targeted parents with preschoolers attending the agency to foster child resilience and promote nurturing parenting. Holmes et al. (2023) created the first system of trauma-informed city recreation centers, referred to as Neighborhood Resource and Recreation Centers (NRRCs), that serve K − 12 youth and adults through mental and physical health education, as well as career and leadership development. The NRRCs also have social workers and counselors proficient in trauma-informed care who provide short-term direct services, and all recreation center staff are trained in trauma-informed practice. Lastly, the Bounce Back League is a trauma-informed sports program targeting children ages 9–12 integrated into BGC Canada, formerly the Boys & Girls Clubs of Canada, focused on training staff and coaches to be proficient in trauma-sensitive practices to cultivate a safe space for play and sport while training youth to develop emotion regulation and social skills (Shaikh et al., 2021). Each of these programs was designed to explicitly address the mental health needs of youth exposed to poverty-related stress and traumatic events by providing mental health support to youth directly and/or by training important members of youths’ ecological context, including caregivers and OST program staff.

Feasibility of the violence intervention and Prevention (VIP) Initiative

The VIP Initiative was initiated in November 2022, and program evaluation data from the first eight months were collected in strict adherence to the protocol approved by the West Chester University institutional review board (IRB # FY2023-67) and described here. The overarching aim of the VIP Initiative was to increase immediate and long-term access to evidence-based, trauma-informed mental health care for youth and young adults impacted by community gun violence. Free trauma-informed services were delivered by mental health practitioners referred to as VIP clinicians, who were trained clinical psychology doctoral students supervised by licensed psychology faculty within the graduate program’s Community Mental Health Services (CMHS) training clinic. Data collected to examine feasibility of the VIP Initiative included number of community agencies who partnered with us, number of staff who participated in professional development training, number of youth referred for services, and number of youth who received services by type of intervention.

Our community partners were six community-based OST programs providing free or low-cost after-school and summer camp activities within a small city in southeastern Pennsylvania. The university team and the community partners agreed that trauma-informed services were warranted because of the city’s history of community violence: there were 621 violent crimes in the city reported to law enforcement in 2018, which was the last year these data were publicly available, making it the fourth most violent city in the state that year (FBI, 2018). Also in 2018, approximately one-third of residents in the metro area lived in concentrated poverty, where 40% or more of their neighbors were in households at or below the poverty line (The Center Square, 2021). The most recent 5-year estimate of persons in poverty in the city is 29%, and in terms of ethnic and racial makeup of the city, 66.5% of residents identify as Hispanic, 43% identify as White, 17.2% identify as multiracial, and 12.6% identify as Black (US Census Bureau, 2023). In addition, the city has been designated by the federal government as a mental health professional shortage area (HRSA, 2023) with only one community mental health center, based on 2018 data from the Agency for Healthcare Research and Quality (Reading Hospital, 2022, p. 56).

The VIP Initiative increased access to trauma-informed services by providing professional development training to the staff of partnering OST programs and delivering four types of trauma-informed interventions in the OST programs (see Table 1). Intervention delivery began two months after the VIP Initiative was established, following VIP clinician orientation to the CMHS clinic procedures and introduction of clinicians on site to OST program staff and youth through “meet and greets.” Additionally, VIP clinicians received intensive training in evidence-based trauma treatments for both youth and adults, specifically Trauma-focused Cognitive Behavioral Therapy (TF-CBT; Cohen et al., 2017) and Cognitive Processing Therapy (CPT; Resick et al., 2016). Our team relied on “evidence-based practice” as a guiding theoretical framework—we started with interventions that already had strong empirical research support and tailored these interventions to meet the community’s needs, preferences, and cultural expectations (APA, 2006).

Table 1. Description of trauma-informed services delivered in OST programs through the VIP Initiative.

Service	Description	Setting
Psychotherapy	Individual therapy using evidence-based and trauma-focused treatment protocols. VIP clinicians used Trauma-focused Cognitive Behavioral Therapy^a and Cognitive Processing Therapy^b with youth for 12–15 sessions depending on the specific protocol.	In-person on-site at OST programs Telehealth
Mental Health Promotion Groups	Group sessions utilizing modules from the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents^c. Modules included: getting to know emotions, changing emotions and behaviors, identifying body clues, looking at thoughts, and using detective thinking for problem solving.	In-person on-site at OST programs
Single-session Drop-in Consultation	Drop-in support conversations using a single-session consultation framework. VIP clinicians met with youth for 15–30 minutes to discuss a single concern using a solution-focused approach.	In-person on-site at OST programs
Single-session Group Intervention	Single-session group utilizing the Action Brings Change^d intervention. Four 50-minute groups were held with youth in two OST programs with a week between each group. The content of each group was formatted to be stand-alone due to the single-session structure of the intervention.	In-person on-site at OST programs
Professional Development Training	Didactic training for OST program staff and outpatient clinicians in a community mental health setting. Content focused on trauma, traumatic stress, and fostering self-care.	In-person on-site at OST programs Virtual

^aCohen et al. (2017). ^bResick et al. (2016). ^cEhrenreich-May et al. (2017). ^dSchleider et al. (2019).

Care recipients included both youth and young adults who attended OST programs and the adults who worked at OST programs. Therapy services were conducted via telehealth or in-person at OST programs. We also offered in-person mental health promotion groups and single-session drop-in (aka walk-in) services for individual youth at OST programs. Finally, we offered in-person single-session group interventions for youth at OST programs. To increase accessibility of services, opt-out forms for passive consent were sent home with youth under age 18 for participation in mental health promotion groups and single-session group interventions. Consent was not required for individual drop-in services, as the nature of these conversations was not therapeutic, but active consent to receive services was obtained for all individual therapy clients. Table 2 summarizes the demographic makeup of the recipients of VIP services. An equal percentage (45%) of males and females received intervention services, the vast majority of whom were at or below the age of 17, and nearly three-quarters of intervention recipients identified as Hispanic and Black non-Hispanic. Sixty-three percent of PDT recipients were male, while 65% were between the ages of 18–34 years old. Also, consistent with the demographics of the city overall, the majority of OST staff (58%) who received PDT identified as Hispanic.

Table 2. Demographics for recipients of trauma-informed services through the VIP Initiative.

	Recipients of intervention services^a		Recipients of professional development training
Characteristics	N	%	N	%
Gender
Male	43	45%	24	63%
Female	43	45%	14	37%
Not Reported	9	10%	0	–
Age Range
0–12	55	58%	0	–
13–17	30	32%	6	16%
18–24	1	1%	18	47%
25–34	1	1%	7	18%
35–44	0	–	4	11%
44+	1	1%	3	8%
Not Reported	7	7%	0	–
Race/Ethnicity
Black not Hispanic	21	22%	7	18.5%
White not Hispanic	3	3%	7	18.5%
Hispanic Black or White	48	51%	22	58%
Multiracial	6	6%	2	5%
Not Reported	17	18%	0	–

^aRecipients of intervention services include individual clients who completed a therapy intake, group participants, and drop-in participants. Therapy intake sessions and individual therapy were offered in Spanish for clients and caregivers whose primary language was Spanish.

VIP clients were referred for individual therapy in one of three ways: through face-to-face contact with VIP clinicians embedded within OST programs, through OST staff contacting VIP clinicians, and through phone contact with CMHS office staff. Of the 28 clients referred for psychotherapy, including youth, their family members, and OST staff members themselves, 82% (n = 23) had an initial contact, defined as an initial screening appointment (phone call or in-person), 43.5% (n = 10) of which initiated treatment (i.e., attended at least one appointment, such as intake or subsequent sessions; see Figure 1). Potential clients were matched with VIP clinicians based on clinician caseload capacity, preferred modality (i.e., in-person vs. telehealth), and schedule availability. The proportion of our referrals that began treatment (43.5%) approaches initiation rates for outpatient community mental health services, where between 48 − 69% of youth referred for services have attended at least one session (Ghafoori et al., 2019; Langer et al., 2015). However, the VIP Initiative’s capacity is more limited than community mental health centers, since VIP clinicians are not full-time employees; we expect a treatment initiation rate of approximately 65% after including youth who have been in contact with the program and are waiting for services are matched with a clinician. Of the clients who began treatment, 71.4% did so in person at an OST program location, and the remaining 28.6% chose to receive services via telehealth. An evidence-based trauma treatment, either TF-CBT or CPT, was implemented for 100% of clients who initiated treatment and completed a treatment plan (i.e., agreement to focus on reducing the impact of traumatic stress). Treatment duration for both TF-CBT and CPT are between 12 and 15 sessions to reduce the symptoms of traumatic stress.

Figure 1. Psychotherapy referrals and treatment initiation for the VIP Initiative.

VIP mental health promotion groups were offered at four OST programs where program staff indicated the greatest need. Each group ran once per week after school and consisted of four sessions. Twenty-four children in total participated in the mental health promotion groups, and each group ranged from four to 10 participants. Two groups had children ages 12 and under, one group had children ages nine and under, and the last group had children ages 10–13. The mental health promotion groups covered topics drawn from modules of the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children (UP-C; Ehrenreich-May et al., 2017). UP-C involves the assessment of “top problems” to build motivation, and then interventions from modules are used to address depression and anxiety symptoms (Ehrenreich-May et al., 2017 p. 3). Youth participants identified their top problems and VIP clinicians facilitated content from five UP-C modules: getting to know emotions, identifying body clues, changing emotions and behaviors, looking at thoughts, and using detective thinking for problem solving. Time constraints and intermittent closures of the OST program prevented VIP clinicians from giving two more modules to address conflict management and present-moment awareness of emotions.

The single-session services offered by the VIP Initiative were drop-in conversations for problem-solving support and an evidence-based single-session intervention teaching behavioral activation. For a 3- to 6-month period, VIP clinicians were available on-site at OST programs during after-school hours (4–6 p.m.) for drop-in conversations with youth, using a brief solution-focused approach centered around a single concern prioritized by the youth. VIP clinicians had four drop-in conversations with three different youths, ages seven, nine, and 14 years old. The other single-session intervention offered by the VIP Initiative was based on the Action Brings Change (ABC; Schleider et al., 2019) intervention which reduced depression symptoms at 3-month follow-up compared to a control intervention among a diverse group of adolescents (Schleider et al., 2022). ABC is a web-based activity for youth that promotes behavioral activation through psychoeducation and actively practicing how to take enjoyable actions to improve mood and overcome negative thought cycles; we adapted the content to present it in a group format at two recreational summer camps. We conducted four groups ranging in size from 12 to 18 youth between the ages of 11–14 years old. A total of 57 youth participated across two groups at each OST program. Despite being designed as a single-session intervention, the ABC content was delivered in two 50-minute group sessions to promote youth engagement while reinforcing the principal skill of behavioral activation. The content of the first group session closely followed the original format of the ABC intervention with a video activity and demonstrations of how enjoyable activities can improve mood and overcome negative thought cycles. The second group session incorporated an activity drawn from the Resilient in Spite of Stressful Events program for adolescents exposed to poverty-related stressors (Clarke et al., 2022); youth played a game that concluded with a discussion about relatable celebrities who overcame stressful events in their lives, and then the youth identified actions they could take to improve their own mood when faced with stressful conditions and what actions they would suggest to a friend.

VIP clinicians created and presented professional development trainings (PDTs) for OST program administrators (i.e., program and operations managers, site directors, and assistant directors) and youth development staff, who play a key role in coordinating and supervising activities for youth and were often in high school themselves. Trainings were customized based on feedback and collaboration with the OST program administrators. Administrators attended four PDTs, and youth development staff attended two PDTs. The first PDT, attended by both administrators (n = 14) and youth development staff (n = 21), was adapted into two versions to accommodate the different roles and responsibilities of each group of staff members. This first PDT accomplished three objectives: (1) to define trauma, (2) to identify common signs indicating that a child may be experiencing traumatic stress and/or suicidal ideation, and (3) to identify and practice strategies to help trauma-exposed youth, including reflective listening, normalizing, and conducting risk assessments. The second, third, and fourth PDTs for the administrators (n = 14, n = 8, n = 10, respectively) met the following objectives: (1) to identify symptoms of trauma, mood, and anxiety disorders, (2) to identify and practice strategies for responding to youth in the immediate aftermath of a traumatic event, such as a shooting in the community, and when a young person discloses a traumatic event months or years after the exposure, such as a report of child abuse, and (3) to identify strategies for involving caregivers and accessing local resources in the aftermath of a trauma. The second PDT for youth development staff (n = 24) had the following objectives: (1) to distinguish between signs of suicidal ideation and non-suicidal self-injury (NSSI), (2) to identify when to involve an administrator in response to suspected or reported suicidal ideation or NSSI, and (3) to identify supportive strategies such as mentorship and promoting peer connection. An estimated 67% of administrators and 80% of youth development staff members attended at least one PDT, and many of the administrators and youth development staff attended multiple trainings.

Although the VIP Initiative is a new undertaking, our preliminary data indicate that delivering trauma-informed mental health services in OST programs is feasible. In particular, there was high demand from OST administrators for PDTs, with five trainings offered over an eight-month period in response to their requests, and 95 residents of this high-crime community received trauma-informed mental health care over a six-month period. We were able to reach the largest number of youth via single-session group interventions delivered at summer camps and weekly mental health promotion groups delivered during the after-school hours. In fact, anecdotal evidence suggests that the OST program staff’s positive experiences with the VIP clinicians through PDTs laid the groundwork necessary for the clinicians to collaborate with the OST staff to successfully recruit for, coordinate, and implement the group interventions. For example, three program directors reported to the first-author that they were receptive to the groups because the PDT content was both responsive to community needs and engaging.

While the VIP Initiative was feasible, there were a number of ethical considerations that became clear when working with youth in OST programs: delineating the role of clinicians, establishing a clear service consent process, and reinforcing confidentiality between youth and OST staff. Responsibility for functions of the OST program may be diffuse (e.g., child abuse reporting, conflict management, crisis intervention, etc.) if program staff view embedded clinicians as a source of organizational support without recognizing professional and legal boundaries. Therefore, clarifying the role of clinicians is important. Additionally, consent to services requires determining when someone becomes a client, explaining to youth during drop-in support what is required to become a client, and if program staff should be informed of client status when services occur in the program’s physical space. The last point implicates confidentiality in general, as programs may not have the infrastructure to provide confidential safeguards (e.g., noise machines). Storage of confidential therapy materials and consent paperwork, which may be in unsecured locations at programs, should be considered and would likely necessitate the use of electronic forms. Further, if clinicians provide therapy to program staff, it may introduce a dual role issue and limit capacity for providing services to youth.

Recommendations to enhance trauma-informed service delivery in OST programs

To improve access to trauma-informed services among youth exposed to violent crime, we intend to expand the VIP Initiative in the future. With qualitative data on the effectiveness of the VIP Initiative forthcoming, we offer the following recommendations for the next steps to enhance trauma-informed service delivery in the VIP Initiative and OST programs more broadly:

1. Continue to establish and maintain partnerships that facilitate mutually beneficial outcomes. The initiatives described in this paper arose from a university-community partnership and were mutually beneficial to community partners and to university student learning. Grant funding helped to launch this collaboration by facilitating services at no cost to the community partners and paid training opportunities for students. As a next step, community-based OST programs should consider ways to establish sustainable partnerships in the context of structures that exist regardless of the availability of grant funding. For example, academic medical centers, community mental health clinics, and juvenile justice settings that employ training models would enable the deployment of supervised clinical trainees within OST programs. The most fruitful partnerships are those in which partners share consistent missions and in which each partner stands to benefit from the collaboration. Grassetti et al. (in press) offer strategies for establishing such partnerships with clear communication that is facilitated through mutually drafted memorandums of understanding.

2. Implement universal trauma screening and routine mental health assessments in OST settings. Under-identification of mental health concerns, stigma, and referral biases are a few factors that contribute to unmet mental health needs among youth who have experienced trauma (Spinney et al., 2016; Thyberg & Lombardi, 2022). Routine screenings for trauma exposure and mental health assessments can mitigate these barriers. Universal screening eliminates referral biases by screening all youth and may reduce the stigma associated with targeted psychological services in community settings like schools (Gronholm et al., 2018). Such screening helps to ensure those with psychological needs are identified so that they can be connected to trauma-informed services. Existing research suggests that most parents find mental health screening to be acceptable for children in community contexts such as schools (Soneson et al., 2018, 2022) and their support may extend into other community contexts in which OST programs take place. As such, we recommend that all youth enrolled in OST programs undergo a trauma screening and mental health assessment upon enrollment and annually. Existing literature (Keeshin et al., 2020; Raja et al., 2021) offers tips for screening for both trauma exposure and functional impairment as well as important considerations for agencies considering universal screening (Raja et al., 2021).

3. Expand the role of mental health practitioners to include “consultants” and “collaborators.” In addition to providing direct services to trauma-exposed youth who need them, we recommend that OST agencies consider other ways in which mental health practitioners can be helpful in other roles including trainers, consultants, and collaborators. The decision to offer staff training in the current initiative aligns with research demonstrating that stakeholders value health-focused professional development for staff who work in community settings with children (Soneson et al., 2022). Investing in staff professional development about mental health can nurture a trauma-informed context that helps to enhance the benefits of direct clinical services. The availability of mental health practitioners at community sites facilitated opportunities for staff and mental health practitioners to consult about trauma-informed care. Likewise, mental health practitioners benefited from consultation with community agency staff about the strengths and challenges of individual youth as well as current events impacting the community. This ability to work together in real-time and benefit from each other’s knowledge is akin to “curbside consultations” (Papermaster & Champion, 2017) that occur and benefit care in other service settings where professionals share their respective expertise as members of an interdisciplinary team. Finally, youth receiving behavioral health care through other youth service systems, such as the school, the behavioral health system, or the child welfare system may benefit from the collaboration of OST staff and mental health practitioners to promote continuity of care through complementary and non-redundant supports.

4. Flex “program implementor” conceptualization to include agency partners, parents, and youth themselves. Traditional mental health models where clinicians implement clinical interventions in specialty clinics are insufficient for meeting the specific needs of the many youth who have experienced trauma. Not all youth who have experienced trauma require clinical interventions, and other programs may be more tailored to meet their needs. Even among youth who do demonstrate a clinical level of mental health needs, the need for services exceeds the capacity of the professional psychological workforce. Creating a trauma-informed agency culture requires contributions from a wide range of stakeholders who can offer programs that are targeted to the specific needs of each youth. As such, we encourage broadening the role of “program implementor” as a next step for community-university partners working in OST programs. Collaborators may consider broadening in the following ways:

   1. Support agency members in developing trauma-informed programs that are most needed by their specific community. Burns and colleagues (2019) offer a model in which an academic-community collaboration resulted in sustainable community-led agency programming by which agency staff provided a parenting education program. Academic partners can support OST agency members in developing and implementing trauma-informed parenting education. Doing so may be a promising strategy for leveraging community wisdom and engaging parents as partners in their children’s mental health care. This approach is also consistent with evidence-based clinical care, considering that parent education is a primary component of TF-CBT.

   2. Engage parents as program implementers, when appropriate. To facilitate the greatest possible access, we focused on implementing direct services to youth in OST programs without the requirement that parents would be available for regular participation. Still, parents are important stakeholders in children’s mental health, and their engagement with and support of their children’s trauma-focused care can enhance clinical outcomes. In addition to participation in therapist-led child therapy sessions when appropriate, some parents can support youth by implementing parts of treatment. For example, the first step of Stepped Care TF-CBT for young children (Salloum et al., 2014) involves parent-led, therapist-assisted treatment in which parents use bibliotherapy and a workbook to engage their child in meetings at home while regularly checking in with a TF-CBT therapist by phone. A pilot study of this approach demonstrated that symptom reductions can be observed during the parent-led part of treatment (Salloum et al., 2014), and the stepped model has demonstrated comparable outcomes to standard TF-CBT among children in treatment in a community mental health nonprofit agency (Salloum et al., 2016). Service delivery models such as Stepped Care TF-CBT in which parents implement pieces of treatment may be useful in the OST context as they make treatment more efficient and cost-effective while engaging parents and empowering them to support their children’s therapeutic progress at a time and place that is convenient for the family.

   3. Consider youth as program implementors. Felter et al. (2023) describe a community-university partnership in which youth leaders were provided with education about the potential impacts of traumatic experiences and trained to support peers with trauma histories. The program positively benefited both the youth leaders and the peers whom they helped. We recommend that community-based OST programs consider training youth leaders to understand the impact of trauma, providing these leaders with supportive opportunities to process their own traumatic experiences and plan for a positive future, and providing structures by which these leaders may offer support to their peers who have experienced trauma.

5. Prioritize practice-based, community-engaged research as an essential part of evidence-based clinical service provision. The research on clinical services as implemented in OST programs is sparse (Lowenthal, 2020). Further, some studies suggest that mental health interventions that show effectiveness in some community settings are not effective in other community settings (Tennity & Grassetti, 2022). As such, more information is needed to inform whether the strategies that were developed in research labs and that demonstrate effectiveness in specialty mental health clinic settings are also effective in community settings such as OST programs. Furthermore, it is important to assess whether adjustments made to clinical practices to improve their fit for community implementation are associated with similar outcomes as demonstrated in lab settings. We recommend that those engaged in university-community partnerships prioritize program evaluation of services and publish their findings so that other OST programs learn from their challenges and build on their successes.

Conclusion

Currently, the leading cause of death among children and adolescents in the U.S. is gun fatalities, due in large part to youth dying from homicide, which occurs at a disproportionately high rate in low-income urban neighborhoods (Goldstick et al., 2022; Kang, 2016). To stem the tide of deleterious effects of community gun violence, mental health practitioners must recognize the structural inequalities that put violence-exposed youth from low-income communities at increased risk for compromised development, including disparities in access to quality mental health care (Castro-Ramirez et al., 2021). Providing accessible, evidence-based, trauma-informed mental health care to a large number of youth who are indirectly exposed to community gun violence simply by living in high-crime neighborhoods is one method of reducing the negative mental health impact on youth and potentially preventing reactive aggression in the aftermath of gun violence. The VIP Initiative is one of a small, but growing, number of approaches for integrating mental health services in OST programs that fill an important protective role for youth in high-crime neighborhoods, and our preliminary data indicate that this approach is feasible.

The data on the VIP Initiative presented here has implications for research and practice. Future directions for research include evaluating acceptability and effectiveness of various services (e.g., PDT, single-session group interventions, drop-in services, short-term therapy) from the perspectives of youth, caregivers, and OST staff and, ultimately, examining the impact of these expanded models of intervention on gun violence in the community. In addition, it would be worthwhile to test the feasibility, acceptability, and effectiveness of a similar initiative in a larger metropolitan area. Practitioners should expand the modalities by which they implement trauma-focused interventions for youth in gun violence hotspots and supervise graduate students in training to increase the labor force and access to care in high need communities. Furthermore, in the future, similar initiatives should address the limitations of the current project, including the de-centralized supervision structure and the delayed start of trauma-focused intervention protocols. The planned structure for the VIP Initiative involved one full-time supervisor to provide clinical and organizational oversight. However, recruitment of a licensed supervising psychologist was impeded by funding delays, so we shifted to assign five doctoral program faculty whose workload included clinical supervision in CMHS to provide oversight of VIP caseloads in the training clinic and to oversee community-based services. This resulted in slow communication between student clinicians, supervisors, CMHS staff, VIP staff, and OST programs. A centralized supervision structure could improve collaboration with OST programs, clarify boundaries around the role of clinicians, and potentially facilitate expansion of services. Also, centralized supervision could decrease the length of time that it took to begin active treatment. Before individual trauma treatment began, student clinicians reported that intake sessions often took two or three sessions, followed by a period of time when the supervisors, CMHS staff, and VIP staff discussed case assignments. This may have impacted engagement when youth and OST staff were ready for services, but the start of treatment was delayed. In addition to a centralized supervision structure, further clinician training and experience in OST programs could enhance the efficiency of intervention delivery.

By advocating for the integration of trauma-informed services in OST programs located in communities with high gun violence, this article contributes to the growing body of literature on trauma-informed care in youth-serving systems (e.g., Lowenthal, 2020). According to SAMHSA (2014, p. 9), a “system that is trauma-informed realizes the widespread impact of trauma…; recognizes the signs and symptoms of trauma in clients, families, [and] staff…; and responds by fully integrating knowledge about trauma into policies, procedures, and practices.” By delivering evidence-based trauma interventions directly to youth and staff members in OST programs and simultaneously providing trauma-informed PDT and trauma treatment to OST program staff, the VIP Initiative aligns with SAMHSA’s guidance for establishing a trauma-informed approach within OST programs and serves as an innovative, alternative to the dominant, yet insufficient, model of mental health treatment delivery for youth exposed to community gun violence (Kazdin, 2019).

Acknowledgements

The authors would like to acknowledge our out-of-school time partners who contributed to the development of the Violence Intervention and Prevention Initiative described in this paper.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Pennsylvania Commission on Crime and Delinquency under Grant 2021-VI-VI-36606 to the first author.