A rapid realist review of trauma-responsive approaches in children’s homes: the NEST study

Background: Children and young people (CYP) living in children’s homes in the United Kingdon (UK) experience high levels of adversity and are at increased risk of poor mental and physical health, educational, and social outcomes. Trauma‑responsive approaches (TRAs) within residential care have been proposed to address the impact of trauma by promoting safety, relational care, and organisational responsibility. However, evidence relating to how TRAs work in UK children’s homes remains fragmented, conceptually diverse, and poorly operationalised, creating uncertainty and barriers to implementation. This rapid realist review examined how, why, for whom, and in what contexts TRAs can improve care quality and experiences for CYP living in UK children’s homes.

Methods: A rapid Realist review began in April 2025, following RAMESES standards and registered with PROSPERO (CRD420251047893). Searches were conducted in June 2025 using six electronic databases, relevant organisational websites and expert recommendation, and updated in April 2026. Evidence was drawn from academic and grey literature published from 2001. Forty-four documents met the inclusion criteria. Data extraction and synthesis used realist logic to develop context-mechanism-outcome configurations (CMOCs). Extensive stakeholder engagement included care-experienced young people, residential practitioners, clinicians, commissioners, and researchers, to guide and prioritise theory development, and validate findings.

Results: The synthesis identified seven core domains underpinning effective TRAs in children’s homes: (1) trauma-responsive organisational culture, (2) therapeutic relationships and dyadic models, (3) staff wellbeing and support, (4) training and implementation quality, (5) system-level integration and structural support, (6) CYP-centred practice and empowerment, (7) enabling change. Eighty-six CMOCs explained how relational safety, reflective practice, emotionally co-regulated care, and organisational alignment activate mechanisms that improve staff wellbeing, placement stability, and CYPs emotional wellbeing. Organisational culture and leadership emerged as critical elements in enabling or constraining trauma-responsive approaches.

Conclusions: This review consolidates a heterogeneous evidence base into a coherent programme theory explaining how TRAs operate in UK children’s homes. Findings demonstrate that TRAs are most effective when implemented as a whole‑system, relational, and reflective approach. The resulting theoretical framework provides robust foundations for co-designing, implementing, and evaluating tailored TRAs to improve outcomes for CYP and to support the residential care workforce.

[This is a preprint; it has not been peer reviewed by a journal.]