Heather Forkey, MD, Child Health Equity Center Core Faculty, and colleagues recently published findings from implementing an adapted national evidence-informed childhood trauma and resilience promotion curriculum. Despite the high prevalence of childhood trauma, a majority of physicians report a gap in knowledge concerning trauma identification and response.1.2 Educating future pediatricians to be trauma-responsive providers is a critical step forward in mitigating the potentially devastating lifelong effects of childhood trauma.
Childhood trauma occurs when children experience events that threaten their safety or the safety of their parents or caregivers.3 Examples of traumatic events are psychological, physical, or sexual abuse, neglect, witnessing or experiencing domestic violence, natural disasters, serious accidents, and war experiences.4 According to a 2013 study by Heinzelmann and Gill, an estimated 90% of children experience trauma.5 Without appropriate intervention, exposure to trauma during childhood raises the risk of lifelong developmental (e.g., abnormal reactions to stress and learning difficulties) and health problems (e.g., diabetes, heart disease, cancer, and mental illness in adulthood).6 Growing up in an unsafe, resource-impoverished, and highly stressful environment with limited access to resources increases the likelihood of exposure to trauma in addition to nontraumatic stress.7 Disadvantaged neighborhoods often lack adequate community schooling and have “a high risk of community, family, and sex-related violence, higher divorce rates, unwanted pregnancies, and a stressogenic atmosphere.”7,8 It is worth noting that communities of color experience significantly greater increases in firearm violence and assaults compared to more affluent, white neighborhoods.9
A trauma-informed approach is not a standard part of most pediatric healthcare systems, and providers often are unaware of the trauma children, and their families have experienced. Consequently, re-traumatization is likely to occur, and necessary services are not provided to families.6,10 Trauma-informed care (TIC) aims to minimize the risk that medical care will trigger traumatic reactions or become traumatic; address distress and provide emotional support to the entire family; promote positive coping, and provide guidance throughout the recovery process.11 According to the Substance Abuse and Mental Health Services Administration, a trauma-informed approach can help those working within systems of care understand, identify, and respond to those who have experienced trauma or may be at risk for experiencing traumatic events.12
The six principles of TIC13
2) Trustworthiness and transparency
3) Peer support
4) Collaboration and mutuality
5) Empowerment, voice, and choice
6) Cultural, historical, and gender issues
Educational Approach and Innovation
After identifying the residency training gap in the Department of Pediatrics at the University of California Los Angeles, Dr. Forkey and colleagues developed and implemented a nationally delivered evidence-informed childhood trauma and resilience promotion curriculum.2 The alterations made by the authors address the challenges of implementing trauma-informed practices in medical training programs and highly complex healthcare systems. The childhood trauma and resilience education course was restructured into two 2-hour sessions during the intern’s required Developmental-Behavioral Pediatrics rotation. Reducing the time to complete the course increased faculty support and scheduling availability.2 Furthermore, it was important to reach all residents early in their training before differentiating into their post-residency paths since trauma exposure spans both primary and sub-specialty settings.2 Lectures were augmented with case-based learning, allowing students to reflect on patient cases utilizing the course material framework. An integrated care approach was modeled by having a TIC-certified clinical psychologist and faculty pediatrician co-facilitate the sessions.
Key Findings from Program Implementation2
- Almost half the interns who entered residency reported no prior medical school training in adverse childhood experiences or toxic stress.
- Upon completing the program, residents self-reported statistically significant improvement in proficiency in all topic areas (moving from “no knowledge” to “able to apply” or “highly experienced”).
- Residents rated behavioral health education more favorably when sessions were co-facilitated by a TIC-certified clinical psychologist.
- The value of integrated care was illustrated through patient case discussions.
Recommendations for Next Steps2
- Expanding this curriculum to other programs.
- Creating more rigorous assessments of changes to residents’ practice patterns.
- Considering the development of online modules with standardized patient cases to promote asynchronous learning (thus, alleviating the current teaching burden and improving program sustainability).
- Training faculty preceptors on reinforcing the education in continuity clinics.
- Establishing assessment tools for faculty to guide and evaluate residents’ skills.
- Green BL, Kaltman S, Frank L, et al. Primary care providers’ experiences with trauma patients: a qualitative study. Psychol Trauma Theory Res Pract Policy. 2011;3:37-41.
- Thang C, Kucaj S, Forkey H, Lopez N, Ocampo A, Inkelas M, Wilhalme H, Szilagyi M. Training Pediatric Interns to be Trauma-Responsive Providers by Adapting a National Evidence-Informed Curriculum for Pediatricians. Acad Pediatr. 2022 Mar 5:S1876-2859(22)00090-0. doi: 10.1016/j.acap.2022.02.020. Epub ahead of print. PMID: 35259547.
- Peterson S., Early Childhood Trauma. The National Child Traumatic Stress Network. Published January 25, 2018.
- Substance Abuse and Mental Health Services Administration. Understanding Child Trauma. Published August 18, 2022.
- Heinzelmann M., Gill J. Epigenetic Mechanisms Shape the Biological Response to Trauma and Risk for PTSD: A Critical Review. Lyon DE, ed. Nursing Research and Practice. 2013;2013:417010. doi:10.1155/2013/417010
- Hornor G., Davis C., Sherfield J., Wilkinson K. Trauma-Informed Care: Essential Elements for Pediatric Health Care. Journal of Pediatric Health Care. 2019;33(2):214-221. doi:10.1016/j.pedhc.2018.09.009
- Boyle DJ, Hassett-Walker C. Individual-Level and Socio-Structural Characteristics of Violence: An Emergency Department Study. J Interpers Violence. 2008;23(8):1011-1026. doi:10.1177/0886260507313966
- Gelkopf M. Social Injustice and the Cycle of Traumatic Childhood Experiences and Multiple Problems in Adulthood. JAMA Network Open. 2018;1(7):e184488-e184488.
- Schleimer J., Buggs S., McCort C., et al. Neighborhood Racial and Economic Segregation and Disparities in Violence During the COVID-19 Pandemic | AJPH | Vol. 112 Issue 1. Published 2022.
- Oral R, Ramirez M, Coohey C, et al. Adverse childhood experiences and trauma-informed care: the future of health care. Pediatr Res. 2016;79(1):227-233. doi:10.1038/pr.2015.197
- Marsac ML, Kassam-Adams N, Hildenbrand AK, et al. Implementing a Trauma-Informed Approach in Pediatric Healthcare Networks. JAMA Pediatr. 2016;170(1):70-77. doi:10.1001/jamapediatrics.2015.2206
- Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Published online 2015. HHS Publication No. (SMA) 15-4420.
- Center for Disease Control and Prevention. Infographic: 6 Guiding Principles To A Trauma-Informed Approach | CDC. Published June 2, 2022.
About the author:
Angela Magardino, MPH, is a Graduate Research Assistant on the WE CARE study team. Her research interests focus on how physical and social environments influence disparities in pediatric health and well-being. She is passionate about advocating for environmental, climate, and child health justice as well as transforming the structures underlying racial and health inequities.