Training Pediatricians to be Trauma-Responsive

Training Pediatricians to be Trauma-Responsive

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

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

Trauma-Informed Care

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

1) Safety

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.
References:
  1. 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.
  2. 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.
  3. Peterson S., Early Childhood Trauma. The National Child Traumatic Stress Network. Published January 25, 2018. 
  4. Substance Abuse and Mental Health Services Administration. Understanding Child Trauma. Published August 18, 2022.
  5. 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
  6. 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
  7. 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
  8. Gelkopf M. Social Injustice and the Cycle of Traumatic Childhood Experiences and Multiple Problems in Adulthood. JAMA Network Open. 2018;1(7):e184488-e184488. 
  9. 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.
  10. 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
  11. 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
  12. Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Published online 2015. HHS Publication No. (SMA) 15-4420. 
  13. 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.

Rani Jones, BS (She/Her)

Project Coordinator

Rani Jones is the current Project Coordinator for the Child Health Equity Center. She graduated from Rensselaer Polytechnic Institute (RPI) in 2023 with her B.S. in Biochemistry and Biophysics, and a minor in Behavioral and Cognitive Neuroscience. During her time as an undergraduate, she spent a lot of time volunteering with children in the New York capital region. She is very interested in public health and plans to continue her education at RPI to pursue her Ph.D. in Biochemistry and Biophysics in the Fall.
Rani_headshot

Rani Jones, BS (She/Her)

Project Coordinator

Rani Jones is the current Project Coordinator for the Child Health Equity Center. She graduated from Rensselaer Polytechnic Institute (RPI) in 2023 with her B.S. in Biochemistry and Biophysics, and a minor in Behavioral and Cognitive Neuroscience. During her time as an undergraduate, she spent a lot of time volunteering with children in the New York capital region. She is very interested in public health and plans to continue her education at RPI to pursue her Ph.D. in Biochemistry and Biophysics in the Fall.

Maia Archer, BA (She/Her)

Career path intern

Maia Archer graduated from Boston University with her B.A. in Biology, double minoring in French and Public Health. She is an intern for the Child Health Equity Center primarily assisting with the Pilot Lyft Transportation Program and Food is Medicine Program. Maia will be continuing her academic journey at George Washington University to receive her Masters in Public Health with a concentration in Health Promotion.

Child Health Equity Center

Maia Archer, BA (She/Her)

Career PATH Intern

Maia Archer graduated from Boston University with her B.A. in Biology, double minoring in French and Public Health. She is an intern for the Child Health Equity Center primarily assisting with the Pilot Lyft Transportation Program and Food is Medicine Program. Maia will be continuing her academic journey at George Washington University to receive her Masters in Public Health with a concentration in Health Promotion.

Monick Powell, C-TAGME (She/Her)

Fellowship Coordinator

Monick Powell, C-TAGME, is the Pediatric Training Program Coordinator at UMass Chan Medical School and UMass Memorial Children’s Medical Center. She acts as Coordinator for the Program to Advance Training in Child Health Equity (PATH) Fellowship. She was born in Puerto Rico, grew up in New York, and has been working at UMass since 2004 in various positions in Pediatrics. Ms. Powell established and leads the institutional Training Programs Coordinator Advisory Committee.

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Monick Powell, C-TAGME (She/Her)

Fellowship Coordinator

Monick Powell, C-TAGME, is the Pediatric Training Program Coordinator at UMass Chan Medical School and UMass Memorial Children’s Medical Center. She acts as Coordinator for the Program to Advance Training in Child Health Equity (PATH) Fellowship. She was born in Puerto Rico, grew up in New York, and has been working at UMass since 2004 in various positions in Pediatrics. Ms. Powell established and leads the institutional Training Programs Coordinator Advisory Committee.

Larry Rhein, MD, MPH (He/Him)

Advisor

Larry Rhein, MD, MPH, joined the faculty at UMass Chan Medical School in June 2016. He is an Associate Professor of Pediatrics and Chair of the Department of Pediatrics. Dr. Rhein is board-certified in both pediatric pulmonology and neonatology. He is a health services researcher with a focus on respiratory outcomes of neonatal lung disease and is a national expert on lung disease of prematurity. Dr. Rhein runs a research program focused on optimizing respiratory status in infants with severe lung diseases, particularly infants who are technology- or oxygen-dependent. He has pioneered several protocols for safe outpatient oxygen weaning, which allows infants to be discharged from the neonatal intensive care unit much earlier. Through clinical trials and analysis of physiological data, Dr. Rhein hopes to develop new strategies to prevent and treat neonatal and pediatric lung disease.

Photo of Dr. Larry Rhein, MD, MPH

Larry Rhein, MD, MPH (He/Him)

Advisor

Larry Rhein, MD, MPH, joined the faculty at UMass Chan Medical School in June 2016. He is an Associate Professor of Pediatrics and Chair of the Department of Pediatrics. Dr. Rhein is board-certified in both pediatric pulmonology and neonatology. He is a health services researcher with a focus on respiratory outcomes of neonatal lung disease and is a national expert on lung disease of prematurity. Dr. Rhein runs a research program focused on optimizing respiratory status in infants with severe lung diseases, particularly infants who are technology- or oxygen-dependent. He has pioneered several protocols for safe outpatient oxygen weaning, which allows infants to be discharged from the neonatal intensive care unit much earlier. Through clinical trials and analysis of physiological data, Dr. Rhein hopes to develop new strategies to prevent and treat neonatal and pediatric lung disease.

Michelle Trivedi, MD, MPH (She/Her)

Child Health Equity Center CORE FACULTY

Michelle Trivedi, MD, MPH, is a pediatric pulmonologist and clinician-scientist who studies sustainable community-based interventions that seek to improve asthma health for children. She is an Associate Professor of Pediatrics and Population Quantitative Health Sciences at UMass Chan Medical School. Dr. Trivedi is Principal Investigator on a National Institutes of Health (NIH)-funded clinical trial of Asthma Link, a clinic-school partnership that delivers school-supervised asthma therapy to children with poorly controlled asthma in 52 schools across Massachusetts. 

 

With a focus on sustainable, pragmatic interventions, she has developed a novel methodology for stakeholder engagement, grounded in implementation science, that elicits input from children, parents, pediatricians, community and systems-level stakeholders (payors, legislators, and public health officials) in order to adapt evidence-based interventions to real-world settings. The ultimate goal of this methodology and her work is to develop interventions that produce positive public and population health impact, particularly for historically marginalized populations.

Photo of Dr. Michelle Trivedi

Michelle Trivedi, MD, MPH (She/Her)

Child Health Equity Center CORE FACULTY

Michelle Trivedi, MD, MPH, is a pediatric pulmonologist and clinician-scientist who studies sustainable community-based interventions that seek to improve asthma health for children. She is an Associate Professor of Pediatrics and Population Quantitative Health Sciences at UMass Chan Medical School. Dr. Trivedi is Principal Investigator on a National Institutes of Health (NIH)-funded clinical trial of Asthma Link, a clinic-school partnership that delivers school-supervised asthma therapy to children with poorly controlled asthma in 52 schools across Massachusetts. 

With a focus on sustainable, pragmatic interventions, she has developed a novel methodology for stakeholder engagement, grounded in implementation science, that elicits input from children, parents, pediatricians, community and systems-level stakeholders (payors, legislators, and public health officials) in order to adapt evidence-based interventions to real-world settings. The ultimate goal of this methodology and her work is to develop interventions that produce positive public and population health impact, particularly for historically marginalized populations.

Meg Parker, MD, MPH (She/Her)

Child Health Equity Center CORE FACULTY

Meg Parker, MD, MPH, is an Associate Professor of Pediatrics and Chief of the Division of Neonatology at UMass Chan Medical School and UMass Memorial Children’s Medical Center. Dr. Parker is a neonatal health services researcher and holds several federal and foundation grants in the area of social disparities in preterm birth outcomes; she has a particular interest in safe sleep and breastfeeding. 

Dr. Parker is also an expert in multi-site implementation science and is the Co-Chair of the Neonatal Quality Improvement Collaborative of Massachusetts and an Improvement Advisor from the Institute of Healthcare Improvement. She has led multi-site NICU quality improvements focused on breastfeeding and family engagement. Dr. Parker applies a health equity lens to her local and multisite quality improvement projects.

Photo of Dr. Meg Parker

Meg Parker, MD, MPH (She/Her)

Child Health Equity Center CORE FACULTY

Meg Parker, MD, MPH, is an Associate Professor of Pediatrics and Chief of the Division of Neonatology at UMass Chan Medical School and UMass Memorial Children’s Medical Center. Dr. Parker is a neonatal health services researcher and holds several federal and foundation grants in the area of social disparities in preterm birth outcomes; she has a particular interest in safe sleep and breastfeeding. 

Dr. Parker is also an expert in multi-site implementation science and is the Co-Chair of the Neonatal Quality Improvement Collaborative of Massachusetts and an Improvement Advisor from the Institute of Healthcare Improvement. She has led multi-site NICU quality improvements focused on breastfeeding and family engagement. Dr. Parker applies a health equity lens to her local and multisite quality improvement projects.

Heather Forkey, MD (She/Her)

Child Health Equity Center CORE FACULTY

Heather Forkey, MD, is a pediatrician and a Professor of Pediatrics at the UMass Chan Medical School. She also directs the Child Protection Program and Foster Children Evaluation Service (FaCES) of the UMass Memorial Children’s Medical Center. Dr. Forkey is particularly interested in meeting the health and developmental needs of children who have experienced trauma. In collaboration with colleagues, she has trained thousands of professionals and parents about the impacts of childhood trauma and has developed innovative resources to make that work easier. She published the first textbook on trauma-informed care for pediatrics and presents nationally and internationally on the topic. Dr. Forkey also serves in leadership roles for the National Child Traumatic Stress Network and the American Academy of Pediatrics.

Photo of Dr. Heather Forkey

Heather Forkey, MD (She/Her)

Child Health Equity Center CORE FACULTY

Heather Forkey, MD, is a pediatrician and a Professor of Pediatrics at the UMass Chan Medical School. She also directs the Child Protection Program and Foster Children Evaluation Service (FaCES) of the UMass Memorial Children’s Medical Center. Dr. Forkey is particularly interested in meeting the health and developmental needs of children who have experienced trauma. In collaboration with colleagues, she has trained thousands of professionals and parents about the impacts of childhood trauma and has developed innovative resources to make that work easier. She published the first textbook on trauma-informed care for pediatrics and presents nationally and internationally on the topic. Dr. Forkey also serves in leadership roles for the National Child Traumatic Stress Network and the American Academy of Pediatrics.

Nisha Fahey, DO, MSc (She/Her)

Child Health Equity Center CORE FACULTY

Nisha Fahey, DO, MSc, is an Assistant Professor at UMass Chan Medical School in the Division of General Pediatrics and a faculty member in the Child Health Equity Center with a focus on global health. Dr. Fahey leads an institutional collaboration with an academic tertiary care center in rural western India focused on research capacity building and community engagement to identify and address barriers to care and health inequities in rural community settings. Through this collaboration, she has led the implementation of several research projects in India; recent projects have focused on maternal-child health and social determinants of health. In addition, she is passionate about exploring how digital technologies can be used to reduce health inequities. Her current research focuses on developing ways to promote the practice of Kangaroo Mother Care among mother-neonate dyads across a variety of settings.

Photo of Dr. Nisha Fahey

Nisha Fahey, DO, MSc (She/Her)

Child Health Equity Center CORE FACULTY

Nisha Fahey, DO, MSc, is an Assistant Professor at UMass Chan Medical School in the Division of General Pediatrics and a faculty member in the Child Health Equity Center with a focus on global health. Dr. Fahey leads an institutional collaboration with an academic tertiary care center in rural western India focused on research capacity building and community engagement to identify and address barriers to care and health inequities in rural community settings. Through this collaboration, she has led the implementation of several research projects in India; recent projects have focused on maternal-child health and social determinants of health. In addition, she is passionate about exploring how digital technologies can be used to reduce health inequities. Her current research focuses on developing ways to promote the practice of Kangaroo Mother Care among mother-neonate dyads across a variety of settings.

Sarabeth Broder-Fingert, MD, MPH (She/Her)

Child Health Equity Center CORE FACULTY

Sarabeth Broder-Fingert, MD, MPH, is a pediatrician and implementation scientist who studies early diagnosis and treatment for autistic children and children with other developmental, behavioral, and/or mental health disorders. She is Vice Chair for Clinical Research in Pediatrics and Associate Director for Research at the Eunice Kennedy Shriver Center at UMass Chan Medical School. Dr. Broder-Fingert is Principal Investigator on multiple National Institutes of Health (NIH)-funded awards focused on testing and/or evaluating the implementation of autism interventions. Dr. Broder-Fingert has published more than 60 peer-reviewed manuscripts and serves as an editor for the Autism and Hospital Pediatrics journals.

Photo of Dr. Sarabeth Broder-Fingert

Sarabeth Broder-Fingert, MD, MPH (She/Her)

Child Health Equity Center CORE FACULTY

Sarabeth Broder-Fingert, MD, MPH, is a pediatrician and implementation scientist who studies early diagnosis and treatment for autistic children and children with other developmental, behavioral, and/or mental health disorders. She is Vice Chair for Clinical Research in Pediatrics and Associate Director for Research at the Eunice Kennedy Shriver Center at UMass Chan Medical School. Dr. Broder-Fingert is Principal Investigator on multiple National Institutes of Health (NIH)-funded awards focused on testing and/or evaluating the implementation of autism interventions. Dr. Broder-Fingert has published more than 60 peer-reviewed manuscripts and serves as an editor for the Autism and Hospital Pediatrics journals.

Alison LeBlanc, MS, PMP (She/Her)

Child Health Equity Center EXECUTIVE DIRECTOR

Alison LeBlanc, MS, PMP, is an experienced development strategist and child health equity advocate with over a decade of experience designing and implementing initiatives to address adverse social determinants of health. Ms. LeBlanc subscribes to the philosophy “nothing about us without us.” To this end, she has extensive experience fostering bidirectional community partnerships and coalition building. She also has a strong track record of building sustainable centers of excellence in safety-net healthcare systems. 

As a disability and chronic disease self-advocate, Ms. LeBlanc has spent years redefining what it means to promote inclusivity and belonging and is dedicated to continually raising the bar for herself and her colleagues. Ms. LeBlanc completed her undergraduate degree at Wesleyan University and completed her master’s in communications at the S.I. Newhouse School of Public Communications at Syracuse University.

Photo of Alison LeBlanc, MS, PMP

Alison LeBlanc, MS, PMP (She/Her)

Child Health Equity Center EXECUTIVE DIRECTOR

Alison LeBlanc, MS, PMP, is an experienced development strategist and child health equity advocate with over a decade of experience designing and implementing initiatives to address adverse social determinants of health. Ms. LeBlanc subscribes to the philosophy “nothing about us without us.” To this end, she has extensive experience fostering bidirectional community partnerships and coalition building. She also has a strong track record of building sustainable centers of excellence in safety-net healthcare systems. 

As a disability and chronic disease self-advocate, Ms. LeBlanc has spent years redefining what it means to promote inclusivity and belonging and is dedicated to continually raising the bar for herself and her colleagues. Ms. LeBlanc completed her undergraduate degree at Wesleyan University and completed her master’s in communications at the S.I. Newhouse School of Public Communications at Syracuse University.

Arvin Garg, MD, MPH (He/Him)

Child Health Equity Center FOUNDING DIRECTOR

Arvin Garg, MD, MPH, is a general pediatrician and clinician-scientist who studies addressing unmet social needs through family-centered healthcare system-based interventions. He is the Founding Director of the Child Health Equity Center and the Founding Program Director of the Program to Advance Training in Child Health Equity (PATH) Fellowship. He is currently a Professor of Pediatrics and Vice Chair of Health Equity at UMass Chan Medical School and UMass Memorial Children’s Medical Center. Dr. Garg is also Associate Chief Quality Officer for Health Equity for UMass Memorial Health

Since 2009, Dr. Garg has been continuously funded by the National Institutes of Health (NIH) and has received extramural funding from private foundations. He is Principal Investigator or Co-Investigator on multiple NIH-funded awards focused on testing and/or evaluating the implementation of interventions addressing social needs. He has published over 80 peer-reviewed manuscripts and serves as Associate Editor for the Journal of Developmental & Behavioral Pediatrics. He was recently the Chair of the Health Care Delivery Committee for the Academic Pediatric Association.

Photo of Dr. Arvin Garg

Arvin Garg, MD, MPH (He/Him)

Child Health Equity Center FOUNDING DIRECTOR

Arvin Garg, MD, MPH, is a general pediatrician and clinician-scientist who studies addressing unmet social needs through family-centered healthcare system-based interventions. He is the Founding Director of the Child Health Equity Center and the Founding Program Director of the Program to Advance Training in Child Health Equity (PATH) Fellowship. He is currently a Professor of Pediatrics and Vice Chair of Health Equity at UMass Chan Medical School and UMass Memorial Children’s Medical Center. Dr. Garg is also Associate Chief Quality Officer for Health Equity for UMass Memorial Health. 

Since 2009, Dr. Garg has been continuously funded by the National Institutes of Health (NIH) and has received extramural funding from private foundations. He is Principal Investigator or Co-Investigator on multiple NIH-funded awards focused on testing and/or evaluating the implementation of interventions addressing social needs. He has published over 80 peer-reviewed manuscripts and serves as Associate Editor for the Journal of Developmental & Behavioral Pediatrics. He was recently the Chair of the Health Care Delivery Committee for the Academic Pediatric Association.