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.