Mapping "Trauma-Informed" Legislative Proposals in U.S. Congress

Behavioral Health Services Outcomes That Matter Most to Caregivers of Children, Youth, and Young Adults with Mental Health Needs

This project documents the service outcomes that caregivers value most. A diverse group of caregivers, representing six regions of the United States, participated in two rounds of virtual one-hour focus groups. In round 1, participants identified what they hoped to gain from using behavioral health services for themselves, their families, and their child and discussed what made services a positive experience for them. They then reported their top-three most-hoped-for outcomes. In round 2, groups validated and refined summary findings from round 1. Caregivers prioritized service quality outcomes, primarily. They expressed a desire for an accessible, respectful, and supportive treatment environment, underpinned by well-trained and culturally responsive professionals. Caregivers also desire seamless cross-sector provider collaboration and care transitions, which integrate the insights and preferences of families and children themselves to craft a customized care plan. Priority outcomes not related to service quality included hoping to gain increased knowledge, resources, and tools and techniques to support the mental health needs of their children, to see their children improve their daily functioning and for their child develop more effective interpersonal communication skills. Caregivers also reported hoping to experience less stigma related to the mental health needs of their children and to achieve personal fulfillment for themselves and their children. Research, policies, and mental health services should prioritize and be designed to address the outcomes that matter to youth and families.

Individual and Social Risk and Protective Factors as Predictors of Trajectories of Post-traumatic Stress Symptoms in Adolescents

The present study elucidates heterogeneity in post-traumatic stress symptoms (PTSS) across adolescence in a sample of youth who have experienced myriad types and combinations of potentially traumatic events (PTEs), including substantiated physical abuse, sexual abuse, neglect and/or at least one other self-reported PTE. A machine learning technique was used to assess a multivariate set of variables (e.g., PTEs, individual risk and protective factors, social risk and protective factors, and racial and ethnic minority status) as predictors of PTSS trajectory group membership. The sample included 498 maltreated (n = 275) and comparison (n = 223) 14-19-year-old female adolescents (M = 15.27, SD = 1.06 at Time 1) assessed annually until age 19. 45.7% of participants were White, 45.3% Black, 0.4% Native American, 0.8% Hispanic, and 7.7% other. Growth mixture modeling identified three distinct trajectories of PTSS: (1) recovery (56%); (2) moderate, chronic (25%); and (3) high, chronic (19%). An elastic net model was used to test predictors of membership in the recovery versus the high, chronic PTSS trajectory groups. Results demonstrated that the recovery trajectory was characterized by the absence of sexual abuse, physical abuse, and other traumas, higher self-esteem, less affective dysregulation, less risky peers, lower levels of parent depression, and being of racial/ethnic minority status. Findings help to characterize individual variation in trajectories of PTSS following PTEs by underscoring the unique trauma responses of racial and ethnic minority youth and offering possible targets of interventions to promote recovery from PTSS.

A landscape assessment of the activities and capacities of evidence-to-policy intermediaries (EPI) in behavioral health

BACKGROUND

A significant gap exists between the production of research evidence and its use in behavioral health policymaking. Organizations providing consulting and support activities for improving policy represent a promising source for strengthening the infrastructure to address this gap. Understanding the characteristics and activities of these evidence-to-policy intermediary (EPI) organizations can inform the development of capacity-building activities, leading to strengthened evidence-to-policy infrastructure and more widespread evidence-based policymaking.

METHODS

Online surveys were sent to 51 organizations from English-speaking countries involved in evidence-to-policy activities in behavioral health. The survey was grounded in a rapid evidence review of the academic literature regarding strategies used to influence research use in policymaking. The review identified 17 strategies, which were classified into four activity categories. We administered the surveys via Qualtrics and calculated the descriptive statistics, scales, and internal consistency statistics using R.

RESULTS

A total of 31 individuals completed the surveys from 27 organizations (53% response rate) in four English-speaking countries. EPIs were evenly split between university (49%) and non-university (51%) settings. Nearly all EPIs conducted direct program support (mean = 4.19/5 [sd = 1.25]) and knowledge-building (4.03 [1.17]) activities. However, engagement with traditionally marginalized and non-traditional partners (2.84 [1.39]) and development of evidence reviews using formal critical appraisal methods (2.81 [1.70]) were uncommon. EPIs tend to be specialized, focusing on a group of highly related strategies rather than incorporating multiple evidence-to-policy strategies in their portfolios. Inter-item consistency was moderate to high, with scale α's ranging from 0.67 to 0.85. Ratings of respondents' willingness to pay for training in one of three evidence dissemination strategies revealed high interest in program and policy design.

CONCLUSIONS

Our results suggest that evidence-to-policy strategies are frequently used by existing EPIs; however, organizations tend to specialize rather than engage in a breadth of strategies. Furthermore, few organizations reported consistently engaging with non-traditional or community partners. Focusing on building capacity for a network of new and existing EPIs could be a promising strategy for growing the infrastructure needed for evidence-informed behavioral health policymaking.

Review: Structural Racism, Children's Mental Health Service Systems, and Recommendations for Policy and Practice Change

OBJECTIVE

Racism is a public health crisis that impacts on children's mental health, yet mental health service systems are insufficiently focused on addressing racism. Moreover, a focus on interpersonal racism and on individual coping with the impacts of racism has been prioritized over addressing structural racism at the level of the service system and associated institutions. In this paper, we examine strategies to address structural racism via policies affecting children's mental health services.

METHOD

First, we identify and analyze federal and state policies focused on racism and mental health equity. Second, we evaluate areas of focus in these policies and discuss the evidence base informing their implementation. Finally, we provide recommendations for what states, counties, cities, and mental health systems can do to promote antiracist evidence-based practices in children's mental health.

RESULTS

Our analysis highlights gaps and opportunities in the evidence base for policy implementation strategies, including the following: mental health services for youth of color, interventions addressing interpersonal racism and bias in the mental health service system, interventions addressing structural racism, changes to provider licensure and license renewal, and development of the community health workforce.

CONCLUSION

Recommendations are provided both within and across systems to catalyze broader systems transformation.

A Policy Mapping Analysis of Goals Related to Bank Accounts in Federal Legislative Proposals

The US struggles to fully bank the unbanked and underbanked populations. This paper examined the policy landscape around these efforts by exploring the following research questions: (1) What policy goals that may impact the availability of low-cost, basic bank accounts that have been introduced in Congress as legislation? (2) How far in the legislative process did the legislation advance? (3) What populations did these proposed laws target? and (4) What related policy goals were pursued most ardently over the past 20 years? We conducted a policy mapping content analysis of all bank account-related bills (N = 32) proposed in Congress between 1999 and 2020 (May) (106th–116th Congresses). Two researchers independently coded basic characteristics (e.g., type, status, sponsorship), focal populations, and illustrative mechanisms for policy goals using a taxonomy developed by the researchers. Researchers compared codes and addressed discrepancies through consensus. New codes were created as needed. Goals appearing most often were expanding access to bank accounts (81.2%), increasing consumer protection (81.2%), and reducing costs of basic accounts (78.2%). Increasing consumer disclosure (37.5%) and expanding the type of institutions that offer basic accounts (9.4%) were addressed infrequently in the legislation. No legislation addressed the policy goal of expanding account access in minority populations and communities. Explicit attention toward unbanked and underbanked households, racial/ethnic minorities, and other vulnerable populations was rare. This study represents the first systematic analysis of key features of the US congressional response to the problem of affordability and accessibility of bank accounts. Legislative attention to the policy goals of expanding access and types of institutions that offer accounts is needed.

Systematic Review of Evaluations of Trauma-Informed Organizational Interventions That Include Staff Trainings

Enthusiasm for trauma-informed practice has increased dramatically. Organizational interventions that train staff about trauma-informed practice are frequently used to promote trauma-informed systems change, but evidence about these interventions' effects has not been integrated. A systematic review was conducted of studies that evaluated the effects of organizational interventions that included a "trauma-informed" staff training component. A search was conducted in July 2017 and studies were identified in PubMed, PsycINFO, and the Published International Literature on Traumatic Stress database, limited to articles published in English after 2000. Six hundred and thirty-two articles were screened and 23 met inclusion criteria. Seventeen studies used a single group pretest/posttest design, five used a randomized controlled design, and one used a quasi-experimental design with a nonrandomized control group. The duration of trauma-informed trainings ranged from 1 hr to multiple days. Staff knowledge, attitudes, and behaviors related to trauma-informed practice improved significantly pre-/posttraining in 12 studies and 7 studies found that these improvements were retained at ≥1month follow-up. Eight studies assessed the effects of a trauma-informed organizational intervention on client outcomes, five of which found statistically significantly improvements. The strength of evidence about trauma-informed organization intervention effects is limited by an abundance of single group, pretest/posttest designs with short follow-up periods, unsophisticated analytic approaches, and inconsistent use of assessment instruments. In addition to addressing these methodological limitations, priorities for future research include understanding intervention effects on clients' perceptions of care and the mechanisms through which changes in staff knowledge and attitudes about trauma-informed practice influence client outcomes.

Evidence-Based Human Trafficking Policy: Opportunities to Invest in Trauma-Informed Strategies

Human trafficking is a critical social issue characterized by chronic trauma among victims, and frequently preceded by traumatic experiences that contribute to risk of victimization. Therefore, the research-based practice of trauma-informed care is a highly appropriate lens for both prevention and intervention. This work examines federal legislation in the United States related to human trafficking for references to trauma, as well as how the use of research could implicitly direct public policy responses toward trauma-informed approaches. Legislation on human trafficking has risen substantially since 1989, and the use of research and trauma language within these policies has also observed substantial increases. While the use of trauma language was associated with limited progression in the policy process, legislation using research language was more likely to pass out of Committee and become enacted. Moreover, legislation may leverage research in ways that have the potential to bolster trauma-informed practice among human trafficking victims. Specifically, research can be used to describe the problem and causal mechanisms (e.g., impact of trauma), guide "best practice" for service delivery, and generate knowledge through studies and evaluations that guide future policy. Therefore, human trafficking legislation that implicitly guides trauma-informed practice via the use of research may be particularly promising for the field.

Using a trauma-informed policy approach to create a resilient urban food system

OBJECTIVE

Food insecurity is associated with toxic stress and adverse long-term physical and mental health outcomes. It can be experienced chronically and also triggered or exacerbated by natural and human-made hazards that destabilize the food system. The Baltimore Food System Resilience Advisory Report was created to strengthen the resilience of the city's food system and improve short- and long-term food security. Recognizing food insecurity as a form of trauma, the report was developed using the principles of trauma-informed social policy. In the present paper, we examine how the report applied trauma-informed principles to policy development, discuss the challenges and benefits of using a trauma-informed approach, and provide recommendations for others seeking to create trauma-informed food policy.

DESIGN

Report recommendations were developed based on: semi-structured interviews with food system stakeholders; input from community members at outreach events; a literature review; Geographic Information System mapping; and other analyses. The present paper explores findings from the stakeholder interviews.

SETTING

Baltimore, Maryland, USA.

SUBJECTS

Baltimore food system stakeholders stratified by two informant categories: organizations focused on promoting food access (n 13) and community leaders (n 12).

RESULTS

Stakeholder interviews informed the recommendations included in the report and supported the idea that chronic and acute food insecurity are experienced as trauma in the Baltimore community.

CONCLUSIONS

Applying a trauma-informed approach to the development of the Baltimore Food System Resilience Advisory Report contributed to policy recommendations that were community-informed and designed to lessen the traumatic impact of food insecurity.