Adverse Childhood Experiences and Trauma-Informed Care: An Online Module for Pediatricians

Applying a Trauma-Informed Lens to Challenging Adolescent Encounters: A Faculty Development Session for Pediatricians

Introduction

Patient encounters perceived to be challenging are common and contribute to both suboptimal patient health outcomes and provider burnout. A trauma-informed care (TIC) approach to these encounters is critical, as many of the characteristics associated with challenging patient encounters can be linked to a history of trauma exposure.

Methods

Our team created and delivered a 1-hour synchronous virtual session intended to bolster provider knowledge of TIC principles and their application to challenging adolescent encounters. Participants were all faculty and staff engaged in pediatric primary care at an urban academic center, including physicians, nurse practitioners, psychologists, and social workers. The content was rooted in adult learning principles and included didactic components anchored to case-based learning with facilitated group discussions and opportunities for reflection. We used paired pre- and postsession self-assessments of provider knowledge, confidence, and practice related to TIC using Likert-scale and free-text questions. Descriptive statistics and a paired t test were used to determine the impact of the session on these metrics.

Results

In 24 paired surveys, there were statistically significant increases (p ≤ .001) in participant perceived knowledge, confidence, and practice, with 100% of participants having a statistically significant improvement in one or more of these domains. There were also strongly positive Likert-scale and free-text responses regarding content relevance and delivery.

Discussion

We demonstrate that a brief session can create improvement in pediatric providers' perceived knowledge about the application of TIC principles to challenging adolescent encounters as well as confidence in their ability to put these into practice.

Assessment of Adverse Childhood Experiences and Social Determinants of Health: A Survey of Practices in Pediatric Weight Management Programs

Introduction: Adverse childhood experiences (ACEs) and social determinants of health (SDoH) are associated with increased incidence of pediatric obesity. Recent literature highlights an imperative need to assess ACEs and SDoH among youth and families with obesity to identify those individuals requiring targeted interventions. The primary objective of the present study was to examine the frequency, methodology, and barriers in evaluation of ACEs and SDoH within pediatric weight management programs (PWMPs). Methods: Invitations were e-mailed to a comprehensive directory of 92 PWMPs in the United States with a link to complete an electronic survey. Results: Forty-one PWMPs from 26 states completed the survey. Assessment of one or more ACEs and SDoH was common and typically took place during the initial patient visit by the psychologist or medical practitioner through unstructured conversations. Reported barriers to assessment included lack of time to assess and to follow-up, lack of clinic protocols, and inadequate referral resources. Programs offering bariatric surgery and those with embedded mental health clinicians reported fewer barriers to ACEs/SDoH referral resources, while family-based and healthy lifestyle-focused programs perceived more barriers related to insufficient support staff and time to follow-up with families. Conclusions: Most PWMPs assess a subset of ACEs and SDoH; however, approaches to assessment vary, are often unstructured, and several barriers remain to optimizing assessment and follow-up. Future research should evaluate standardized ACEs/SDoH assessment protocols, ideal workflow, and their impact on obesity treatment and related health outcomes.

The effect of adverse childhood experience training, screening, and response in primary care: a systematic review

Background

Adverse childhood experiences (ACEs) can have harmful, long-term health effects. Although primary care providers (PCPs) could help mitigate these effects, no studies have reviewed the impacts of ACE training, screening, and response in primary care.

Methods

This systematic review searched four electronic databases (PubMed, Web of Science, APA PsycInfo, CINAHL) for peer-reviewed articles on ACE training, screening, and/or response in primary care published between Jan 1, 1998, and May 31, 2023. Searches were limited to primary research articles in the primary care setting that reported provider-related outcomes (knowledge, confidence, screening behavior, clinical care) and/or patient-related outcomes (satisfaction, referral engagement, health outcomes). Summary data were extracted from published reports.

Findings

Of 6532 records, 58 met inclusion criteria. Fifty-two reported provider-related outcomes; 21 reported patient-related outcomes. 50 included pediatric populations, 12 included adults. A majority discussed screening interventions (n = 40). Equal numbers (n = 25) discussed training and clinical response interventions. Strength of evidence (SOE) was generally low, especially for adult studies. This was due to reliance on observational evidence, small samples, and self-report measures for heterogeneous outcomes. Exceptions with moderate SOE included the effect of training interventions on provider confidence/self-efficacy and the effect of screening interventions on screening uptake and patient satisfaction.

Interpretation

Primary care represents a potentially strategic setting for addressing ACEs, but evidence on patient- and provider-related outcomes remains scarce.

Funding

The California Department of Health Care Services and the Office of the California Surgeon General.

Be ExPeRT (Behavioral Health Expansion in Pediatric Residency Training): A Case-Based Seminar

Introduction

Pediatric residents report behavioral or mental health (B/MH) assessment and treatment as a training gap and often feel ill-equipped to address these issues in clinical practice. We developed a novel interactive training program to improve resident confidence in managing common pediatric B/MH conditions.

Methods

The Be ExPeRT curriculum comprised a half-day interactive seminar on attention deficit hyperactivity disorder, anxiety, depression, and suicidality followed by monthly case-based discussions. Content included didactic material, role-play, and case discussion. The training was optional and open to pediatric or combined medicine-pediatrics trainees.

Results

Twenty-three residents (70% female) participated in four separate seminars over 2 years. Of the participants attending the seminars, 17 (74%) completed the presurvey, and 16 (70%) completed the postsurvey. Statistically significant improvement was noted in comfort treating major depressive disorder (41% pre, 94% post, p = .002), suicide risk (29% pre, 94% post, p < .001), and anxiety (24% pre, 94% post, p < .001) following program participation. Twelve (75%) of the 16 participants completing the survey rated the training in the top 5%-10% with respect to other resident learning experiences.

Discussion

We developed this curriculum to enhance trainee knowledge and comfort in addressing common pediatric B/MH conditions in primary care. Significant improvement was noted in self-reported comfort in treating major depressive disorder, suicide risk, and anxiety, and the program was well received. The curriculum can be adapted for use in any training program for primary care providers to provide B/MH education that may be lacking or supplement existing programming.

Trauma-Informed Care Curricula for the Health Professions: A Scoping Review of Best Practices for Design, Implementation, and Evaluation

PURPOSE

Trauma-exposed persons often experience difficulties accessing medical care, remaining engaged in treatment plans, and feeling psychologically safe when receiving care. Trauma-informed care (TIC) is an established framework for health care professionals, but best practices for TIC education remain unclear. To remedy this, the authors conducted a multidisciplinary scoping literature review to discern best practices for the design, implementation, and evaluation of TIC curricula for health care professionals.

METHOD

The research team searched Ovid MEDLINE, Cochrane Library, Elsevier's Scopus, Elsevier's Embase, Web of Science, and the PTSDpubs database from the database inception date until May 14, 2021. Worldwide English language studies on previously implemented TIC curricula for trainees or professionals in health care were included in this review.

RESULTS

Fifty-five studies met the inclusion criteria, with medicine being the most common discipline represented. The most prevalent learning objectives were cultivating skills in screening for trauma and responding to subsequent disclosures (41 studies [74.5%]), defining trauma (34 studies [61.8%]), and understanding trauma's impact on health (33 studies [60.0%]). Fifty-one of the studies included curricular evaluations, with the most common survey items being confidence in TIC skills (38 studies [74.5%]), training content knowledge assessment (25 studies [49.0%]), participant demographic characteristics (21 studies [41.2%]), and attitudes regarding the importance of TIC (19 studies [37.3%]).

CONCLUSIONS

Future curricula should be rooted in cultural humility and an understanding of the impacts of marginalization and oppression on individual and collective experiences of trauma. Moreover, curricula are needed for clinicians in more diverse specialties and across different cadres of care teams. Additional considerations include mandated reporting, medical record documentation, and vicarious trauma experienced by health care professionals.

Antiracist Curriculum Implementation for Pediatric Residents

Objectives

Racism has been recognized as a public health crisis, with calls for greater focus on antiracism in medical training. We sought to evaluate a longitudinal antiracist curriculum among pediatric residents.

Methods

In 2020-2021, we delivered seven educational sessions to pediatric trainees in a single residency program. We administered pre-/post-surveys to assess changes in awareness of structural racism, knowledge of health inequities, antiracist clinical skills, and individual/institutional advocacy behaviors. Awareness was measured with 27 Likert-type items spanning five conceptual domains (schools, healthcare, justice system, employment, and housing/transportation). We evaluated knowledge with 18 true/false or multiple-choice questions. Participants indicated comfort with clinical skills using 13 Likert-type items drawn from national toolkits and policy statements. Individual/institutional advocacy behaviors were measured with 14 items from the Antiracism Behavioral Inventory. McNemar or paired Wilcoxon signed-rank tests compared measures before and after implementation.

Results

Out of 121 residents, 79 (65%) completed pre-surveys, 47 (39%) completed post-surveys, and 37 (31%) were eligible for matching across responses. 78% of respondents were female and 68% identified as White. We found significant increases in awareness across several conceptual domains (schools: p = 0.03; healthcare: p = 0.004; employment: p = 0.003; housing/transportation: p = 0.02). Mean knowledge score increased after implementation (p = 0.03). Self-reported clinical skills improved significantly (p < 0.001). Individual advocacy behaviors increased (p < 0.001); there were no changes in institutional advocacy.

Conclusion

We demonstrate improvements in several educational constructs with a novel antiracist curriculum. Efforts to scale and sustain this work are ongoing, and additional teaching and evaluation methodologies may be incorporated in the future.

Integrating Adverse Childhood Experiences Into Undergraduate Nursing Curriculum: A Scoping Review

BACKGROUND

Adverse childhood experiences (ACEs) are traumatic events occurring in childhood that can have severe effects on health throughout the life span. Quality nursing care includes the knowledge and skills to recognize patients who were exposed to ACEs and respond appropriately.

METHOD

A scoping review of the literature was conducted as the foundation for implementing ACEs into baccalaureate nursing curricula.

RESULTS

A total of 22 articles were examined and included 15 research studies, two literature reviews, one quality improvement project, and four discussion articles. The literature reflects a prevalence for case-based ACEs content and the importance of student safety measures during content implementation.

CONCLUSION

Knowledge derived from this review can assist nursing educators to integrate ACEs education into baccalaureate nursing curricula and identify research areas for further investigation. [J Nurs Educ. 2022;61(12):673-678.].

Trauma-Informed Care in the Classroom: Our Experience with a Content Warning in a Medical School Course

Trauma is now recognized as a common human experience that has consequences, including adverse effects on learning outcomes. Principles of trauma-informed care include awareness of the impact of trauma and use of strategies to prevent retraumatization. While well-described in medical and mental health care, these principles have been inconsistently applied in the medical education classroom. Content warnings can be part of a trauma-informed classroom approach that notifies learners about potentially distressing topics, allows individuals to employ self-care, and seeks to resist retraumatization. This article describes our experience integrating a content warning about reproductive topics in a second-year medical school course.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-022-01559-0.

Child Adversity and Trauma-Informed Care Teaching Interventions: A Systematic Review

OBJECTIVES

Health professionals need training to provide trauma-informed care (TIC) for children with adverse childhood experiences (ACEs), which can affect short- and long-term health. We summarize and evaluate published curricula for health professionals on ACEs and TIC.

METHODS

We searched PubMed, Embase, Web of Science, CINAHL, Cochrane Central Register of Controlled Trials, PsychInfo, and MedEdPORTAL through January 2021. Studies meeting the following criteria were included: Described teaching interventions on ACEs, TIC, and child abuse and maltreatment; included health care providers or trainees as learners; were written in English; included an abstract; and described a curriculum and evaluation. We reviewed 2264 abstracts, abstracted data from 79 studies, and selected 51 studies for qualitative synthesis.

RESULTS

Studies focused on ACEs/TIC (27), child abuse (14), domestic/intimate partner violence (6), and child maltreatment/parental physical punishment (4). Among these 51 studies, 43 were published since 2010. Learners included a mix of health professionals (34) and students (17). Duration, content, and quality of the 51 curricula were highly variable. An analysis of 10 exemplar curricula on ACEs and/or TIC revealed high and very high quality for methods and moderate to very high quality for curriculum evaluation, suggesting that they may be good models for other educational programs. Four of the 10 exemplars used randomized controlled trials to evaluate efficacy. Studies were limited to English language and subject to publication bias.

CONCLUSIONS

ACEs and TIC are increasingly relevant to teaching health professionals, especially pediatricians, and related teaching curricula offer good examples for other programs.

Addressing Trauma and Building Resilience in Children and Families: Standardized Patient Cases for Pediatric Residents

INTRODUCTION

Adverse childhood experiences (ACEs) and trauma are common and can negatively impact children's health. Standardized patient (SP) learning may provide trainees with knowledge and skills to screen for and manage ACEs, apply trauma-informed care approaches, and teach resilience strategies.

METHODS

With content experts, we developed three SP cases based on common clinical encounters, as well as didactic and debriefing materials. Case 1 focused on somatic symptoms in an adolescent with ACEs, case 2 focused on an ACE disclosure by a parent, and case 3 focused on de-escalation. The workshop required facilitators, SPs, simulation exam room and meeting space, and audiovisual equipment. It lasted 4 hours and included an orientation (1 hour), the three SP cases (totaling 2 hours), and group debriefing (1 hour).

RESULTS

We conducted five identical workshops with 22 pediatric residents. Participants responded favorably to case fidelity and applicability to their clinical work. Resident mean self-assessment scores improved significantly from baseline. Specifically, we assessed comfort with inquiring about and discussing ACEs, explaining the health impacts of trauma, identifying protective factors, resilience counseling, and de-escalation. Over 90% of responses indicated that residents were likely to apply what they had learned to their clinical practice.

DISCUSSION

These findings demonstrate that our SP cases were well received and suggest that such curricula can help pediatric residents feel more prepared to address trauma and promote resilience. Future work will assess these outcomes, as well as behavior change, in a larger sample to further substantiate these promising findings.

Family Medicine Resident Knowledge of Adverse Childhood Experiences

Introduction

Exposure to adverse childhood experiences (ACEs) has been associated with poor health in adulthood. Primary care providers can provide more appropriate medical care and intervene if they ask patients about ACEs. The purpose of this study is to determine existing knowledge and attitudes about ACEs among family medicine residents within the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region.

Methods

Researchers developed a nine-question survey to assess family medicine residents' knowledge and attitudes about ACEs, and their comfort level in addressing ACEs. The survey was distributed to 540 residents in 22 family medicine residency programs in the WWAMI region.

Results

Most residents reported they had some (32%) or moderate (35%) knowledge of the ACEs study. However, 30% reported no knowledge of the ACEs study, and very few (3%) reported significant knowledge. Of 117 respondents reporting at least some prior knowledge of ACEs, 42% had first heard about ACEs during residency. The ACEs topics that respondents felt least comfortable addressing during a patient encounter were a patient's personal history of sexual abuse (75%) and witnessing physical abuse (47%). Most residents (84%) indicated that they would like to see ACEs integrated into their residency curriculum.

Discussion

This study demonstrates a gap in residency training on the topic of ACEs in family medicine residencies within the WWAMI region. Residents are uncomfortable addressing ACEs with patients but are receptive to learning about this topic. More teaching about ACEs can increase residents' comfort level with addressing these topics in the primary care setting.

Teaching Trauma-Informed Care: A Symposium for Medical Students

INTRODUCTION

A large body of evidence links exposure to childhood trauma with negative health outcomes. Training future physicians to recognize and respond to trauma is paramount, and engaging medical students in the preclinical years affords the opportunity to foster the development of a trauma-informed lens that can then be solidified during clinical clerkships.

METHODS

We developed and implemented a 4-hour trauma-informed care (TIC) symposium for 179 second-year medical students at the George Washington University School of Medicine and Health Sciences during the Patients, Populations, and Systems course. The symposium included three interactive didactic sessions focusing on the connection between trauma and health and TIC principles. A facilitated small-group discussion allowed students to apply TIC principles to a patient case, followed by reflection and evaluation.

RESULTS

The overall rating of the TIC symposium was 4 out of 5. Strengths included integration of a small-group case with discussion on application of TIC in practice, experience of the lecturers and small-group facilitators, and review of research relating adversity to specific health outcomes. Suggestions for improvement included incorporating role-play and standardized patients. Content analysis of student reflections mapped to the domains of physician competency.

DISCUSSION

A 4-hour symposium can affect student knowledge and understanding of TIC. Teaching TIC presents an opportunity to prepare medical students for a career in medicine through cultivation of required physician competencies. Next steps include enhanced opportunities to practice TIC and follow-up analysis of participants to determine behavior change during clinical years.

Interactive Case-Based Childhood Adversity and Trauma-Informed Care Electronic Modules for Pediatric Primary Care

INTRODUCTION

Training health professionals for the skills and capacity to respond adequately to children and adults who have been exposed to adverse childhood experiences is recognized as an essential need in health care. Accessible opportunities to educate physicians and physician-trainees are limited.

METHODS

Four computer-based e-modules were created focusing on addressing childhood adversity and implementing trauma-informed care in the pediatric primary care setting. These childhood adversity and trauma-informed care (CA-TIC) e-modules were designed as an individualized, self-directed experience to allow for distance learning with flexibility to be embedded into existing coursework. To foster an engaging learning environment, we narrated the modules, prioritized images, and included the opportunity for participant interaction via multiple-choice and short-answer questions. Twenty-eight pediatric residents, two medical students, four attending physicians, and one fellow at Children's National Hospital completed the e-modules.

RESULTS

Overall, participants rated the CA-TIC e-modules 4.6 (SD = 0.5) out of 5 for design and quality. Using paired t tests and Wilcoxon signed rank tests, we found statistically significant score increases from presession to postsession for participants' knowledge, attitudes, practice, and confidence related to CA-TIC. The most commonly cited learning points and practice changes included asking about trauma in practice and the seven C's of resilience.

DISCUSSION

A trauma-informed, strengths-based approach to care can assist health care providers in mitigating the link between adversity and related poor health outcomes. The CA-TIC e-modules provide an opportunity to train health professionals using an innovative, self-directed, and low-resource mechanism.

Introducing ACEs (Adverse Childhood Experiences) and Resilience to First-Year Medical Students

INTRODUCTION

Adverse childhood experiences (ACEs) are associated with negative mental and physical health outcomes and predictive of higher sociodemographic risk. Introducing ACEs into undergraduate medical education is key to prevention, early recognition, and intervention.

METHODS

In a 1-hour lecture, held live and viewed online, we delivered a condensed introduction to ACEs to first-year medical students. Live-classroom participants completed pre-/postsession questionnaires self-assessing their knowledge of 10 content areas on a 5-point Likert scale. We analyzed quantitative data to determine mean scores and differences. We synthesized qualitative data obtained from feedback.

RESULTS

One hundred twenty-four students, including 32 live-classroom attendees and 92 online viewers, participated in this activity. Self-assessment scores increased in all content areas measured, with a mean increase of 1.5 (p < .0001). The most significant increases occurred in identifying household dysfunction as ACEs (increase of 2.3), calculating an ACE score (increase of 2.2), differentiating between child abuse acts of commission and omission (increase of 1.9), describing resilience (increase of 1.7), and recognizing the link between ACEs and chronic medical conditions (increase of 1.4). Participants found the lecture informative, appreciating the use of the case illustrating how ACEs impact health and an interactive slide on the risks conferred by cumulative ACEs. Learners welcomed the positive message of resilience.

DISCUSSION

Introducing ACEs in medical student education is feasible. Educating the next generation of health providers on ACEs while highlighting prevention and resilience and teaching trauma-informed care is crucial. This lecture can be readily incorporated into medical student curricula.