Mental Health for LGBTQIA+ Older Adults

LGBTQIA+ older adults share a unique set of risk factors that impact mental health. This article provides an overview of the minority stress and allostatic load models and how they can lead to worse physical and mental health outcomes. The article also describes unique epidemiologic and psychosocial context for various aspects of mental health among LGBTQIA+ older adults. Within each section are suggestions for health care providers when addressing these mental health issues and caring for LGBTQIA+ older adults in all settings.

Home-Based Care for Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, or another diverse gender identity Older Adults

The home-based medicine ecosystem is rapidly expanding. With this expansion, it is increasingly important to understand the unique needs of homebound older adults. There is likely significant intersectionality across the lesbian, gay, bisexual, transgender, queer or questioning, or another diverse gender identity (LGBTQ+) older adult population and the homebound population. This article begins to outline some strategies and approaches to entering the home of LGBTQ+ older adults in inclusive and trauma-informed ways and encourages home-based care teams, organizations, and health systems to utilize existing resources created by the LGBTQ+ aging community to provide universal skills training for the workforce.

Evaluating a web-based training curriculum for disseminating best practices for the care of newborns with neonatal opioid withdrawal syndrome in a rural hospital, the NOWS-NM Program

BACKGROUND

The incidence of neonatal opiate withdrawal syndrome (NOWS) in the US has grown dramatically over the past two decades. Many rural hospitals not equipped to manage these patients transfer them to hospitals in bigger cities.

METHODS

We created a curriculum, the NOWS-NM Program, a web-based curriculum training in best practices. To evaluate the curriculum, we conducted pre- and post-surveys of NOWS knowledge, attitudes, and care practices, plus post-curriculum interviews and focus groups.

RESULTS

Fourteen participants completed both pre- and post-curriculum surveys. They indicated an increase in knowledge and care practices. A small number of respondents expressed negative attitudes about parents of infants with NOWS at pre-test, the training curriculum appeared to have no impact on such attitudes at post-test. Sixteen participants participated in focus groups or interviews. Qualitative data reinforced the positive quantitative results and contradicted the negative survey results, respondents reported that the program did reduce stigma and improve provider/staff interactions with patients.

CONCLUSIONS

This curriculum demonstrated positive impacts on NOWS knowledge and care practices. Incorporating focus on core concepts of trauma-informed care and self-regulation in future iterations of the curriculum may strengthen the opportunity to change attitudes and address the needs expressed by participants and improve care of families and babies with NOWS.

Women's experiences of trauma-informed care for forced migrants: A qualitative interview study

Introduction

Forced migration affect the health and wellbeing of millions of women. The aim was to explore experiences of trauma-informed care among women who are forced migrants.

Methods

This was an exploratory qualitative study. Eleven women who had concluded treatment at multidisciplinary trauma centers in Sweden were interviewed, recruited through consecutive sampling. Audio-recorded interviews were transcribed and analyzed with systematic text condensation.

Results

Women dealt with mental and physical manifestations in a challenging psychosocial situation. Various structural and individual barriers were addressed that hindered access to adequate health services. Women appreciated various benefits of the treatment and recalled the care as supportive and compassionate. However, undergoing treatment was considered demanding, requiring significant determination and energy. Participants suggested that peer support could enhance the support.

Conclusions

Migrant women experience a range of health-related burdens and encounter barriers to trauma-informed care. While demanding, treatment has the potential to alleviate symptoms. Health professionals and stakeholders providing trauma-informed care need to ensure that their services are accessible and culturally sensitive towards the unique needs of women. Peer support has the potential to enhance support further, which need further evaluation.

Documentation of Trauma-Informed Care Elements for Young People Hospitalized After Assault Trauma

INTRODUCTION

Violent traumatic injury, including firearm violence, can adversely impact individual and community health. Trauma-informed care (TIC) can promote resilience and prevent future violence in patients who have experienced trauma. However, few protocols exist to facilitate implementation of TIC for patients who survive traumatic injury. The purpose of the study is to characterize documentation of TIC practices and identify opportunities for intervention in a single academic quaternary care center.

METHODS

This study is a retrospective chart review analyzing the documentation of trauma-informed elements in the electronic medical record of a random sample of youth patients (ages 12-23) admitted for assault trauma to the pediatric (n = 50) and adult trauma (n = 200) services between 2016 and mid-2021. Descriptive statistics were used to summarize patient demographics, hospitalization characteristics, and documentation of trauma-informed elements. Chi-square analyses were performed to compare pediatric and adult trauma services.

RESULTS

Among pediatric and adult assault trauma patients, 36.0% and 80.5% were hospitalized for firearm injury, respectively. More patients admitted to the pediatric trauma service (96%) had at least one trauma-informed element documented than patients admitted to the adult service (82.5%). Social workers were the most likely clinicians to document a trauma-informed element. Pain assessment and social support were most frequently documented. Safety assessments for suicidal ideation, retaliatory violence, and access to a firearm were rarely documented.

CONCLUSIONS

Results highlight opportunities to develop trauma-informed interventions for youth admitted for assault trauma. Standardized TIC documentation could be used to assess risk of violent reinjury and mitigate sequelae of trauma.

Evaluating the Effectiveness of Trauma-Informed Care Frameworks in Provider Education and the Care of Traumatized Patients

INTRODUCTION

Trauma-informed care (TIC) spans many different health care fields and is essential in promoting the well-being and recovery of traumatized individuals. This review aims to assess the efficacy of TIC frameworks in both educating providers and enhancing care for adult and pediatric patients.

METHODS

A literature search was conducted using PubMed, EMBASE, Proquest, Cochrane, and Google Scholar to identify relevant articles up to September 28, 2023. Studies implementing TIC frameworks in health care settings as a provider education tool or in patient care were included. Studies were further categorized based on adult or pediatric patient populations and relevant outcomes were extracted.

RESULTS

A total of 36 articles were included in this review, evaluating over 7843 providers and patients. When implemented as a provider education tool, TIC frameworks significantly improved provider knowledge, confidence, awareness, and attitudes toward TIC (P < 0.05 to P < 0.001). Trauma screenings and assessments also increased (P < 0.001). When these frameworks were applied in adult patient care, there were positive effects across a multitude of settings, including women's health, intimate partner violence, post-traumatic stress disorder, and inpatient mental health. Findings included reduced depression and anxiety (P < 0.05), increased trauma disclosures (5%-30%), and enhanced mental and physical health (P < 0.001).

CONCLUSIONS

This review underscores the multifaceted effectiveness of TIC frameworks, serving both as a valuable educational resource for providers and as a fundamental approach to patient care. Providers reported increased knowledge and comfort with core trauma principles. Patients were also found to derive benefits from these approaches in a variety of settings. These findings demonstrate the extensive applicability of TIC frameworks and highlight the need for a more comprehensive understanding of their applications and long-term effects.

Specialised residential care for older people subject to homelessness: experiences of residents and staff of a new aged care home in Australia

BACKGROUND

The number of older people experiencing homelessness in Australia is rising, yet there is a lack of specialised residential care for older people subject to homelessness with high care and palliative needs. To address this significant gap, a purpose-built care home was recently opened in Sydney, Australia.

METHODS

This qualitative study explores the experiences of both residents and staff who were living and working in the home over the first twelve months since its opening. Residents were interviewed at baseline (n = 32) and after six months (n = 22), while staff (n = 13) were interviewed after twelve months. Interviews were analysed using a reflexive thematic analysis approach informed by grounded theory.

RESULTS

Three main themes emerged: (1) Challenges in providing care for older people subject to homelessness with high care needs; (2) Defining a residential care service that supports older people subject to homelessness with high care needs, and (3) Perception of the impact of living and working in a purpose-built care home after six months (residents) and twelve months (staff) since its opening. A key finding was that of the complex interplay between resident dependency and behaviours, referral pathways and stakeholder engagement, government funding models and requirements, staff training and wellbeing, and the need to meet operational viability.

CONCLUSION

This study provides novel insights into how the lives of older people subject to homelessness with high care needs are affected by living in a specifically designed care home, and on some of the challenges faced and solved by staff working in the care home. A significant gap in the healthcare system remains when it comes to the effective provision of high care for older people subject to homelessness.

Providing Continuity in Infant Mental Health Services for Medically Fragile Infants and Their Families

Having a baby who is prenatally or postnatally diagnosed with a medical condition places considerable stress on the parents, infants, and their developing relationship. Infant mental health (IMH) services offer an opportunity to address the challenges and support the parent-infant relationship. The present study outlined a continuum of care IMH program embedded within various medical settings of a large metropolitan children's hospital. Applications of IMH principles within the fetal care center, neonatal intensive care unit, high risk infant follow-up clinic, and the patient's home are described. Descriptive data about families served across settings and a case study are provided in order to illustrate the implementation of this unique IMH intervention model.

Mediating effect of suicidal ideation in the association between child abuse and premenstrual syndrome among female adults

INTRODUCTION

Premenstrual symptoms encompass a range of physical, emotional, and behavioral changes that cyclically occur before menstruation. Childhood abuse has been associated with subsequent mental health challenges, yet its relationship with exacerbating premenstrual symptoms remains an understudied area. Furthermore, suicidal ideation often emerges from traumatic backgrounds such as child abuse, creating another layer of complexity. Given the rising suicide rates in Lebanon, and the concurrent increase in reported child abuse cases, this research focuses on the role of suicidal ideation as a mediator between child abuse and premenstrual syndrome.

METHODS

This cross-sectional study involved 915 female university students in Lebanon. Participants completed an online questionnaire encompassing demographic details, health lifestyle, the Premenstrual Symptoms Screening Tool (PSST), Columbia-Suicide Severity Rating Scale (C-SSRS), and Child Abuse Self Report Scale (CASRS-12). The mediation analysis was conducted using PROCESS MACRO v3.4 model 4; three pathways derived from this analysis: pathway A from the independent variable to the mediator, pathway B from the mediator to the dependent variable, Pathway C indicating the direct effect from the independent to the dependent variable.

RESULTS

The results of the mediation analysis showed that suicidal ideation mediated the association between all types of child abuse and the presence of PMS. Higher psychological (Beta = 0.21; p < 0.001), neglect (Beta = 0.02; p = 0.017), physical (Beta = 0.19; p < 0.001) and sexual (Beta = 0.20, p < 0.001) child abuse were significantly associated with higher suicidal ideation, which was significantly associated with the presence of PMS (Beta = 0.38, p = 0.001; Beta = 0.57, p < 0.001; Beta = 0.45, p < 0.001; and Beta = 0.50, p < 0.001) respectively. Finally, higher psychological (Beta = 0.17, p < 0.001), physical (Beta = 0.11, p = 0.024), but not sexual (Beta = 0.07, p = 0.198) child abuse was directly and significantly associated with the presence of PMS, whereas higher neglect (Beta = -0.06, p = 0.007) was significantly associated lower odds of having PMS.

CONCLUSION

This study highlights the mediating role of suicidal ideation in the complex association between different types of childhood abuse and premenstrual symptoms. The findings emphasize the need for trauma-informed care and tailored interventions to address the diverse impact of these factors. Recognizing the intricate relationships between child abuse, suicidal ideation, and PMS can aid healthcare providers in comprehensively addressing young women's mental and reproductive well-being. Trauma-informed care, tailored interventions and awareness of potential connections between childhood maltreatment are essential in managing these complex challenges.

Are midwives trained to recognise perinatal depression symptoms? Results of MAMA (MAternal Mood Assessment) cross-sectional survey in Italy

PURPOSE

To assess the knowledge, clinical experience, and attitudes of Italian midwives toward perinatal depression (PND) and to explore how these factors impact the quality of care.

METHODS

We conducted a cross-sectional online survey among 152 midwives employed in public hospitals across Italy. The questionnaire covered a range of topics, including demographic data, professional experience, knowledge of PND symptoms, risk factors, and clinical management, as well as communication skills and personal experiences with PND cases.

RESULTS

A concerning 76.3% of midwives displayed inadequate knowledge of PND based on current scientific literature. Those with a more comprehensive understanding were notably more confident in their practice, expressing significantly fewer apprehensions about communicating with mothers (25.8% vs 74.2%) and lesser concerns about the mothers' future well-being (38.9% vs 62.95%). The survey results also emphasised the midwives' call for specialised guidelines and formal training in PND management and underscored the value of communication skills, continuity of care, and family engagement in supporting affected mothers.

CONCLUSION

This inaugural study sheds light on the current state of knowledge and attitudes among Italian midwives regarding PND. It pinpoints crucial areas for educational enhancement and practice improvement, suggesting that elevated levels of midwife expertise in PND could significantly elevate the standard of care and expedite early diagnosis and treatment.

Utilizing screening as a trauma-responsive approach in pediatric health care settings

Given the widespread impact of child trauma, it is important that child- and family-serving systems adopt trauma-informed care. Because of their integral relationships with families, pediatricians and family medicine physicians play critical roles in disrupting negative societal and developmental cascades for trauma-exposed youth through their potential for early identification and intervention. When implemented alongside organization-wide trauma-informed care practices, trauma screening is one concrete trauma-informed care practice that has shown both feasibility and positive impacts on pediatric healthcare. In support of this practice, the Care Process Model for Pediatric Traumatic Stress (CPM-PTS) helps pediatric care providers to identify and respond to children and adolescents who may need trauma-focused supports. In this paper we discuss the importance of pediatric physicians adopting trauma-informed care and how evidence-based screening practices in pediatric settings is a trauma-responsive approach with great potential for meeting unmet needs among trauma-exposed children and families.

Trauma-informed climate scale-10 and attitudes related to trauma-informed care-10: An examination of scale psychometrics using data from disability service providers

BACKGROUND

Assessment is fundamental to the implementation of trauma-informed care. As trauma-informed care advances among organizations supporting people with intellectual and developmental disabilities (IDD), it is critical that they have access to validated assessment tools.

OBJECTIVE

This is the first study to examine the psychometric properties of two brief measures associated with trauma-informed care, Trauma-Informed Climate Scale (TICS-10) and Attitudes Related to Trauma-Informed Care (ARTIC-10), using data from the IDD service industry.

METHODS

We employed structural equation modeling to examine the factor structure, reliability of TICS-10 and ARTIC-10, and construct validity with the ProQOL using secondary data from 374 service providers.

RESULTS

We confirmed the factorial validity of TICS-10 and ARTIC-10 with single factor solutions; however, modifications were necessary to achieve adequate model fit.

CONCLUSIONS

The current study provides initial evidence of the validity and reliability of TICS-10 and ARTIC-10 when used within organizations supporting people with IDD. Recommendations for subsequent improvements and future research of the scales are provided.

Adverse childhood events and mental health problems in cancer survivors: a systematic review

PURPOSE

The purpose of this study was to systematically review the literature on the association between adverse childhood events (ACEs) and mental health problems in cancer survivors.

METHODS

This review was conducted in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Four databases (PubMed, PsychINFO, Web of Science, and Cochrane) were searched on 27-08-2023.

RESULTS

Of the 1413 references yielded by the literature search, 25 papers met inclusion criteria and were reviewed. Most studies were performed in the USA, most included breast cancer survivors, and the number of included participants ranged between 20 and 1343. ACEs were relatively prevalent, with self-report rates ranging between 40 and 95%. Having been exposed to ACEs was a risk factor for heightened levels of emotional distress, anxiety, depressive symptoms, and fatigue during cancer treatment. Results varied depending on the variables included, and per subscale, but were consistent across different cultures and heterogenous patient groups.

CONCLUSION

The association between ACE and mental health outcomes was significant in most studies. In order to improve treatment for this vulnerable population, it may be necessary to screen for ACEs before cancer treatment and adjust treatment, for example, by means of trauma-informed care (TIC), which recognizes and responds to the impact of trauma on individuals seeking healthcare.

Toward the Cessation of Seclusion and Mechanical Restraint Use in Psychiatric Hospitals: A Call for Regulatory Action

The use of seclusion and mechanical restraints (S-R) in psychiatric hospitals remains widespread despite the traumatizing effects and risk for lethality associated with these practices. Neither the Centers for Medicare and Medicaid Services (CMS) nor The Joint Commission (TJC) have updated their guidelines on the use of S-R since 2005. Their regulations do not include current best practices, such as the evidence-based six core strategies (6CS) or other trauma-informed approaches, despite robust data on their effectiveness in preventing violence and S-R use. The authors describe Pennsylvania State hospitals' nearly 10-year cessation of S-R use via their continuous adherence to 6CS. In contrast, the authors describe the significant decrease in S-R use during the implementation of 6CS at a public psychiatric hospital while under U.S. Department of Justice (DOJ) monitoring and the resumption of high S-R use after DOJ monitoring and adherence to 6CS ended. The authors emphasize the importance of external regulatory oversight and mandates to safely achieve and sustain the cessation of S-R use in psychiatric hospitals. Urging CMS and TJC to update their regulations, the authors offer a roadmap to more effectively mandate the reduction and eventual cessation of S-R use in psychiatric hospitals.

Clinical Trainee Perspectives on the Implementation of Trauma-Focused Training

OBJECTIVE

Despite the high prevalence of trauma exposure in the United States and calls for the implementation of trauma-focused psychotherapy training, scant opportunities exist for such training in graduate clinical psychology programs. This study aimed to guide the implementation of trauma-focused psychotherapy training in graduate curricula by examining clinical trainees' perspectives on their current training and desired features for trauma-specific learning environments. The absence of research that centers trainee voices is notable; therefore, this study specifically focuses on trainee perspectives on implementation.

METHODS

The New Haven competencies, developed by the American Psychological Association to support efforts to improve trauma-specific training, were used as a framework to guide the development of a mixed-methods survey. Current doctoral students (N=18) in one clinical psychology program completed the survey.

RESULTS

Trainees overwhelmingly perceived the competencies to be relevant to their psychological assessment and therapy training and to their professional goals but noted a general lack of available trauma-specific training. Nearly all trainees believed that trauma-specific training should be required and expressed varied opinions regarding how requirements should be structured. Important features of a safe and supportive learning environment were reported to include coconstructed norms, choice and flexibility for participation, and integrated wellness practices. Further, instructors' trauma awareness, cultural humility, and responsiveness to students' experiences were emphasized by trainees as important.

CONCLUSIONS

Effective implementation of trauma-specific psychotherapy training should be guided by ongoing dialogue between trainees and training stakeholders.

The impact of transfer from an alongside midwifery unit to labor and delivery on birthing women: A qualitative study

OBJECTIVE

To explore laboring women's thoughts, feelings, and experiences of transferring from an Alongside Midwifery Unit or free-standing birth center to labor and delivery.

DESIGN

A qualitative online survey was used for this research.

SETTING

An Alongside Midwifery Unit in the southwestern United States.

PARTICIPANTS

Eight women over the age of eighteen who had transferred to labor and delivery from either the AMU or free-standing birth center.

FINDINGS

Five themes emerging from the women's transfer experiences. It was important for the women to maintain their physiologic birth ideals. The initiation of transfer, even a discussion, altered the atmosphere in the birthing room. Women experienced a range of emotions surrounding the transfer. The stories spoke to mourning the loss of physiologic birth experience. Some women expressed guilt about the potential effects on their infants. Post-birth women had realizations about their mental and physical capabilities and limitations.

KEY CONCLUSIONS

This pertinent study addressed the effect on women when a transfer needs to occur from an Alongside Midwifery Unit or free-standing Birth Center to the Labor and Delivery Unit. Regardless of the reason, a transfer affected all participants. The psychological impact can have significant consequences on mother and baby's wellbeing. Women need an opportunity to share their story. The fifth theme of learning about themselves mentally and physically is new and not identified in other studies.

IMPLICATIONS FOR PRACTICE

Clinical recommendations are proposed to improve understanding and integrate into one's mindset, care processes, and clinical practice. Post-birth care should continue for these women until they completely process and come to a resolution of their experience of transferring to labor and delivery.

"Survive, learn to live with it … or not": A narrative analysis of women's repeat victimization using a lifecourse perspective

Violence against women is a global public health concern, with high levels of prevalence and debilitating consequences for victims, including a higher risk of revictimization. Quantitative evidence shows a strong association between previous experiences of sexual victimization, particularly in childhood, and future victimization. However, there is limited rigorous qualitative scholarship that advances understanding about revictimization experienced from childhood into adulthood. In this study, we address this gap offering a novel contribution to qualitative insights on revictimization using a life-course perspective. We conducted a rigorous qualitative secondary analysis, adopting a feminist narrative approach, to explore how individuals make sense of their experiences of abuse. Findings showed five main themes about survivors' experiences of repeat victimization across the life-course including: abuse experiences in childhood and adolescence; mental health and 'risky' coping mechanisms; naming abuse in early adulthood; seeking support in adulthood; surviving and a life beyond abuse. Most participants experienced multiple incidents of sexual abuse in childhood, which led to helplessness, shame, blame, and normalization of their experiences, creating a vulnerability to repeat victimization. Childhood abuse had later mental health impacts. Many participants used risky coping mechanisms, such as substance use. Survivors tended to be seen through the lens of their mental health diagnosis and addiction rather than through the lens of how abuse caused complex trauma. To address the impacts of revictimization and complex trauma affecting women across the globe, healthcare policy and services need a narrative and trauma-informed approach, over the short-, medium- or longer-term, enabling survivors to make sense of the connected nature of their experiences and accumulated vulnerability resulting from the abuse by others, rather than factors associated with the individual (their mental ill health, for example, or substance use). This is important as women's individual understanding is critical to processing trauma and abuse, and to longer-term recovery.

Trauma-informed care in the emergency department: concepts and recommendations for integrating practices into emergency medicine

The experience of psychological trauma is common and has become even more prevalent during the COVID-19 pandemic for both health care workers and the general population [1-3]. Traumatic experiences can have varied and lasting physical and mental health effects on patients, beyond what we are privy to in the acute environment of the emergency department. The effects of these prior traumatic experiences can be exacerbated by interaction with the healthcare system, and yet emergency medicine physicians have no standardized methods for working with patients in a trauma-informed way. The systematic implementation of trauma-informed care (TIC) practice requires the cooperation of multiple domains within the health care system, including focus on the physical environment, direct care, and administrative practices. Here we provide recommendations specific to emergency medicine for the development and implementation of TIC in the regular patient-clinician interaction, situated within the context of the TIC framework as outlined by the Substance Abuse and Mental Health Services Administration (SAMHSA) [4].

Assault Injury and Community Violence

Community violence happens between unrelated individuals, who may or may not know each other, generally outside the home, and often results in assaultive injuries. Community violence interventions can prevent assaultive injuries and assist victims of community violence. Trauma-informed care is foundational to the success of community violence intervention. Place-based environmental interventions can decrease community violence on the population level, and further research and developments are needed in this area. Substance use is a significant barrier to intervention program involvement and greater research and program development is needed to support substance use treatment of those impacted by community violence.

Violence Exposure and Trauma-Informed Care

Addressing violence in pediatrics requires a working knowledge of trauma-informed care (TIC). TIC weaves together our current understanding of evolution, child development, and human physiology and how these explain common childhood responses to traumatic events. In this article, we describe our current approach to treating childhood trauma in the context of violence. Ultimately, TIC relies on the pediatrician's ability to keep trauma high on their differential diagnosis. TIC leverages a child's natural strengths and biologic processes by (1) scaffolding the patient's relationships to safe, stable, and nurturing adults and (2) strengthening core resilience skills while addressing trauma symptoms when necessary.

Lessons Learned Serving Pregnant, Postpartum, and Parenting People with Substance Use Disorders in Massachusetts: The Moms Do Care Program

PURPOSE

The purpose of this paper is to describe the design and implementation of a multidisciplinary, integrated approach to supporting pregnant, postpartum, and parenting people (PPPP) and their families affected by substance use disorders (SUD).

DESCRIPTION

Between 2015 and 2022, the Moms Do Care (MDC) Program, sponsored by the Massachusetts Department of Public Health Bureau of Substance Addiction Services, established or expanded 11 co-located medical and behavioral health teams in locations across Massachusetts. These teams provided trauma-informed primary and obstetrical health care, SUD treatment and recovery services, parenting support, and case management for approximately 1048 PPPP with SUD.

ASSESSMENT

By enhancing the capacity of medical and behavioral health providers offering integrated care across the perinatal health care continuum, MDC created a network of support for PPPP with SUD. Lessons learned include the need to continually invest in staff training to foster teambuilding and improve integrated service delivery, uplift the peer recovery coach role within the care team, improve engagement with and access to services for communities of color, and conduct evaluation and sustainability planning.

CONCLUSION

MDC prioritizes trauma-informed integrated care, peer recovery, and commits to addressing inequities and stigma; thus, this program represents a promising approach to supporting PPPP impacted by SUD. The MDC model is relevant for those working to build multidisciplinary, integrated systems of health care and perinatal SUD services for marginalized populations.

Art is Patient: A Museum-Based Experience to Teach Trauma-Sensitive Engagement in Health Care

Psychological trauma is ubiquitous, an often hidden yet influential factor in care across clinical specialties. Interdisciplinary health professions education is mobilizing to address the importance of trauma-sensitive care. Given their attention to complex human realities, the health humanities are well-poised to shape healthcare learners' responses to trauma. Indeed, many such arts and humanities curricula propose narrative exercises to strengthen empathy, self-reflection, and sensitive communication. Trauma, however, is often unwordable, fragmentary, and physically encoded, incompatible with storying methods. This article presents a recent innovation, the Art is Patient seminar series, which focuses on aesthetic exercises to help learners access and share non-verbal, embodied, and relational responses to art. Based in an art museum context, it provides successive experiences of approaching, witnessing, and engaging with visual art as an analogue to developing trauma-sensitive relationships. Reflections on the process locate the seminar vis-à-vis health humanities practices, aesthetics, and trauma-informed approaches.

Trauma and Trauma-Informed Care in Early Intervention in Psychosis: State of Implementation and Provider Views on Challenges

OBJECTIVE

Although trauma is increasingly recognized as a major risk factor for psychosis and for its link to treatment outcomes, the landscape of trauma-related practices in specialized early psychosis services in the United States and other countries remains only poorly characterized. Research documenting the perspectives of frontline providers is also lacking. The primary goals of this study were to document the state of trauma-related policy implementation in early intervention in psychosis (EIP) programs and to gather provider perspectives.

METHODS

This was a mixed-methods project involving an international EIP provider survey, followed by in-depth provider interviews. The survey was disseminated in Australia, Canada, Chile, the United Kingdom, and the United States. In total, 164 providers, representing 110 unique sites, completed the survey. Frequencies were calculated for responses to survey items, and open-ended responses were analyzed with a systematic content analysis.

RESULTS

The survey findings suggested low implementation rates for a variety of assessment and support practices related to trauma and trauma-informed care. Coding of open-ended responses revealed numerous concerns and uncertainties among providers regarding the relationship between trauma and psychosis and the state of the EIP field.

CONCLUSIONS

An expansion of research and service development aimed at better meeting the trauma-related needs of young people with psychosis is essential, with implications for EIP outcomes and service user and staff experiences.

Applying Trauma-Informed Design Principles to Therapeutic Residential Care Facilities to Reduce Retraumatization and Promote Resiliency Among Youth in Care

Purpose: This conceptual paper connects the literature on the experiences and needs of youth in therapeutic residential care, trauma-informed frameworks utilized in these settings, and early research on trauma-informed design to facilitate an understanding of these connections and move towards developing a blueprint for trauma-informed design in residential settings for traumatized youth. Methods: A critical literature review drawing on trauma theory, trauma-informed care, evidence-based design, and trauma-informed design was conducted to inform the argument presented in this conceptual paper. Results: While many therapeutic residential care models engage trauma-informed care approaches to support staff in promoting healing environments for youth who have histories of complex trauma, the focus has remained on the psychosocial environment of care, and has yet to be systematically applied to the design of the built environment in which these programs are implemented. By applying the principles of trauma-informed care to the built environment, trauma-informed design has the potential to reduce retraumatization and promote resiliency among youth in care. Conclusions: Ultimately, this conceptual paper illustrates the value of further developing trauma-informed design principles to apply to settings that serve traumatized youth, such as therapeutic residential care facilities.

Understanding needs and expectations to start effective communities of practice

BACKGROUND

Communities of practice (CoPs) are frequently used in health settings to enhance knowledge and support action around public health issues. Yet, most are ineffective and often at risk of not delivering on this promise. To prevent loss of time and resources by organisations, facilitators, and members, this paper argues for a reliable assessment of the needs of people who intend to join and to set realistic expectations to assure effective communities of practice. This research proposes a valid and reliable needs assessment and analysis tool for starting communities of practice, by presenting the results of using such a tool.

METHODS

Inception needs assessments were developed, tested and administered to 246 respondents entering five communities of practice that focused on one of three public health issues: health literacy, mental health literacy and trauma-informed care. One community of practice had a global audience, four were based in Australia. Data from the needs assessments were analysed qualitatively and supplemented with descriptive statistics. Results were used to develop an analysis tool to support future communities of practice.

RESULTS

The short-term expectations of respondents included seeking to increase their knowledge and getting to know other members of the community of practice. Long-term expectations shifted towards undertaking action, collaborating and improving health outcomes. While respondents learning expectations included a wide range of topics, they articulated very specific knowledge they expected to share with others. There were high expectations of receiving practical support from the facilitator and a strong preference for meetings with synchronous interaction. Most respondents who planned to join focused initially on the direct and individual benefits and participation they expected from others, whereas they indicated limited intention to actively contribute to the learning needs of other community members. Respondents appeared to need to take time to build self-confidence and trust, and frequently applied a wait-and-see attitude.

CONCLUSIONS

The findings of this study suggest that an inception needs assessment allows members to express their needs and expectations, which directly informs the direction and structure of a community of practice, gives voice to members, and supports facilitators in managing expectations.

Family-Based Psychosocial Care for Transgender and Gender-Diverse Children and Youth

Parental and caregiver inclusion is critical in providing psychosocial care for transgender and gender-diverse (TGD) children and adolescents. High levels of trauma among TGD youth call for the use of evidence-based models and resources to decrease family rejection and increase affirmation and support while healing trauma that is both related to and unrelated to the child's gender identity and expression. The integrated Family Acceptance Project-Trauma-Focused Cognitive Behavioral Therapy treatment model provides a structured and effective approach to engaging TGD youth with trauma and their parents.

Health care professionals' self-efficacy in identifying and treating human trafficking victims

BACKGROUND

Human trafficking is characterized as a violation of human rights that exploits males and females of any age for personal or financial gain. Recently, health care professionals have been identified as feasible change agents in this global issue. However, many health care professionals are not trained in identifying and treating human trafficking victims. Through human trafficking education, health care professionals have the potential to be better equipped to recognize and assist trafficking victims and guide them to the specialized care they need.

OBJECTIVE

The purpose of this study was to measure the effect of a trauma-informed human trafficking education intervention and the impact of this training on the self-efficacy of health care professionals in identifying and recognizing human trafficking victims in healthcare settings.

DESIGN

The study was a quasi-experimental research design with snowball and convenience recruitment SETTING: 100 % virtual, online.

PARTICIPANTS

Health care professionals (N = 30) including Nurse Practitioners, Physician Assistants, Registered Nurses, Licensed Practical Nurses, Certified Medical Assistants, Certified Nursing Assistants, Emergency Medical Technicians, and Paramedics from a variety of healthcare settings.

METHODS

30 min total program to include Qualtrics pre-intervention Violence Against Women Health Care Provider survey, 20 min educational intervention on YouTube©, and an identical Qualtrics post-intervention survey.

RESULTS

Total of 30 sets of paired data. The results showed statistically significant improvement in self-efficacy in all survey questions pre- and post-human trafficking educational intervention (p < .001).

CONCLUSIONS

An increase in health care professionals' self-efficacy in identifying and treating human trafficking victims yields better patient and health care system outcomes. Trauma-informed human trafficking education for all health care professionals is recommended.

Providing Trauma Informed Care During Anorectal Evaluation

PURPOSE OF REVIEW

Patients with a history of gastrointestinal (GI) conditions report high rates of psychological trauma. This review discusses the impact of previous trauma, as well as interactions with the medical system, on a patient's physical and mental health. Trauma-informed strategies for improving patient care during gastroenterology procedures are provided.

RECENT FINDINGS

History of trauma increases risk of developing GI conditions and re-traumatization during sensitive anorectal procedures (i.e., anorectal manometry, balloon expulsion testing). Trauma-informed strategies include consistent trauma screening for all patients, obtaining consent before and during procedures, creating a safe environment, allowing for privacy, and post-procedure debriefing. Due to high rates of psychological trauma in the gastroenterology setting and the risk of medical trauma from the GI procedures themselves, having an established trauma-informed plan of care for all patients can reduce risk of iatrogenic harm and improve quality of care for patients with GI conditions.

Barriers and Facilitators to the Online Delivery of a School-Based Intervention to Reduce Racial Trauma

Students of color face disproportionate rates of adverse childhood experiences, including racial discrimination in school settings. Effective interventions strategies are needed to address school-based racial trauma. Link for Equity was designed to be a culturally-responsive trauma-informed intervention that includes universal cultural humility training for teachers. As a result of the COVID-19 pandemic, the in-person trauma-informed cultural humility training was adapted for online delivery. The purpose of this study was to assess barriers and facilitators that impacted online delivery of the training. We conducted semi-structured interviews with 25 high school teachers from three public school districts in the Midwestern United States who participated in the online training. Interview transcripts were coded by two team members, and thematic analysis was utilized. Barriers and facilitators to online delivery were identified across five domains: receptivity, logistics, engagement, comfort, and application. The implications of these barriers and facilitators are discussed and tailored recommendations for the virtual delivery of culturally-responsive trauma-informed interventions to reduce racial discrimination in schools are provided.

A trauma-informed approach to suicide prevention for the COVID-19 pandemic

During the COVID-19 pandemic, researchers have questioned how the devastation of the pandemic might impact suicide rates. While initial evidence on suicide rates during the early stages of the pandemic is mixed, there are signs we should still remain vigilant. One way of conceptualizing the long-term effects of the pandemic is as a source of multiple traumatic events: the collective trauma of widespread illness and death and social upheaval, individual traumas from the virus itself (e.g., serious illness and disability, traumatic grief, vicarious trauma), traumas from the social and economic consequences (e.g., domestic violence, unemployment), and its intersections with pre-pandemic traumas and oppression. Given trauma is a well-established risk factor for suicide, this carries significant implications for suicide prevention in the wake of the pandemic. Yet access to trauma-informed care, education, and research remains limited. The pandemic presents a unique opportunity to address these gaps and implement a trauma-informed approach to suicide prevention. Building on existing frameworks, we describe how effective suicide prevention for the pandemic must incorporate trauma-informed and trauma-specific services, strategies, and policies; capacity building; collaborative research; and knowledge exchange. Attending to the traumatic effects of the pandemic may reduce the long-term impact on suicide rates.

Process Mapping to inform implementation of Trauma-Informed Care for youth aged 14-24 with HIV in the Southern United States

Background

Trauma-Informed Care (TIC) is an evidence-based approach for improving health outcomes by providing systematic, trauma- sensitive and -responsive care. Because TIC adoption varies by setting and population, Implementation Science (IS) is particularly well-suited to guide roll-out efforts. Process Mapping (PM) is an IS model for creating shared visual depictions of systems as they are to identify rate-limiting steps of intervention adoption, but guidance on how to apply PM to guide TIC adoption is lacking. Authors of this study aimed to develop a novel method for conducting TIC-focused PM.

Methods

A real-life TIC implementation study is presented to show how TIC-focused PM was conducted in the case example of a pediatric HIV clinic in a Southern urban area with a high burden of psychological trauma among youth with HIV. A five-phase PM model was applied to evince clinic standards of care, including Preparation, planning and process identification; Data and information gathering; Map generation; Analysis; and Taking it forward. Practices and conditions from four TIC domains were assessed, including Trauma responsive services; Practices of inclusivity, safety, and wellness; Training and sustaining trauma responsiveness; and Cultural responsiveness.

Results

The TIC-focused PM method indicated the case clinic provided limited and non-systematic patient trauma screening, assessment, and interventions; limited efforts to promote professional quality of life and elicit and integrate patient experiences and preferences for care; no ongoing efforts to train and prepare workforce for trauma- sensitive or -responsive care; and no clinic-specific efforts to promote diversity, equity, and inclusion for patients and personnel.

Conclusion

Principles and constructs of resilience-focused TIC were synthesized with a five-phase PM model to generate a baseline depiction of TIC in a pediatric HIV clinic. Results will inform the implementation of TIC in the clinic. Future champions may follow the TIC-focused PM model to guide context-tailored TIC adoption.

Sexual exploitation of children: Barriers for boys in accessing social supports for victimization

BACKGROUND

The global evidence regarding sexual exploitation of children (SEC) is expanding, however, the majority of research continues to focus on girls. ECPAT International's Global Boys Initiative is a major contribution to broadening knowledge by exploring how sexual exploitation impacts boys specifically.

OBJECTIVE

This discussion paper explores data from the initiative to better understand how boys and children of all genders may be impacted by sexual exploitation.

PARTICIPANTS AND SETTING

During 2019-21, research was undertaken by ECPAT member organizations into the sexual exploitation of boys in 10 primarily low-and-middle income countries globally. The initiative also supported a global systematic scoping review of published and gray literature published in this issue (Moss et al., in press).

METHODS

Gender norms analysis of Initiative data identifies critical thematic issues impairing access to support services for victimized boys.

RESULTS

Most disconcerting is gender-based stigmatization from services that can compound children's trauma. Justice-based, rather than trauma-informed models of support predominate in responses for boys. Legal frameworks create barriers when binary gendered terminology defines sexual violence, thereby excluding anyone other than women and girls from protection.

CONCLUSIONS

Three solutions emerged to improve access to support for more children affected by sexual exploitation: (1) challenge problematic gender norms and consequent practices, such as gendered terminology in legislation, that create barriers for boys and gender-diverse children; (2) create psychologically, emotionally, and physically safe circumstances (i.e. trauma-informed care) for all children to know help-seeking is possible; and (3) undertake proactive support that specifically connects boys and gender-diverse children to therapeutic services like drop-in centers, night-time counseling, and emergency shelter.

Borderline personality disorder features and their relationship with trauma and dissociation in a sample of community health service users

BACKGROUND

Previous studies have indicated that borderline personality disorder (BPD) is closely associated with trauma and dissociation. Nevertheless, BPD is a heterogeneous condition, and not all people with BPD have severe dissociation. This study examined whether the relationship of BPD features with trauma and dissociation would remain significant after controlling for some general non-specific mental health distress. We also made the first attempt to explore which specific BPD features would be particularly associated with dissociation.

METHODS

We analyzed survey data from a sample of community health service users in Hong Kong (N = 376). Hierarchical multiple regression and data-driven network analysis were used.

RESULTS

The lifetime prevalence of DSM-5 BPD was 16.0% in our sample. Of participants who met criteria for BPD, 43.3% scored above cutoff on the dissociation measures, thus possibly having clinically significant dissociative symptoms. BPD features were associated with adulthood trauma and psychoform dissociation even after controlling for age, depression and self-esteem. Network analysis showed that some BPD features - including impulsivity, identity disturbance and suicidal/self-mutilation behaviors - were particularly associated with dissociation; other BPD features such as interpersonal-related problems had relatively weak to no connection with dissociation.

CONCLUSIONS

Our results suggested that some particular BPD features might be dissociative in nature, although further longitudinal research is required. We argue that a trauma-informed perspective should be employed when working with clients presenting with BPD features despite these features being commonly stigmatized. Further research on the intervention needs of the people with BPD who suffer from high levels of dissociation is required.

Integration of Trauma-informed Care Into the Doctor of Pharmacy Curriculum

Trauma-informed care (TIC) is a framework based on understanding and responding to individuals' experiences of psychological trauma (defined as harmful circumstances that have a lasting impact on emotional well-being), as well as fostering their sense of safety and empowerment. Health profession degree programs are increasingly integrating TIC training into their curricula. Although literature is scarce regarding TIC education in academic pharmacy, student pharmacists will likely encounter patients, co-workers, and peers who have experienced psychological trauma. Students may also have experienced psychological trauma themselves. Therefore, student pharmacists would benefit from TIC learning, and pharmacy educators should consider implementing trauma-informed education. This commentary defines the TIC framework, explores its benefits, and considers an approach to implementing the TIC framework in pharmacy education with little disruption to existing curricula.

Homelessness, COVID-19, and discourses of contagion

In March 2020, when the COVID-19 pandemic began in Canada, public health and medical authorities quickly identified emergency shelters and people experiencing homelessness as particularly at risk of contracting and spreading COVID-19 (Knight et al., 2021). Drawing on interviews with 28 service providers in organizations that primarily serve people experiencing homelessness in Ottawa, Ontario, Canada and a media scan, we explored how people who worked in and accessed these organizations negotiated discourses of contagion and infection throughout the COVID-19 pandemic. This paper is informed by Goffman's (1963) theory of stigma, complemented by Crawford's (1994) idea of the Self and unhealthy Other. We argue that people experiencing homelessness, the spaces that they occupy, and the people they engage with, have been discursively marked as dangerous vectors of infection who present a risk to the health of the whole population, rather than as vulnerable to the health consequences and social disruption of COVID-19. Consequently, people experiencing homelessness have experienced further stigmatization throughout the pandemic as they have been separated from their communities, friends, and families, left without support or shelter, internalized blame for the spread of COVID-19, and faced dehumanization, grief, and trauma resulting from uneven COVID-19 interventions. We highlight these findings to support the application of trauma- and violence-informed care in service settings to prevent the further traumatization of people experiencing homelessness in services intended to support them.

Evidence-Based Pearls: How the Healthy Work Environment Effects Multidisciplinary Trauma Teams

Trauma remains a leading cause of death among adults. Care of the trauma patient requires highly skilled trauma teams. Trauma care begins in the field, then presents to the emergency room, proceeds to intensive care in many cases, and finally reaches recovery and rehabilitation. For patients, it can be a long road. To be effective, multidisciplinary trauma teams must expertly drill and practice skills, communicate among team members in closed loops, make split decisions affecting patient outcomes, and see the care through to the end. Many disruptions during the course of providing trauma care can alter safe outcomes for patients. The American Association of Critical Care Nurses Six Essentials of the Healthy Work Environment are presented as a framework to provide excellence in trauma care, both for the patient and team members. The six essentials of a healthy work environment include skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.

Nursing students' views on trauma-informed pediatric nursing care and family-centered care

PURPOSE

We studied the views of nursing students on family-centered care (FCC) and their knowledge, opinions, self-rated competence, current practice, and perceived implementation barriers with regard to trauma-informed pediatric nursing care.

METHODS

This survey was a descriptive correlational study. The sample consisted of 261 nursing students, 3rd and 4th years, who had completed the Child Health and Diseases Nursing Course. The data were obtained using the "Student Information Form," "Family-Centered Care Attitude Scale," and "trauma-informed care (TIC) Provider Survey."

RESULTS

Nursing students were knowledgeable and held favorable opinions about TIC. The survey showed that students with higher levels and those with a hospitalization experience during childhood had higher scores regarding TIC. A positive relationship was found between the students' TIC to mean score and FCC attitude mean score.

CONCLUSIONS

Nursing students are not competent to practice TIC, especially with pediatric patients. Therefore, they need to develop relevant skills for helping pediatric patients.

PRACTICE IMPLICATIONS

Efforts to improve nursing students' trauma-informed pediatric care should highlight specific skills related to helping pediatric patients manage emotional responses to difficult medical experiences. By integrating TIC into the baccalaureate curricula, nursing educators can provide the students with appropriate skills and facilities so that they can provide holistic and highly effective care to highly vulnerable patients.

Trauma-informed and family-centered paediatric resuscitation: Defining domains and practices

Aim

For paediatric patients and families, resuscitation can be an extremely stressful experience with significant medical and psychological consequences. Psychological sequelae may be reduced when healthcare teams apply patient- and family-centered care and trauma-informed care, yet there are few specific instructions for effective family-centered or trauma-informed behaviours that are observable and teachable. We aimed to develop a framework and tools to address this gap.

Methods

We reviewed relevant policy statements, guidelines, and research to define core domains of family-centered and trauma-informed care, and identified observable evidence-based practices in each domain. We refined this list of practices via review of provider/team behaviours in simulated paediatric resuscitation scenarios, then developed and piloted an observational checklist.

Results

Six domains were identified: (1) Sharing information with patient and family; (2) Promoting family involvement in care and decisions; (3) Addressing family needs and distress; (4) Addressing child distress; (5) Promoting effective emotional support for child; (6) Practicing developmental and cultural competence. A 71-item observational checklist assessing these domains was feasible for use during video review of paediatric resuscitation.

Conclusion

This framework can guide future research and provide tools for training and implementation efforts to improve patient outcomes through patient- and family-centered and trauma-informed care.

Trauma-informed care (TIC) best practices for improving patient care in the emergency department

A patient's current or previous experience of trauma may have an impact on their health and affect their ability to engage in health care. Every year, millions of patients who have experienced physically or emotionally traumatic experiences present to emergency departments (ED) for care. Often, the experience of being in the ED itself can exacerbate patient distress and invoke physiological dysregulation. The physiological reactions that lead to fight, flight, or freeze responses can make providing care to these patients complex and can even lead to harmful encounters for providers. There is a need to improve the care provided to the vast number of patients in the ED and create a safer environment for patients and healthcare workers. One solution to this complex challenge is understanding and integrating trauma-informed care (TIC) into emergency services. The federal Substance Abuse and Mental Health Service Administration's (SAMHSA) six guiding principles of TIC offer a universal precaution framework that ensures quality care for all patients, providers, and staff in EDs. While there is growing evidence that TIC quantitatively and qualitatively improves ED care, there is a lack of practical, emergency medicine-specific guidance on how to best operationalize TIC. In this article, using a case example, we outline how emergency medicine providers can integrate TIC into their practice.

Barriers and enablers for the implementation of trauma-informed care in healthcare settings: a systematic review

BACKGROUND

Healthcare services can be re-traumatising for trauma survivors where they trigger memories of past distressing events and exert limits to a survivor's sense of autonomy, choice, and control. The benefits of receiving trauma-informed healthcare are well established; however, factors that promote or impede the implementation of trauma-informed care are not yet well characterised and understood. The aim of this review was to systematically identify and synthesise evidence regarding factors that promote or reduce the implementation of TIC in healthcare settings.

METHODS

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2.0 guidelines. Scopus, MEDLINE, Proquest, PsycINFO and grey literature were searched for original research or evaluations published between January 2000 and April 2021 reporting barriers and/or facilitating factors for the implementation of trauma-informed care in a healthcare setting. Two reviewers independently assessed the quality of each included study using the Mixed Methods Appraisal Tool (MMAT) Checklist.

RESULTS

Twenty-seven studies were included, 22 of which were published in the USA. Implementation occurred in a range of health settings, predominantly mental health services. The barriers and facilitators of implementing trauma-informed care were categorised as follows: intervention characteristics (perceived relevance of trauma-informed care to the health setting and target population), influences external to the organisation (e.g. interagency collaboration or the actions of other agencies) and influences within the organisation in which implementation occurred (e.g. leadership engagement, financial and staffing resources and policy and procedure changes that promote flexibility in protocols). Other factors related to the implementation processes (e.g. flexible and accessible training, service user feedback and the collection and review of initiative outcomes) and finally the characteristics of individuals within the service or system such as a resistance to change.

CONCLUSIONS

This review identifies key factors that should be targeted to promote trauma-informed care implementation. Continued research will be helpful for characterising what trauma-informed care looks like when it is delivered well, and providing validated frameworks to promote organisational uptake for the benefit of trauma survivors.

REGISTRATION

The protocol for this review was registered on the PROSPERO database (CRD42021242891).

Research note reliability and validity of Japanese version of the trauma-informed care provider survey (TIC provider survey)

OBJECTIVE

Robust instruments to evaluate the ability of trauma-informed care among healthcare workers need to be developed, as this would help the implementation of trauma-informed care to prevent re-traumatization of patients. This study aims to assess the reliability and validity of the Japanese version of the Trauma-Informed Care (TIC) Provider Survey. A total of 794 healthcare workers were surveyed using a self-administered questionnaire, including the TIC Provider Survey, and six measures that were considered to be correlated with it. We calculated the Cronbach's alpha coefficient to investigate the internal consistency of each category of the TIC Provider Survey (knowledge, opinions, self-rated competence, practices, and barriers). Spearman's rank correlation coefficients were used to investigate the correlation between each category of the TIC Provider Survey, and other measures of construct validity.

RESULTS

Cronbach's alpha coefficients of each category of the TIC Provider Survey were 0.40 (Knowledge), 0.63 (Opinions), 0.92 (Self-rated competence), 0.93 (Practices), and 0.87 (Barriers). The Spearman's rank correlation coefficients were small. We confirmed the reliability of the acceptable levels and examined the validity of modest or unacceptable levels of the Japanese version of the TIC provider survey among Japanese workers in a healthcare setting.

Triple-jeopardy! COVID-19, high ACE scores, and the US-Mexico border: Mitigating risks with trauma-informed pedagogy

With the urgent need to increase the number of diverse nurses in the healthcare system, it is more necessary than ever to explore and discuss solutions that help students succeed in the extremely stressful nursing school environment. COVID-19 has exacerbated stress for nursing students nationwide. Additionally, high ACE scores and living on the US-Mexico border put certain students in "triple-jeopardy" for failing. Trauma-informed pedagogy mitigates this danger by creating a secure and productive learning environment.

Creating a parallel process: A new methodological framework for conducting Trauma-Informed Evaluation and Research (TIER) in mental health settings

New understandings of the pervasiveness of adverse childhood experiences and their attendant negative impact over the life course has led to a focus on the provision of Trauma-Informed Care (TIC) in mental health treatment. The Substance Abuse and Mental Health Services Administration operationalizes TIC through six key principles: 1) safety, 2) transparency and trustworthiness, 3) peer support, 4) collaboration, 5) empowerment and, 6) sensitivity to cultural, gender, and historical issues (SAMSHA, 2014). However, there has been little attention paid to how these principles should be operationalized in the context of evaluation. This methodological article first identifies the need for evaluation of TIC programs to mirror the core principles of TIC and then offers specific strategies for conducting research and evaluation in accordance with them. The goal of this work is to define a set of principles for research and evaluation that utilizes the process to reinforce key tenets of TIC and enhance trauma treatment.

Outcomes from an interprofessional curriculum on trauma-informed care among pediatric service providers

The effects of trauma on the health of individuals have been well established as a major public health concern. However, the integration of trauma-informed practices within the multidisciplinary pediatric health care system still faces significant challenges and barriers. This study sought to understand the changes in knowledge, behaviors, and attitudes related to trauma-informed care following administration of a trauma-informed educational intervention. Eighteen pediatric professionals participated in this interprofessional study design. The intervention included several components of self-study, face-to-face active learning experiences, presentations, and case discussions. Six weeks following the intervention, participants engaged in a follow-up focus group dialogue. To crystallize the transformative impact of education in practice, the study used both quantitative and qualitative data. Quantitative data was measured using the Attitudes Related to Trauma Informed Care (ARTIC) scale, while a focus group was used to understand the subjective experiences of participants and the effects of participation on practice. Results showed statistically significant pre- to post-programming improvements across all ARTIC domains. Qualitative themes aligned with the quantitative findings, indicating a sense of empowerment through knowledge, as well as an enhanced awareness of systematic challenges to implementation of trauma-informed care approaches.

Support for Trauma-informed Care Implementation Among Ryan White HIV Clinics in the Southeastern United States

Trauma histories are common among people with HIV and associated with poor HIV outcomes, underscoring the importance of integrating trauma-informed care (TIC) into HIV services. As part of the quantitative phase of an explanatory sequential mixed-methods study, we assessed individual and clinic-wide support (using the Attitudes Related to Trauma-informed Care-45 (ARTIC-45)) and factors influencing TIC support through surveys with 152 administrators, providers, and staff from 38 Ryan White Clinics (RWCs) in the Southeastern US. Mean responses to the ARTIC-45 Personal and System Support Subscales were 5.18 (SE = 0.09; range 1-7) and 4.45 (SE = 0.16; range 1-7), respectively. In bivariate analysis, higher personal and system support were associated with strong clinic leadership culture (personal support: β = 0.08, t-value = 2.66, p = 0.009; system support: β = 0.16, t-value = 4.71, p < 0.001) and lower staff burnout (personal support: β=-0.05, t-value=-3.10, p = 0.002; system support: β=-0.07, t-value=-3.63, p < 0.001). System support was also associated with rural clinic setting (β = 0.61, t-value = 2.34, p = 0.021), strong staff culture (β = 0.14, t-value = 4.70, p = < 0.001), and resource availability (β = 0.16, t-value = 5.76, p < 0.001), and negatively associated with academic clinic setting (β=-0.52, t-value=-2.25, p = 0.026). Thus, while there is encouraging individual support for TIC, RWCs need tools (training and/or resources) to foster leadership and staff culture and trauma support to enable their transition to trauma-informed HIV care.

Intimate Partner Violence

IPV is a widespread and destructive public health problem that impacts women across the world and the lifespan. IPV encompasses a wide range of negative behaviors towards a person's romantic partner which include physical aggression, sexual violence, stalking, psychological torment, and coercive behaviors. Persons who experience IPV face a wide range of debilitating physical, mental health, and financial outcomes compared to those who have never experienced violence. Physicians play an important role in caring for patients who have experienced violence; knowledge of IPV's impact, consequences, treatment, and patient preferences around IPV discussions can lead to improved patient satisfaction and outcomes.

ACE: "What Happened to You" Screening for Adverse Childhood Experiences or Trauma-Informed Care

Trauma is common within the United States. It is important for individuals to understand how trauma may affect their health and how trauma in childhood can have adverse effects on a child's development and health. To reduce retraumatization of patients, it is imperative to use trauma-informed approaches in a clinical encounter. Screening is an effective way to understand a patient's trauma history. When screening for trauma, it is important to take a family-centered approach and provide appropriate referrals if a patient screens positive for trauma. Primary care providers are essential players in addressing and preventing trauma.

Differences in trauma-informed care implementation by clinic-level factors across Ryan White HIV clinics in the Southeastern United States

Trauma is common among people with HIV (PWH) and associated with low HIV care engagement, thus trauma-informed care (TIC) integration within HIV services is critical. From December 2019 to April 2020, we conducted surveys with 321 administrators, providers, and staff of 46 Ryan White HIV clinics (RWCs) in 8 Southeastern U.S. states to assess level of TIC implementation and clinic-level factors associated with TIC adoption. The mean score for TIC implementation was highest for the Physical Environment domain (μ = 4.08, SE = 0.07), followed by Screening, Assessment, and Treatment Services (μ = 3.96, SE = 0.07), Cross-sector Collaboration (μ = 3.75, SE = 0.08), Engagement and Involvement (μ = 3.92, SE = 0.09); and Training and Workforce Development (μ = 3.54, SE = 0.12). Greatest gaps were in staff TIC training, staff support, presence of onsite legal, spiritual, and housing services, and seeking patients' definitions of safety and developing their individualized crisis/safety plans. Across most TIC implementation domains, clinic type, urbanicity, academic affiliation, and presence of onsite psychosocial support services were associated with level of TIC adoption. Thus, RWCs have the necessary foundation to integrate TIC practices, but further progress will require addressing identified gaps. The overall lack of significant difference in TIC implementation across domains by clinic-level factors suggests that a RW network-wide approach to enhancing TIC integration is feasible.