Identifying and supporting trafficked individuals: provider and community organization perspectives on existing sociotechnical approaches.

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. 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. 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. 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.

BackgroundPeople's trust in health care and health care professionals is essential for the effectiveness of health care, especially for chronically ill people, since chronic diseases are by definition (partly) incurable. Therefore, it may be understandable that chronically ill people turn to complementary and alternative medicine (CAM), often in addition to regular care. Chronically ill people use CAM two to five times more often than non-chronically ill people. The trust of chronically ill people in health care and health care professionals and the relationship of this with CAM use have not been reported until now. In this study, we examine the influence of chronically ill people's trust in health care and health care professionals on CAM use.MethodsThe present sample comprises respondents of the 'Panel of Patients with Chronic Diseases' (PPCD). Patients (≥25 years) were selected by GPs. A total of 1,625 chronically ill people were included. Trust and CAM use was measured by a written questionnaire. Statistical analyses were t tests for independent samples, Chi-square and one-way analysis of variance, and logistic regression analysis.ResultsChronically ill people have a relatively low level of trust in future health care. They trust certified alternative practitioners less than regular health care professionals, and non-certified alternative practitioners less still. The less trust patients have in future health care, the more they will be inclined to use CAM, when controlling for socio-demographic and disease characteristics.ConclusionTrust in future health care is a significant predictor of CAM use. Chronically ill people's use of CAM may increase in the near future. Health policy makers should, therefore, be alert to the quality of practising alternative practitioners, for example by insisting on professional certification. Equally, good quality may increase people's trust in public health care.

Understanding Trauma-Informed Care in the PALTC Setting

ABSTRACTSome 21 million adults and children are labor-trafficked or sex-trafficked through force, fraud, or coercion. In recognition of the interface between trafficking victims and the healthcare setting, over the last 10 years there has been a notable increase in training of health care professionals (HCPs) on human trafficking (HT) and its health implications. Many organizations have developed curricula and offered training in various clinical settings. However, methods and content of this education on trafficking vary widely, and there is little evaluation of the impact of the training. The goal of this study was to assess the gaps and strengths in HT education of HCPs in the US. This mixed-method study had two components. The first component consisted of structured interviews with experts in human trafficking HCP education. The second portion of the study involved an analysis of data from HCP calls to the National Human Trafficking Resource Center (NHTRC). The interviews captured trainer-specific data on types of HT training, duration and frequency, key content areas, presence of evaluation approaches and indicators, as well as an assessment of barriers and strengths in HT training for HCP. NHTRC call database analysis demonstrated increasing trends since 2008 in calls by HCPs. Overall findings revealed the need for standardization of HT training content to assure correct information, trauma-informed and patient-centered care, and consistent messaging for HCPs. Evaluation metrics for HT training need to be developed to demonstrate behavior change and impact on service delivery and patient-centered outcomes for HT victims, according to our proposed adapted Kirkpatrick’s Pyramid model. HT training and evaluation would benefit from an agency or institution at the national level to provide consistency and standardization of HT training content as well as to guide a process that would develop metrics for evaluation and the building of an evidence base.Abbreviations: AAP: American Academy of Pediatrics; ACF: Administration for Children and Families; CME: Continuing medical education; ED: Emergency department; HCP: Health care professional; HEAL: Health, Education, Advocacy, and Linkage; HHS: United States Department of Health and Human Services; HT: Human trafficking; IOM: United States Institute of Medicine; MH: Mental health; NHTRC: National Human Trafficking Resource Center; SOAR: Stop, Observe, Ask, and Respond to Health and Wellness Training

Minority and non-minority patients in the United States have different levels of trust in health care; however, few studies have examined how determinants of trust and distrust in health care vary across diverse groups. To explore how trust in health care institutions varies across diverse populations. We conducted 17 focus groups with 117 participants in Chicago: 9 with African American, 5 with Hispanic, and 3 with white participants. Discussions were audiotaped, transcribed verbatim and coded using grounded theory analysis to identify dominant themes. We found a core set of factors that contribute to trust and distrust across racial/ethnic groups. In addition, there were unique factors that contributed to distrust among African Americans and Hispanics. Both of these groups discussed expectations of discrimination in the health care setting and African Americans discussed expectations of being experimented on as determinants of distrust. Based on these findings, we developed a hypothetical model of how different factors influence trust and distrust in health care across these different racial/ethnic groups. Contributors to trust and distrust in health care institutions are not always uniform across racial/ethnic groups. These differences should be addressed in future research and efforts to enhance trust in health care institutions.

ObjectivesMost people who have experienced sexual violence (SV) will disclose the event(s) to someone. Key recipients of disclosure are those working in healthcare. Telling someone in healthcare about experiences of...

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

AimsThis pilot study addresses the implementation of trauma-informed practice within healthcare settings. Given the profound impact of trauma on individuals’ health and well-being, there's an increasing recognition of the importance of integrating trauma-informed care into healthcare systems. This project aims to evaluate and enhance healthcare professionals' understanding, awareness, and confidence in implementing trauma-informed practices through targeted interventions.MethodsThe project initiated with a baseline assessment through surveys among healthcare professionals to gauge their initial understanding, awareness, and confidence levels in applying trauma-informed practices in their work environments (n = 9). Subsequently, a structured teaching session was conducted to provide education and training on trauma-informed care. Post-session, a reassessment survey measured improvements in awareness, understanding, and confidence levels (n = 5).Following this, a visual aid – a comprehensive poster summarizing key aspects of trauma-informed practice – was created and displayed prominently in healthcare settings. A second cycle of the quality improvement initiative was undertaken, measuring outcomes after the implementation of the poster. Surveys were administered again to evaluate the impact of the visual aid on sustaining and further enhancing healthcare professionals’ adherence to trauma-informed practices (n = 3).ResultsPost-teaching session assessments demonstrated a notable improvement in levels of awareness (44%), and confidence (56%) among healthcare professionals regarding trauma-informed practices, as well as recognition of signs & symptoms of trauma (44%). Subsequent to the poster's introduction, the second cycle of assessments showcased sustained levels of awareness, understanding, and confidence among the participants.ConclusionThe project underscores the effectiveness of targeted interventions – educational sessions and visual aids – in augmenting healthcare professionals’ understanding, awareness, and confidence in implementing trauma-informed practices. The improvement in these metrics post-interventions emphasizes the value of ongoing education and visual support tools in fostering a trauma-informed approach within healthcare settings. Embedding such practices can significantly impact patient care, fostering a more supportive and empathetic environment for individuals affected by trauma.

Trauma informed care (TIC) is an important approach for people who have experienced trauma. Although psychological first aid (PFA) may be effective training in TIC, no study reported an association between PFA training and TIC. This study aimed to investigate the association between PFA training and attitudes toward TIC among health care professionals in Japan. Japanese health care professionals were recruited for a survey conducted from May 21 to June 18, 2021. TIC was assessed by the Attitudes Related to Trauma Informed Care Scale 10-item short form (ARTIC-10). A question about PFA training participation was originally developed through discussion among researchers. Univariate and multiple linear regression analyses were used to examine the association between the PFA experience and ARTIC-10. In total, 484 (3.6%) health care professionals completed all questions. Among them, 77 (15.9%) had experienced PFA training. Univariate and multiple linear regression analyses showed that PFA experience (B = 0.19, 95% CI: 0.02-0.36, P = 0.03; B = 0.17, 95% CI: 0.01-0.34, P = 0.04) was significantly associated with ARTIC-10. This study was the first to show an association between PFA training and attitudes toward TIC among health care professionals, which was a significant result for future research on PFA training, TIC, and trauma care.

Multi-level prevention of human trafficking: The role of health care professionals

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Information is a key issue for people who use health services and their families and friends. In the UK, this was raised consistently by those involved in a national ‘listening exercise’, in 2005.1 The resulting White Paper Our Health, Our Care Our Say2 reinforced much of the government information strategy published in the previous year.3 The Brain and Spine Foundation is a UK-based charity that aims to improve the quality of life for people with neurological conditions (http://www.brainandspine.org.uk). The organization was awarded a grant by the Department of Health to produce a toolkit to help health and social care professionals providing information to people affected by neurological conditions. The project forms part of the implementation of The National Service Framework (NSF) for Long-term Conditions, published last year.4 The toolkit is being developed in association with the Neurological Alliance (http://www.neural.org.uk) and the Long-term Medical Conditions Alliance (LMCA; http://www.LMCA.org.uk). A series of small discussion groups were held last year throughout England and Wales to explore: (i) current obstacles in the provision of and access to information, (ii) how a toolkit might be used and (iii) to refine the toolkit's content and shape. Discussions were held with groups of people affected by neurological conditions, with voluntary sector organizations concerned with neurological conditions and with mixed groups of health and social care professionals from a variety of settings. In addition, a questionnaire survey of health and social care professionals was conducted. Care for people with neurological conditions in the UK has been very patchy. While there are some world-class centres of expertise, there are also areas of the country where there is little specialist provision.5 Traditionally, for people with neurological conditions, the majority of input has been provided by specialists (e.g. neurologists and rehabilitation consultants). However, because of shortages in these workforces, and the long-term nature of many of the conditions, people have often been left without specialist support. Access to information has become a major issue for these people who may have little contact with health and social care professionals after initial diagnosis of their condition. This is consistently reported both by individuals affected by neurological conditions as well as organizations representing them.5 A key issue explored in developing the toolkit relates to why people do not get the information they want, despite much information apparently being available, and from a proliferation of sources. Two explanations were found. First, information provided by health professionals does not always match with the information sought after by people with neurological, and other long-term conditions. Secondly, people often want very local information, whereas what is generally available is not specific to their geographical location or situation. These issues are explored further below. Another issue that became evident was that health and social care professionals did not always recognize their role in relation to providing information to people with whom they came into contact. There is a need to encourage health-care professionals to view every consultation as an opportunity to assess information needs and ensure that these are met directly or by referral to a dependable alternative source. The toolkit will, therefore, aim to signpost to sources of information on the issues of concern to people with neurological conditions. It was found that there are four key areas consistently identified by people affected by neurological conditions where they want more information. Interestingly, the groups of health and social care professionals consulted also identified these issues as a problem area for information giving. The lack of information related to benefits, employment and finance was an issue raised repeatedly by people with neurological conditions when they discussed information. When asked what information requests they found difficult to address, health professionals also identified information about benefits. This is not a new issue and surveys from the neurological charities have been reporting this for years.6 It is possible that the reason this issue has not been addressed is that health professionals do not see such issues as within their remit. These ‘social care issues’ are often seen as being the province of those working outside health-care settings. There may be a tendency to see people with a diagnosis of a long-term condition as having a continuum of needs; starting with medical needs, and medical information needs, at the diagnostic phase and progressing to ‘social’ needs later on as someone adapts to their illness or disability, and particularly if it progresses/degenerates. However, when people with neurological conditions talk about their information needs, it is clear that some of their first concerns on diagnosis are their employment and financial status –Should I go back to work tomorrow? What should I tell my employer? If I leave work how will I support myself and my family? What support will my partner get if they need to look after me? Should I move house? The health professional is more likely at this time to be focused on providing information about possible treatment options or a drug regime. Concerns about sex and relationship issues were often raised (even in focus groups where people who did not know each other). People had found information on sources of support very hard to access. Health and social care professionals were similarly at a loss to know where to go for such information. There seemed to be a tendency to hope the questions were not asked and very few health-care professionals said that they would ever raise the issue as they would not know how to deal with this or whom to refer to. This is a significant quality of life issue for people affected by many neurological, and other long-term conditions, including cancer. There is a need to address it and ensure that health and social care professionals are signposted to sources of information and advice. Complementary therapies have played a large part in the management of neurological conditions, partly because of the fact that there are often very few surgical or drug treatments available. Many health professionals find it difficult to provide information about treatments that they feel do not have a robust evidence base and that have not been traditionally available in the National Health Service (NHS). While for some conditions this is changing, it is likely that people with a life-long illness for which there is no cure will continue to seek both ‘wonder cures’ and palliative treatments. Using the toolkit health professionals will be able to signpost people to information about various complementary therapies and information about which therapies people with a similar condition have found helpful. This kind of information is often available through local and national voluntary sector organizations. Providing a diagnosis and prognosis is clearly within the domain of health-care professionals, yet all agree it is a difficult area to address. People affected by neurological conditions often report that they do not get adequate information about what to expect. Again this possibly stems from the fact that there was, and still is for many, very little that can be offered in the way of treatment and cure. Neurological conditions can also be very unpredictable. If health-care professionals view their domain as providing information about treatment options and medicines there may well be limited information they can give. There are, however, as outlined above, a range of other information needs that people with neurological conditions have at diagnosis. If these needs are addressed it is likely both that people would feel more able to manage their condition and also report that their information needs had been met. The information people often valued the most, and which they found hard to access, was about local services and sources of support. For example, people talked about finding someone who could help them fill in their benefit form, the local rehabilitation service that accepted self-referrals, the MS support group that met two streets away, yet had taken 18 months to discover. Addressing local information presents a challenge for a toolkit that has been designed for health and social care professionals across England and which will necessarily be focused at a countrywide level. As noted above, however, this is a crucial finding of the work conducted with people affected by neurological conditions. Those working on the Better Information3 strategy also identified the need for local information and the Department of Health has recently announced their intention to pilot a local integrated approach to information in order that local health and social care organizations jointly maintain an accessible database of all services and support groups in their local area.2 The project will provide a template for local information in the toolkit outlining what information should be available, based on issues that people affected by neurological conditions have raised as information needs, and indicating possible local sources of information and support locally. The ground work will necessarily be conducted at a local level, but it is hoped by providing a template and sources list we will avert excessive duplication of effort, whilst ensuring that the content of local directories and databases are focused on the needs of people affected by neurological conditions. In addition, it will be very important to ensure local voluntary organizations supporting and representing people with neurological conditions are involved in commissioning local information databases. This will be essential; to ensure firstly that the resource is focused on local needs; secondly, that the very valuable services and support provided by voluntary sector groups are included and thirdly, because of the local knowledge they have about sources of health and social care support in its widest sense. Often, during the discussions with people affected by neurological conditions, they talked about eventually tracking down the information, or service or person, through contact with a local support group or voluntary organization. For example, if you wanted to know who could help you fill out a benefit form, how to get a wheelchair, where to get hydrotherapy, who to talk to about a relationship problem the local branch of the Parkinson's Disease Society or MS Society would be a very good starting point. At national level, voluntary sector organizations produce the information often reported to be the most useful by people affected by neurological conditions. Most include in their information portfolios fact sheets and booklets about the issues raised above (complementary therapies, sex and relationships, prognosis, benefits) and about many other aspects of living with a neurological condition. There is reluctance, however, amongst health and social care professionals to provide information about these organizations to people affected by neurological conditions. A survey by the Motor Neurone Disease Association7 in 2002 found that 44% of people diagnosed with motor neurone disease that year had not been told of the Association or given contact details. In the discussions to develop the toolkit people often reported stumbling on a local or national voluntary organization ‘by accident’. The toolkit will need to make it easier for health professionals to signpost to these sources of information and support. Health professionals may feel better assured about directing people to voluntary sector sources of information if they could guarantee the quality. The Department of Health have also recently announced the intention to develop an Information Accreditation Scheme (IAS).3 It will be very important that voluntary sector providers of information are enabled to participate in this scheme in order that they can continue to disseminate the information that people affected by neurological, and other long-term conditions find so useful. A pilot version of the toolkit is currently being produced. This will be a signposting tool with generic checklists and templates. It is anticipated there will be a launch towards the end of 2006. Nikki Joule is an independent health policy consultant and Project Officer at the Brain and Spine Foundation (http://www.brainandspine.org.uk). She is also on the Steering Group of the Patient Information Forum (http://www.pifonline.org.uk).

Recent progress in understanding the lifelong effects of early childhood adversities has clarified the need for an organized strategy to identify and intervene with children, adolescents, and families who may be at risk for maladaptive responses. Trauma-informed care (TIC) in child health care operationalizes the biological evidence of toxic stress with the insights of attachment and resilience to enhance health care delivery to mitigate the effects of trauma. The resulting pediatric health care delivery strategy promotes and restores resilience in children and adolescents, partners with families to support relational health, and reduces secondary trauma among pediatric health care clinicians. This policy statement summarizes what policy makers, legislators, and health care organizations need to consider in terms of infrastructure, resources, and financial support to facilitate the integration of TIC principles into all pediatric points of care. The accompanying clinical report describes the elements of TIC in the direct care of children, adolescents, and families and covers the spectrum from prevention to treatment. The recommendations in this statement and the clinical report build on other American Academy of Pediatrics policies that address the needs of special populations (such as children and adolescents in foster or kinship care, in immigrant and refugee families, or in poor or homeless families) and are congruent with American Academy of Pediatrics policies and technical reports concerning the role of pediatric clinicians in the promotion of lifelong health.Over the past 2 decades, basic science has explained how cumulative adverse childhood experiences in the relative absence of safe, stable, nurturing relationships (SSNRs)1 alter neurohormonal stress responses, gene expression, telomere length, brain development, and immunity, enabling researchers to elucidate how the body biologically embeds childhood trauma. Recent studies of toxic stress support assertions that the origins of lifelong health are in early childhood and that chronic stress in childhood strongly predicts adult health status.2,3 In the context of expanding evidence, pediatricians and others involved in community-based early childhood systems need strategies to mitigate the damaging effects of early childhood trauma and to promote resilience in children and families. Trauma-informed care (TIC) offers an organizing principle for pediatric practice that improves awareness of the spectrum of trauma-related symptoms, promotes an emotionally safe environment of care, and provides specific interventions to mitigate the effects of trauma exposure.4,5 This policy statement presents recommendations for policy makers, legislators, and health care organizations for implementation of TIC into pediatric health systems. The accompanying clinical report6 presents best-practice guidance for TIC in the direct care of children and adolescents.TIC is defined by the National Child Traumatic Stress Network as medical care in which all parties involved assess, recognize, and respond to the effects of traumatic stress on children, caregivers, and health care providers. TIC also includes attention to secondary traumatic stress (STS), the emotional strain that results when an individual, whether a health care worker or parent, hears about or witnesses the traumatic experiences, past or present, of children.Every pediatric encounter presents opportunities to promote family resilience and relational health.7 Informed by research in infant mental health and neurodevelopment, early relational health refers to the establishment of foundational relationships during the first 3 years of life that are central to successful physiologic, emotional, and moral development of the young child.8 Relational health, in a more general sense, is applicable to all age groups, is dyadic, and includes the capacity of both the child and caregiver to enter into a safe, secure, nurturing relationship allowing both to thrive.1,9,10 Strong foundational relationships support resilience and buffer stress in children, so they can be considered primary prevention of stress-related disturbance. Trauma-informed practices also support relational health and family resilience as important protective factors for those who have been exposed to persistent adversity or potentially traumatic events (see Fig 1).Human neuroendocrine–immune networks respond to internal and external sensors that identify danger and safety by activating in dangerous circumstances and deactivating when danger has subsided.11 Toxic stress responses occur with prolonged activation of the neuroendocrine–immune system and dysregulation of homeostasis (or allostasis if multiple systems are involved)12 in the absence of buffering by SSNRs. Toxic stress responses can result in lifelong impairments in physical, mental, and relational health.13The concept of toxic stress adds an important physiologic basis to the study of attachment and our understanding of trauma. Trauma is defined as an event, series of events, or circumstances experienced by a person as physically or emotionally harmful that can have long-lasting adverse effects on the person’s functioning and well-being (emotional, physical, or spiritual).14 Attachment theory describes the deep and enduring relationship between a child and adult caregiver that ideally provides a secure base from which the child can develop and explore the world.15Resilience is the dynamic process of adaptation to or despite significant adversity by using protective factors and learned skills to manage stressful circumstances.16 Resilience may allow a person to experience tolerable rather than toxic stress in response to adversity. Some characteristics of resilient children include strong executive functions (self-control of attention and impulses) and a strong personal identity, often related to a cultural or faith tradition.17 However, most important to both resilience and relational health is the capacity for young children to form at least one stable, caring, and supportive relationship.9,18Almost half of American children, or 34 million younger than 18 years, have faced at least one potentially traumatic early childhood experience.19 More than 1 in 7 adults report exposure during childhood to 4 or more adverse childhood experiences such as abuse, neglect, or other household adversity,20 including intimate partner violence or parental incarceration. Certain populations are at higher risk for trauma exposure, both physical and emotional. In surveys, poverty or financial stress is the most commonly reported childhood adversity, second only to loss of a parent.21,22 Exposure to divorce, child maltreatment, sexual abuse, intimate partner violence, bullying, parental mental illness, parental substance use problems, and community violence are also common.21 Specific populations at high risk for trauma include children and adolescents who identify as LGBTQ, have developmental or behavioral problems,23–25 are in foster or kinship care, are incarcerated, are living in deep poverty, or are immigrants. Potentially traumatic environmental and community-level conditions include economic stress, school or community violence, adverse experiences during and after immigration, natural disasters, pandemics, and mass-casualty events such as shootings or bombings.Racism is a common cross-cutting risk factor. Racial, ethnic, or religious bigotry magnifies the risk inherent to other special populations.26 Experiences ranging from hate crimes, police profiling, bullying, or microaggressions to covert discrimination are traumatic events and may be internalized as trauma by those who are victims, indirectly or directly, of the events.27,28 Historical trauma refers to the collective, transgenerational emotional and psychological injury of specific ethnic, racial, or cultural groups and their descendants who have experienced major events of oppression such as genocide, forced displacement, or slavery.29,30 Originally applied to children of the Holocaust, the concept is now applied to American Indian and Alaskan native people, African American people, Mexican American people, Japanese American people, and other groups of people who have experienced mass trauma.30 Investigators link historical “soul wounding” to current health and behavioral disorders including substance use disorder, domestic violence, and suicide, particularly in Indigenous communities.29,31 Children separated from families during immigration and/or detained in group facilities overseen by the Office of Refugee Resettlement are a recent special population at severe risk for long-term sequelae resulting from forced family separation.32,33In November 2019, the Centers for Disease Control and Prevention reviewed the emerging literature linking early childhood adversity with adult illnesses20,34 and analyzed survey data from 25 states over 2 years.3,35 Researchers concluded that reducing exposure to early childhood trauma and mitigating posttrauma effects would generally and significantly reduce adult morbidity and mortality. Using logistic regression modeling, they estimated potential reductions in incidence from low for obesity (1.7%) to high for heavy drinking, chronic obstructive pulmonary disease, and depression (23.9%, 27.0%, and 44.1%, respectively). Recommendations included creating healthy communities, supporting SSNRs, and developing programs that apply primary (reducing exposure to childhood adversity) and secondary prevention (mitigating the effects of exposure) on the basis of principles of TIC.The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) presents a list of trauma-related disorders ranging from mild (adjustment disorder) to severe (posttraumatic stress disorder [PTSD]).36 Two additional categories, reactive attachment disorder and disinhibited social engagement disorder, are specific to young children (please see the DSM-5 for complete diagnostic criteria). This nosology can be expanded to describe other presentations common in pediatric health care settings: developmental trauma disorder (DTD), pediatric medical traumatic stress (PMTS), and STS, the last being most relevant for health care workers, family members, and caregivers.The diagnosis of PTSD, as outlined in the current DSM-5, does not adequately describe the variable presentations of trauma manifestations in children across developmental stages.37 Children with complex trauma histories often exhibit heterogeneous developmental symptoms as well as difficulties with intimate relationships and with regulation of attention and impulse control.38 DTD is a proposed new diagnostic category that incorporates these differences and attempts to better describe the disturbances that occur in multiple developmental domains.39 The omission of DTD in the DSM-5 has been controversial,40 and the search for a better nosology of trauma, including DTD, is ongoing.41PMTS refers to the distress that patients and family members experience during hospitalization for a perceived life-threatening diagnosis or while living with or caring for individuals with life-altering chronic conditions.42 PMTS is underrecognized and rarely addressed despite its high prevalence.43,44 Up to 80% of ill or injured children and their families may have traumatic stress reactions after a life-threatening illness, injury, or procedure.45 In some surveys, up to 20% of parents of children admitted to a PICU develop PTSD within a few months.45 The suffering of family members and caregivers is often not addressed because of existing structural and reimbursement obstacles for multigenerational care.Although research on PMTS (and on pediatric postintensive care syndrome)46,47 is ongoing, researchers in 1 study found that approximately 10% of children developed PTSD 3 to 5 months after major surgery, and 28% developed posttraumatic stress symptoms (PTSS) resulting in functional disability by parent report.48 PTSS can also occur after a severe injury or diagnosis of an illness such as cancer. In another family study, more than 10% of children had persistent functional impairment from PTSS at 6 weeks and 1 year after a potentially life-threatening injury or diagnosis, and 15% of mothers and 8% of fathers met criteria for PTSD at 1 year.49As described earlier, STS may occur in parents, other family members, and health care workers such as physicians, nurses, other hospital staff, first responders, and therapists. STS may have many of the same long-term effects on health that affect children exposed to trauma.50 Some health care workers may also develop disabling posttrauma symptoms that can interfere with quality of life both at work and home. Health care workers may have their own trauma histories that contribute to their reactions when exposed to the suffering of others. Nonclinical staff may also experience STS triggered by their own trauma histories, especially if the health care facility is located in an area with high adversity and nonclinical staff live in the vicinity.Preliminary evidence exists of a synergistic effect among STS, depression, and burnout in affected health care workers.51 STS in combination with burnout has been associated with a significant increase in the frequency of medical errors.52,53 Depression, anxiety, and suicide are greater risks for physicians than for the general population. In the United States, the rate of suicide among female physicians is 130% higher than among women who are not physicians; the rate for male physicians is 40% higher than for men who are not physicians.51 Burnout includes a spectrum of pathologic conditions that develop in the context of occupational stress and is almost twice as prevalent among physicians. The risk among nurses for burnout, depression, and STS is even higher. More than half of nurses reported suboptimal mental or physical health,54 approximately 35% reported a high degree of emotional exhaustion,55 and 18% reported depression in national surveys. Reports of posttraumatic stress among health care workers related to the coronavirus disease 2019 pandemic prompted worldwide concern for increased awareness and trauma-informed support for the mental health of all involved.56Core principles that can be helpful for policy development, outlined by the National Council on Behavioral Health (2019)57 are outlined in the following sections. Implementation of TIC at a practice level is described in detail in the accompanying clinical report.6The health care organization, workspace, and every encounter should be characterized by compassion, cultural humility, equity, collaboration, and safety for families and employees. An emotionally safe workplace includes acknowledgment of and particular attention to racial and gender discrimination, including implicit bias both in rendering care and workplace human relations. A review of health care settings from the viewpoints of patients, families, and staff can uncover practices, processes, or details in the environment that are potentially traumatizing.Hospital and health system leadership can annually review policies and procedures to ensure a safe work environment and setting to provide TIC, to reduce STS and burnout, and to promote sensitivity to the needs of trauma survivors.58 The alignment of financial and human capital resources to support an optimal health environment in all levels and locations of care is extremely important. Surveys designed to assess system readiness for implementation are available and can be adapted for pediatric health care settings.Surveillance and standardized screening to assess staff and patients for trauma exposure, symptoms, and strengths are important components of trauma-informed pediatric care. Universal screening, when implemented within the larger context of trauma-informed approaches and endorsed and supported by administrative leadership, reduces stigma and allows standardized responses such as time off or referral to an employee assistance program. Families and youth may be queried at the point of care, such as at the time of hospital admission. Formal screening should always be for the benefit of children and adolescents, avoid retraumatization, and identify protective as well as risk factors.59 More specific information about screening is included in the accompanying clinical report.6Involvement of families and youth in the development of TIC policies and practices, particularly regarding cultural, historical, and gender issues, is essential to building an environment of support and mutuality.14 Both formal and informal structures, such as Family Advisory Councils and family-centered rounds,60 create a cultural expectation of collaboration and enable the health care team to understand the strengths and vulnerabilities of individual families and of the populations served. When appropriate, tribal elders, traditional healers, and other faith community leaders can be included in developing individual care plans or institutional quality-improvement efforts. A whole-person, whole-family, whole-community perspective promotes improved awareness of how cultural backgrounds affect the perception of trauma, safety, and privacy.61,62TIC, from a public health perspective, includes primary, secondary, and tertiary prevention strategies. Primary prevention is a comprehensive approach that addresses social determinants of health (such as structural racism, poverty, and violence) that are often root causes of community trauma.63 Promotion of relational health and other resilience factors (such as strong executive function and self-efficacy) may be considered primary prevention.64 Following the fourth edition of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, promotion of early childhood relational health is a core purpose of both pediatric primary care and early childhood education.65The National Child Traumatic Stress Network includes the promotion of child and family resilience, enhancement of protective factors, awareness of parent or caregiver trauma, and involvement of families in program development and evaluation as secondary prevention.66 Trauma-informed therapies (eg, trauma-focused cognitive behavioral therapy) for symptomatic children and youth are considered tertiary prevention. These therapies are especially important for high-risk populations as identified earlier.67–70 Attachment-based dyadic therapies, such as parent–child interaction therapy, may serve to prevent development of persistent traumatic stress symptoms in high-risk families71 and may be considered both secondary and tertiary prevention.Recruitment and pre-employment practices may help discern the capacity for empathy among prospective employees.72 Training and education of all administrators, clinicians, and staff, both clinical and nonclinical, can promote the appreciation of the lifelong effects of trauma on child and adolescent development and family resilience and the implementation of trauma-aware practices. Continuous quality-improvement programs translate new knowledge and skills about childhood trauma into supervision, training, and patient care.Prevention of STS requires specific training of all staff to raise awareness, promote resilience, and explore the interaction among STS, burnout, depression, substance use, and professional quality of life. Supportive supervision and peer mentoring offer opportunities for all employees to reflect on their own trauma histories and to promote compassion, nonjudgmental attitudes and collaboration.73Trauma-informed health care systems establish and support collaborative, interdisciplinary relationships among community and public health agencies that serve children and adolescents to coordinate care for children, adolescents, and families exposed to trauma. Schools,74 juvenile justice programs,75 mental health professionals,76 home visiting services, child welfare systems,76 and foster care agencies77 are natural partners for pediatric health organizations in promoting community resilience. Many have established TIC programs. Community early intervention programs can help prevent and mitigate adversity and often have the advantage of caring for young children in their natural environment as home visitors.78–80Federal agencies such as the Centers for Disease Control and Prevention can continue and expand research to improve understanding of the developmental effects of trauma and the efficacy of specific interventions for historically resilient populations. Urgently needed are successful strategies to interrupt the intergenerational transfer of family violence. Strategies are also crucial to blunt the impact of historical trauma in communities of color and in American Indian and Alaskan native populations in the United States.30 It is particularly important to identify the origins of and successfully mitigate community violence, including racism, misogyny, and religious, ethnic, and cultural bias.State-level resources can be directed to implementation, dissemination, and evaluation of trauma-informed community programs, such as interagency and multigenerational strategies for opioid dependency. One example of a state interagency, multigenerational treatment program is Ohio START (Sobriety, Treatment and Reducing Trauma).81 States could develop a communication infrastructure to facilitate data sharing, improve interdisciplinary/interagency cooperation, and engage community partners including foundations and academic institutions.Federal guidelines can require that state Medicaid programs ensure comprehensive coverage for all children and adolescents and pregnant mothers without regard for legal or immigration status and mandate that coverage include mental health and substance use disorder services. Financing that increases access to high-quality, comprehensive, coordinated, culturally competent health care for high-risk populations is a high priority. Federal and state regulations can require all insurers, including Medicaid and private health insurers, to include coverage for TIC elements, including surveillance, screening, diagnosis, counseling, case management, follow-up, community collaboration, mental health care, and home visiting.In large health systems, leadership can align its mission and financing with the core elements of trauma-informed systems.82 Supporting TIC includes payment for trauma-informed, integrated mental health services, care coordination, rigorous case management, and seamless referral networks for intensive treatment. Prevention of secondary trauma, including care of affected health care workers, should be built into the mission of the health system.Academic health centers train and educate the next generation of physicians, nurses, and ancillary health personnel and can promote the transformation to TIC in all health settings through education, research, and advocacy. Children’s hospitals and health systems can model mental health integration83 and trauma-informed practices throughout all service lines.84 Because children’s hospitals embrace population health management and community advocacy, they may serve as the anchor institution collaborating with community agencies to address social adversity at the neighborhood level while promoting TIC services.85 Together with community pediatric care systems, academic health centers and children’s hospitals can integrate core elements of education into workforce training for health care workers and community partners such as first responders, child welfare workers, teachers, and juvenile justice personnel.86,87Deborah L. Shropshire, MD, FAAP

Understanding the meaning of trauma-informed care for burns health care professionals in a pediatric hospital: A qualitative study using interpretive phenomenological analysis

The use of Artificial Intelligence (AI) in healthcare is growing quickly and offers big improvements in medical diagnostics, treatment planning, and patient care. However, people often don't trust AI systems, which prevents them from being widely used. This article looks at both the philosophical and practical issues of trust in healthcare AI systems. First, we provide an overview of the current state of AI in healthcare. Then, we review existing research on trust in technology. Based on our findings, we identify three main factors that affect trust in AI: Technology-Related Factors (transparency, reliability, safety), Healthcare Context Factors (how well AI fits into healthcare settings, proper training for professionals), and Individual User Factors (user experience and attitudes toward AI). Our results show that continuous human oversight, strong regulations, and ethical considerations are essential. Addressing these areas is key to making sure AI systems in healthcare are reliable, transparent, and trusted by both healthcare professionals and patients.