Development and Validation of a Trauma-Informed Care Communication Skills Assessment Tool.

BACKGROUND: Trauma-informed care (TIC) is growing in medical education as healthcare systems recognize trauma's impact on health outcomes. TIC acknowledges and responds to the effects of trauma on physical, psychological, and emotional health. As TIC trainings are developed and delivered to healthcare professionals across the learner continuum, curricula need evaluation beyond learner satisfaction and knowledge to better assess changes in skills. We developed the Gap Kalamazoo Communication Skills Assessment Form for Trauma-Informed Care (GKCSAF-TIC) to evaluate pediatric trainees' communication skills in TIC. OBJECTIVE: Describe the development and validity evidence of the GKCSAF-TIC in assessing pediatric residents' TIC skills during standardized patient encounters. METHODS: We developed and implemented the TIC communication skills assessment tool in a one-year prospective cohort study involving pediatric residents. We conducted simulated patient encounters conducted before and after TIC training, with two pediatric faculty attendings assessing each encounter. We gathered validity evidence using Messick's framework, focusing on content, response process, internal structure, and relationship with other variables. RESULTS: We analyzed 57 standardized patient encounters with 33 pediatric interns, including 23 pre-post matched pairs. The development process and rater training supported content and response process validity. Internal consistency, measured by Cronbach's alpha, ranged from 0.93 to 0.96, while inter-rater reliability, measured by intraclass correlations, ranged from 0.80 to 0.83. There was a significant improvement in scores from pre-training to post-training (3.7/5 to 4.05/5; p < 0.05). CONCLUSION: The GKCSAF-TIC demonstrated strong preliminary validity and offers educators a valuable means to assess and provide formative feedback to pediatric trainees about TIC. WHAT'S NEW?: Pediatric trainees are learning about trauma-informed care and need formative feedback on their practice of TIC in the clinical setting. The GKCSAF-TIC can be used to evaluate and provide formative feedback to trainees about their communication skills in providing trauma-informed care.

Pediatric Approach to Trauma Treatment and Resilience-A Novel Relationship-Based Curriculum and Approach to Train Pediatric Professionals to Provide Trauma-Informed Care.

Information and techniques from evidence-based, trauma-informed mental health treatments, resilience and parenting literature and supporting evidence from neuroscience were adapted to provide pediatricians a practical approach and tools to promote resilience and respond to trauma symptoms.

Trauma-Informed Care.

Most children will experience some type of trauma during childhood, and many children suffer from significant adversities. Research in genetics, neuroscience, and epidemiology all provide evidence that these experiences have effects at the molecular, cellular, and organ level, with consequences on physical, emotional, developmental, and behavioral health across the life span. Trauma-informed care translates that science to inform and improve pediatric care and outcomes. To practically address trauma and promote resilience, pediatric clinicians need tools to assess childhood trauma and adversity experiences as well as practical guidance, resources, and interventions. In this clinical report, we summarize current, practical advice for rendering trauma-informed care across varied medical settings.

The Relationship Between Adverse Childhood Experiences and Weight-Related Health Behaviors in a National Sample of Children.

OBJECTIVE: To examine how adverse childhood experiences (ACEs) relate to healthy weight behaviors in children. METHODS: We examined data from the 2016 National Survey of Children's Health. ACE scores were calculated from 6 measures of household dysfunction. Outcome measures included 5 healthy weight behaviors. Logistic regression models assessed associations between ACEs and healthy weight behaviors controlling for sociodemographic variables. RESULTS: Children 6 to 17 years of age (n = 32,528) with 0 ACEs had increased odds of: watching 2 hours or less of television daily (6-12 years: odds ratio [OR] 1.46; 95% confidence interval [CI], 1.20-1.80, 13-17 years: OR 1.64; 95% CI, 1.39-1.94), using electronics for 2 hours or less daily (6-12 years: OR 1.44; 95% CI, 1.15-1.80, 13-17 years: OR 1.86; 95% CI, 1.60-2.16), sharing 4 or more family meals per week (6-12 years: OR 1.39; 95% CI, 1.17-1.66, 13-17 years: OR 1.68; 95% CI, 1.44-1.95), and getting adequate age-specific sleep (6-12 years: OR 1.50; 95% CI, 1.26-1.79, 13-17 years: OR 1.31; 95% CI, 1.11-1.55) when compared to children with one or more ACEs. Children 13 to 17 years of age with 0 ACEs had increased odds of exercising for 60 minutes daily (OR 1.27; 95% CI, 1.02-1.58) when compared to children with one or more ACEs. There was an overall gradient dose pattern; the odds of engaging in a healthy weight behavior decreased as the number of ACEs increased, with mixed significance levels. CONCLUSIONS: In children, ACE exposure is associated with decreased healthy weight behaviors and behavior counseling alone may be insufficient. Trauma-informed care to address intra-familial adversity may be necessary.

Measurement and Identification of Parenting Behaviors Associated with Social-Emotional Outcomes in Children: The Racial and Cultural Appropriateness of a Commonly Used Parenting Measure.

OBJECTIVE: The objective of this study was to examine parenting styles (observed parent-child interactions via the Two-Bag Task) associated with young children's socioemotional outcomes, comparing children from Mexican-American and African American families with children from their White counterparts. METHODS: The Early Childhood Longitudinal Study Birth Cohort data were used to examine 6 global parenting styles with socioemotional outcomes at 48 months of age while controlling for both time-independent and time-depending sociodemographic, maternal mental health, and child characteristics. Data were stratified by race and ethnicity, and weighted longitudinal linear regressions models were estimated using STATA/Xtmixed. RESULTS: The 6 global parenting scores from the Two-Bag Task measures differed across White, African American, and Mexican-American groups of parents. White parents on average scored higher on parenting styles related to sensitivity, positive regard, and cognitive stimulation, whereas Mexican-American and African American parents scored lower. These parenting styles were associated with both approach to learning and social competence outcomes among White children but were nearly nonexistent for Mexican-American and African American children when adjusting for covariates. CONCLUSION: Our results highlight the need to critically evaluate measures of parenting behaviors used in research studies with racially and ethnically diverse families. Examining the comprehensive psychometric properties and cultural appropriateness of parenting measures for diverse families is important to optimally support child development for non-White children. Furthermore, a critical lens is important to mitigate the perpetuation of inaccurate research findings for Mexican-American and African American children.

Key Population Health Outcomes for Children with Medical Complexity: A Systematic Review.

INTRODUCTION: Despite the significant healthcare policy and program implications, a summary measure of health for children with medical complexity (CMC) has not been identified. It is unclear whether existing population health approaches apply to CMC. We conducted a systematic review of the existing peer-reviewed research literature on CMC to describe the health outcomes currently measured for CMC. METHODS: We searched MEDLINE and PsycINFO by linking combinations of key words from three groups of concepts: (1) pediatric, (2) medical complexity, and (3) chronicity or severity. Study eligibility criteria were research studies including CMC with any outcome reported. Data on the outcomes were systematically extracted. Iterative content analysis organized outcomes into conceptual domains and sub-domains. RESULTS: Our search yielded 3853 articles. After exclusion criteria were applied, 517 articles remained for data extraction. Five distinct outcome domains and twenty-four sub-domains emerged. Specifically, 50% of the articles studied healthcare access and use; 43% family well-being; 39% child health and well-being; 38% healthcare quality; and 25% adaptive functioning. Notably lacking were articles examining routine child health promotion as well as child mental health and outcomes related to family functioning. CONCLUSIONS: Key health domains for CMC exist. Adaptations of existing sets of metrics and additional tools are needed to fully represent and measure population health for CMC. This approach may guide policies and programs to improve care for CMC.

Do Subspecialists Ask About and Refer Families with Psychosocial Concerns? A Comparison with General Pediatricians.

Objectives Calls for pediatricians to tend to children's psychosocial concerns have existed for decades because they are known to negatively impact child health. Children with chronic illnesses frequently have child- and family-level psychosocial concerns that complicate the care provided by their pediatric subspecialists. This study compares pediatricians who exclusively practice general pediatrics with subspecialists regarding their inquiring/screening and referring for psychosocial concerns. Physician and practice characteristics associated with these behaviors were examined. Methods We conducted a cross-sectional study using the 2013 American Academy of Pediatrics Periodic Survey of Fellows. Respondents included 304 pediatricians who exclusively practice general pediatrics and 147 subspecialists. The primary analysis compared the current practices of generalists vs. subspecialists with regard to inquiring/screening and referring children with 10 different psychosocial concerns. Covariates included socio-demographics, practice characteristics, and training experiences. Weighted univariate, bivariate and multivariable analyses were performed. Results Less than half of all pediatricians in the sample reported routinely inquiring/screening for most psychosocial concerns, and 2/3 of subspecialists failed to routinely inquire/screen for most of these conditions. Pediatricians who practice general pediatrics exclusively were more likely to inquire/screen (incident rate ratio (IRR) 1.41, p < .05) and refer (IRR 1.59, p < .001) for a greater number of psychosocial concerns than subspecialists, after adjusting for provider and practice characteristics. Having attended a child or adolescent mental health (MH) lecture/conference in the past 2 years was also related to inquiring/screening (IRR 1.24, p < .05). Conclusions Pediatricians infrequently inquire/screen and refer psychosocial concerns, with subspecialists addressing these concerns even less frequently.

A Healthy Life for a Child With Medical Complexity: 10 Domains for Conceptualizing Health.

BACKGROUND AND OBJECTIVES: Defining and measuring health for children with medical complexity (CMC) is poorly understood. We engaged a diverse national sample of stakeholder experts to generate and then synthesize a comprehensive list of health outcomes for CMC. METHODS: With national snowball sampling of CMC caregiver, advocate, provider, researcher, and policy or health systems experts, we identified 182 invitees for group concept mapping (GCM), a rigorous mixed-methods approach. Respondents (n = 125) first completed Internet-based idea generation by providing unlimited short, free-text responses to the focus prompt, "A healthy life for a child or youth with medical complexity includes: ___." The resulting 707 statements were reduced to 77 unique ideas. Participants sorted the ideas into clusters based on conceptual similarity and rated items on perceived importance and measurement feasibility. Responses were analyzed and mapped via GCM software. RESULTS: The cluster map best fitting the data had 10 outcome domains: (1) basic needs, (2) inclusive education, (3) child social integration, (4) current child health-related quality of life, (5) long-term child and family self-sufficiency, (6) family social integration, (7) community system supports, (8) health care system supports, (9) a high-quality patient-centered medical home, and (10) family-centered care. Seventeen outcomes representing 8 of the 10 domains were rated as both important and feasible to measure ("go zone"). CONCLUSIONS: GCM identified a rich set of CMC outcome domains. Go-zone items provide an opportunity to test and implement measures that align with a broad view of health for CMC and potentially all children.

Childhood adversity and parent perceptions of child resilience.

BACKGROUND: Adverse childhood experiences (ACEs) negatively impact health throughout the life course. For children exposed to ACEs, resilience may be particularly important. However, the literature regarding resilience, particularly the self-regulation aspect of resilience, is not often described in children with ACEs. Additionally, family and community factors that might help promote resilience in childhood may be further elucidated. We aimed to describe the relationship between ACEs and parent-perceived resilience in children and examine the child, family, and community-level factors associated with child resilience. METHODS: Using the US-based, 2011-2012 National Survey of Children's Health, we examined adverse childhood experiences (NSCH-ACEs) as the main exposure. Affirmative answers to adverse experiences generated a total parent-reported NSCH-ACE score. Bivariate and multivariable logistic regression models were constructed for parent-perceived child resilience and its association with ACEs, controlling for child, family, and neighborhood-level factors. RESULTS: Among 62,200 US children 6-17 years old, 47% had 0 ACEs, 26% had 1 ACE, 19% had 2-3 ACEs, and 8% had 4 or more ACEs. Child resilience was associated with ACEs in a dose-dependent relationship: as ACEs increased, the probability of resilience decreased. This relationship persisted after controlling for child, family, and community factors. Specific community factors, such as neighborhood safety (p < .001), neighborhood amenities (e.g., libraries, parks) (p < .01) and mentorship (p < .05), were associated with significantly higher adjusted probabilities of resilience, when compared to peers without these specific community factors. CONCLUSIONS: While ACEs are common and may be difficult to prevent, there may be opportunities for health care providers, child welfare professionals, and policymakers to strengthen children and families by supporting community-based activities, programs, and policies that promote resilience in vulnerable children and communities in which they live.