Understanding the Conceptualization and Operationalization of Trauma-Informed Care Within and Across Systems: A Critical Interpretive Synthesis.

Policy Points In order to achieve successful operationalization of trauma-informed care (TIC), TIC policies must include conceptual clarity regarding the definition of both trauma and TIC. Furthermore, TIC requires clear and cohesive policies that address operational factors such as clearly delineated roles of service providers, protocol for positive trauma screens, necessary financial infrastructure, and mechanisms of intersectoral collaboration. Additionally, policy procedures need to be considered for how TIC is provided at the program and service level as well as what TIC means at the organizational, system, and intersectoral level. CONTEXT: Increased recognition of the epidemiology of trauma and its impact on individuals within and across human service delivery systems has contributed to the development of trauma-informed care (TIC). How TIC can be conceptualized and implemented, however, remains unclear. This study seeks to review and analyze the TIC literature from within and across systems of care and to generate a conceptual framework regarding TIC. METHODS: Our study followed a critical interpretive synthesis methodology. We searched multiple databases (Campbell Collaboration, Econlit, Health Systems Evidence, Embase, ERIC, HealthSTAR, IPSA, JSTOR, Medline, PsychINFO, Social Sciences Abstracts, Sociological Abstracts and Web of Science),as well as relevant gray literature and information-rich websites. We used a coding tool, adapted to the TIC literature, for data extraction. FINDINGS: Electronic database searches yielded 2,439 results and after inclusion/exclusion criteria were applied, a purposive sample of 98 information-rich articles was generated. Conceptual clarity and definitional understanding of TIC is lacking in the literature, which has led to poor operationalization of TIC. Additionally, infrastructural and ideological barriers, such as insufficient funding and service provider "buy-in," have hindered TIC implementation. The resulting conceptual framework defines trauma and depicts critical elements of vertical TIC, including the bidirectional relationship between the trauma-affected individual and the system, and horizontal TIC, which requires intersectoral collaboration, an established referral network, and standardized TIC language. CONCLUSIONS: Successful operationalization of TIC requires policies that address current gaps in systems arrangements, such as the lack of funding structures for TIC, and political factors, such as the role of policy legacies. The emergent conceptual framework acknowledges critical factors affecting operationalization.

The medical assessment of bruising in suspected child maltreatment cases: A clinical perspective.

Bruises commonly occur in children and are most often the result of a minor accidental injury. However, bruises can also signal an underlying medical illness or an inflicted injury (maltreatment). Although bruising is the most common manifestation of child physical maltreatment, knowing when to be concerned about maltreatment and how to assess bruises in this context can be challenging for clinicians. Based on current literature and published recommendations, this practice point will help clinicians to distinguish between accidental and inflicted bruises, to evaluate and manage bruising in the context of suspected child maltreatment, and to evaluate for an underlying medical predisposition to bruising.

Les ecchymoses sont courantes chez les enfants et découlent souvent d'une blessure accidentelle mineure. Cependant, elles peuvent également signaler une maladie sous-jacente ou une blessure infligée (maltraitance). Même si les ecchymoses sont les manifestations les plus courantes de la maltraitance physique des enfants, il peut être difficile pour les cliniciens de savoir quand s'inquiéter d'un risque de maltraitance et comment évaluer les ecchymoses dans un tel contexte. D'après les publications et les recommandations publiées récentes, le présent point de pratique aide les cliniciens à distinguer les ecchymoses accidentelles et infligées, à évaluer et à prendre en charge les ecchymoses en présence d'une maltraitance présumée d'enfant et à évaluer la prédisposition médicale sous-jacente aux ecchymoses.

Case conceptualization in child welfare: an underused resource to improve child, family, and provider outcomes.

Case conceptualization, formally known as case formulation, is one tool that assists in determining the best course of action for children and families experiencing family violence that has been under-utilized in child welfare. In this article we present a step-by-step case conceptualization process that considers the child welfare context. We then present a hypothetical case example of a 10-year-old child referred by a child welfare worker to evidence-based treatment for mental health and behavioural concerns. Mental health services are not helpful for the child and further consultation is enlisted. To more effectively guide intervention and treatment planning and ultimately improve outcomes for the child, we present case conceptualization as a process that incorporates relevant aspects of the child and family's history and circumstance. We conclude with a succinct case conceptualization and treatment plan to show how the prognosis of the child can be improved when case conceptualization is employed.

Burn injury from car seat in an 11-month-old infant.

Burns in young infants have long been recognized as a potential cause of nonaccidental injury. Accidental exposure to hot car seat parts resulting in significant burn injury is an unusual mimicker of child abuse. A case involving an 11-month-old child who presented with a significant contact burn injury related to the noncovered, heated, plastic part of a car seat, is described. The present case encourages physicians to maintain an unbiased approach to each referred case and to explore the differential diagnosis by detailed history and physical examination. It also serves as a reminder in caregiver education about the precautions to be taken during long-distance travel with young children and infants.

On sait depuis longtemps que les brûlures sont une cause potentielle de blessure non accidentelle chez les nourrissons. L'exposition accidentelle aux parties brûlantes d'un siège d'auto entraînant une grave brûlure est un imitateur inhabituel de maltraitance. Les auteurs décrivent le cas d'un nourrisson de 11 mois qu'on a emmené consulter en raison d'une importante brûlure de contact liée à la partie de plastique non recouverte et brûlante d'un siège d'auto. Le présent cas invite les médecins à adopter une méthode non biaisée devant chaque cas qui leur est aiguillé et à explorer le diagnostic différentiel au moyen d'antécédents détaillés et d'un examen physique. Il rappelle également aux personnes qui s'occupent d'enfants les précautions à prendre pendant les longs déplacements avec de jeunes enfants et des nourrissons.

Sexual and reproductive health and rights of "last mile" adolescents: a scoping review.

Globally, significant progress has been made in the realm of adolescent sexual and reproductive health. We conceptualised "last mile" adolescents as having two or more of the following factors of identity: refugee, Indigenous, 2SLGBTQIA+, out of school, rurally or remotely located, slum dwelling, incarcerated or previously incarcerated, HIV/AIDS infected, and living with a disability. We conducted a scoping review with an aim to synthesise evidence and identify research gaps in the literature pertaining to the sexual and reproductive health and rights (SRHR) of last mile adolescents. We conducted searches in three databases (Embase, Global Health, and Medline). Fifty-four publications met our inclusion criteria. Our results revealed that the state of evidence on the SRHR of last mile adolescents is poor. Very few studies used qualitative and mixed-method inquiry. The number of studies carried out in North America, Europe, and Oceania were limited. We found insufficient disaggregated data with respect to SRHR-related knowledge, behaviour, and access to services. Adopting an intersectional lens is critical to uncover the multiplicative effects of last mile adolescents' factors of identity on their SRHR. National data systems should be strengthened to enable the collection of quality disaggregated data which can play a vital role in identifying SRHR inequities affecting last mile adolescents. Research priorities should be realigned to generate data globally on the SRHR of last mile adolescents whose lives are marked by intersecting vulnerabilities.

Caregiver-fabricated illness in a child prescribed long-term opioids and benzodiazepines.

Caregiver-fabricated illness in a child (CFIC) can result in unnecessary, potentially harmful medical investigations and treatment. As pediatric pain has historically been undertreated, the movement for more compassionate treatment has led to an increase in analgesic prescribing in children and adolescents. Overall, this has been a positive change but this may also lead to unintentional harm, partic-ularly if CFIC is not considered as a possibility in the presentation. We present a case in which CFIC was associated with long-term prescribing of opioids, benzodiazepines, and other central nervous system depressants.

The Hidden Curriculum: A Good Thing?

Introduction The hidden curriculum is defined as a set of influences that function at the level of the organizational structure and culture to impact learning. Literature supports the significant impact of the hidden curriculum on all levels of learners in medical education. Our project aims to capture the messages being delivered to healthcare providers at our local facility. Methods Multiple one-time educational sessions on the hidden curriculum were provided over a five-year period to healthcare professionals. Participants were asked to share personal examples of their lived experiences with the hidden curriculum. A thematic analysis of the responses was completed and coded by two independent reviewers.  Results Participants consisted of medical students, residents, faculty physicians, and allied health professionals. Their experience of the hidden curriculum emerged in six main themes: Vulnerability, Hierarchy, Privilege, Navigation & Negotiation, Positivity, and Dehumanizing. Conclusion A minority of responses demonstrated the positive impact that the hidden curriculum can have on professional development. This project highlights the importance of formally addressing the hidden curriculum to capitalize on its impact on medical trainees. The results have inspired a project focusing on residents as the population of interest in their unique role as learners and preceptors.

Effects associated with adolescent standardized patient simulation of depression and suicidal ideation.

BACKGROUND: Because of common use of adolescent simulated patients (ASPs), clarification of the risk of negative effects associated with high-stress simulations is essential. This study evaluates the safety of suicidality simulations. METHOD: ASPs participated in a suicidality role or pediatric role. Explicit measures of their impact included the Suicidal Ideation Questionnaire (SIQ) and Reynolds Adolescent Depression Scale-2 (RADS-2), both of which were completed pre-/poststudy. Implicit behavioral measures of impact were also collected during training, including the Implicit Association Test. RESULTS: Three of the 24 participants had clinical RADS-2 and/or SIQ scores. None of these adolescents' mental status deteriorated with SP participation. ASPs in the suicidality role showed behavioral effects consistent with a negative reaction, and two reported brief depression. CONCLUSIONS: ASPs participated in a suicidality simulation without evidence of suicide contagion. However, ASPs' behavioral reactions and self-reported depression suggested a transient depressive reaction.

Mandatory reporting of child abuse and neglect: crafting a positive process for health professionals and caregivers.

Health professionals working with children and their families are often required by law to report to governmental authorities any reasonable suspicion of child abuse and/or neglect. Extant research has pointed toward various barriers to reporting, with scant attention to positive processes to support the reporting process. This paper focuses on the context for mandatory reporting and evidence-informed practice for supporting a more structured and purposeful process of mandatory reporting. These practical strategies discusses: (1) the factors that positively influence the relationship between a child's caregivers and the mandated health professional reporter; (2) a framework and specific skills for discussing concerns about maltreatment and reporting to child protective services with the caregiver(s); and (3) the need for further training and education of health professionals.

Cortisol response to stress in female youths exposed to childhood maltreatment: results of the youth mood project.

BACKGROUND: Few studies have examined stress reactivity and its relationship to major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) among maltreated youth. We examined differences between maltreated and control participants in heart rate and cortisol resting and reactivity levels in response to a psychosocial stressor. METHODS: We recruited 67 female youths aged 12 to 16 with no prior history of depression from child protection agencies and a control group of 25 youths matched on age and postal code. Child maltreatment was measured with two self-report instruments. Psychiatric status was assessed using the Schedule for Affective Disorders and Schizophrenia for School-Aged Children. RESULTS: Piecewise multilevel growth curve analysis was used to model group differences in resting and reactivity cortisol levels and heart rate in response to the Trier Social Stress Test (TSST). During the resting period, both the maltreated and control groups showed a similar decline in levels of cortisol. During the reactivity phase, youth in the control group showed an increase in cortisol levels following the TSST and a gradual flattening over time; maltreated youth exhibited an attenuated response. This blunted reactivity was not associated with current symptoms of MDD or PTSD. There were no group differences in resting and reactivity levels of heart rate. CONCLUSIONS: These findings provide further support for hypothalamic-pituitary-adrenal axis dysregulation among maltreated youth. Since the ability to respond to acute stressors by raising cortisol is important for health, these findings may assist in understanding the vulnerability of maltreated youth to experience physical and mental health problems.

Does mental illness stigma contribute to adolescent standardized patients' discomfort with simulations of mental illness and adverse psychosocial experiences?

OBJECTIVE: Adolescent mental illness stigma-related factors may contribute to adolescent standardized patients' (ASP) discomfort with simulations of psychiatric conditions/adverse psychosocial experiences. Paradoxically, however, ASP involvement may provide a stigma-reduction strategy. This article reports an investigation of this hypothetical association between simulation discomfort and mental illness stigma. METHODS: ASPs were randomly assigned to one of two simulation conditions: one was associated with mental illness stigma and one was not. ASP training methods included carefully written case simulations, educational materials, and active teaching methods. After training, ASPs completed the adapted Project Role Questionnaire to rate anticipated role discomfort with hypothetical adolescent psychiatric conditions/adverse psychosocial experiences and to respond to open-ended questions regarding this discomfort. A mixed design ANOVA was used to compare comfort levels across simulation conditions. Narrative responses to an open-ended question were reviewed for relevant themes. RESULTS: Twenty-four ASPs participated. A significant effect of simulation was observed, indicating that ASPs participating in the simulation associated with mental illness stigma anticipated greater comfort with portraying subsequent stigma-associated roles than did ASPs in the simulation not associated with stigma. ASPs' narrative responses regarding their reasons for anticipating discomfort focused upon the role of knowledge-related factors. CONCLUSION: ASPs' work with a psychiatric case simulation was associated with greater anticipated comfort with hypothetical simulations of psychiatric/adverse psychosocial conditions in comparison to ASPs lacking a similar work experience. The ASPs provided explanations for this anticipated discomfort that were suggestive of stigma-related knowledge factors. This preliminary research suggests an association between ASP anticipated role discomfort and mental illness stigma, and that ASP work may contribute to stigma reduction.

Forensic issues in the assessment of sexually assaulted adolescents.

This article provides a general overview of the principles of conducting a forensic evaluation of adolescents who have been exposed to sexual abuse. This problem is common and is associated with a large burden of suffering. There is a strong likelihood that most paediatricians will be called on to perform such evaluations at some point in time. This overview includes a description of the forensic examination, focuses on such issues as consent and contact with child protection services, and provides specific guidelines about interviewing the adolescent. Familiarity with how to conduct a forensic evaluation will hopefully improve the availability of this service for adolescents. Contact with the legal profession can be stressful. At the same time, paediatricians are in a unique position to advocate on behalf of their adolescent patients.